Abstract
Objective
To describe suspected/confirmed cases of child maltreatment related to fractures in a pediatric hospital in southern Brazil.
Method
Study of the Information System of Notifiable Diseases notifications and the victims’ medical records between January/2016 and December/2020. Variables related to the victim, the perpetrator, the type of abuse, the presence of fractures, and their anatomical location and death were evaluated. Logistic regression was performed to identify fracture-related variables, adjusted for sex and age. The results were expressed in odds ratios and their respective 95% confidence intervals. It was considered significant p < 0.05.
Results
There were 276 cases, 73 infants (26.4%), male predominance (151, 54.7%), with authorship of the mistreatment by relatives (245, 96,0%), 85 (31,5%), they presented fractures, with five deaths (1.9%). Factors related to the presence of fracture: age of the victim (less than two years old; n = 82; or 2.48; 95% CI: 1.45 - 4.25), having more than two aggressors involved (n = 144; or 2.09; 95% CI: 1.16-3.75), the medium being traffic/automobile accident, (n = 52; or 2.65; 95% CI: 1.04–6.75), consult an orthopedist (n = 91; or 6.77 / 95% CI: 3.66–12.51), and the need for surgical intervention (n = 15; OR 36.72; 95% CI: 8.22–164.03).
Conclusions
The importance of suspicion, early identification of aggression, and the correct completion of notifications for activating the system of guaranteeing rights and removal of the aggressor was emphasized.
Keywords
child abuse; bone fractures; violence; negligence
Resumo
Objetivo
Descrever os casos suspeitos/confirmados de maus-tratos infantis relacionados a fraturas, atendidos em um hospital pediátrico no Sul do Brasil.
Método
Estudo das notificações do Sistema de Informação de Agravos de Notificação e dos prontuários das vítimas, entre janeiro/2016 e dezembro/2020. Avaliadas variáveis relacionadas à vítima, ao autor, à tipologia de maus-tratos, à presença de fraturas e sua localização anatômica e óbito. Regressão logística foi realizada para identificar as variáveis relacionadas à fratura, ajustada para sexo e idade, expressa em razão de chance e seus respectivos intervalos de confiança de 95%. Foi considerado significativo p < 0.05.
Resultados
Houve 276 casos, 73 lactentes (26,4%), predomínio do sexo masculino (151, 54,7%), com autoria dos maus-tratos por parentes (245, 96,0%), 85 (31,5%), apresentaram fraturas, sendo cinco óbitos (1,9%). Fatores relacionados à presença de fratura: idade da vítima (menor de dois anos; n = 82; RC 2,48; IC 95%: 1,45 - 4,25), ter mais de dois agressores envolvidos (n = 144; RC 2,09; IC 95%: 1,16 - 3,75), o meio ser trânsito/acidente automobilístico, (n = 52; RC 2,65; IC 95%: 1,04–6,75), consultar com ortopedista (n = 91; RC 6,77 / IC 95%: 3,66–12,51), e necessidade de intervenção cirúrgica (n = 15; RC 36,72; IC 95%: 8,22–164,03).
Conclusões
Ressaltada a importância da suspeição e identificação precoce da agressão, o preenchimento correto das notificações, para o acionamento do sistema de garantia de direitos e afastamento do agressor.
Palavras-chave
maus-tratos infantis; fraturas ósseas; violência; negligência
Introduction
Violence against children has been present in humanity since primitive times and is often linked to the educational process at home, characterized by any acts, omissions, or negligence in the care provided to the child and which can result in death, emotional or physical harm, abuse or sexual exploitation.11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
In the United States, of 680 thousand cases of violence against children, 75.0% were related to neglect, 18.0% to physical violence, and 8.0% to sexual violence33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065
4 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590
5 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128-66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014 - for every 1000 children, 9.1 suffer aggression,44 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590,55 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128 only 8 out of 100 cases of physical violence in the U.S. are reported.77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014 There is recidivism in up to 50.0% and, in these, the risk of death reaches 10.0%.77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014
In Brazil, physical aggression in minors varies between 20.0%88 Brasil. Instituto Brasileiro de Geografia e Estatística - IBGE. Censo Demográfico. Rio de Janeiro: IBGE; 2012 and 35.1%.11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
In 2019, there were 159,063 complaints of mistreatment by Disque Direitos Humanos (Disque 100 [Call Human Rights]), an increase of 15.0% compared to 2018.99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019 Of these 86,837 (55.0%) referred to domestic violence against children and adolescents: neglect (38.0%), psychological violence (23.0%), physical violence (21.0%), sexual violence (11.0%), exploitation of child labor (3.0%) and others (3.0%).99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019
Many of these acts of violence do not leave physical marks. When present, they are associated with soft tissue injuries (more prevalent), with those affecting the head and abdomen regions being the main causes of death in this group.66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,1010 Tiyyagura G, Beucher M, Bechtel K. Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment. Pediatr Emerg Med Pract 2017;14(07):1-32 Bone fractures are the second most common finding in victims of violence.11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014 Up to about 50.0% of fracture occurrences occur in the first year of life - and a third of these types of injuries occur in those under 3 years of age.33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,1111 Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775 They are the result of child violence. Suspicion should be advanced with caution when the lesions do not correspond to the mechanism of trauma or the declared history.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822,1313 Cheong VS, Karunaratne A, Amis AA, Bull AMJ. Strain rate dependency of fractures of immature bone. J Mech Behav Biomed Mater 2017;66:68-76
Thermal damage, unexplained soft tissue or skull injuries, rib and/or multiple fractures, delay in seeking medical attention, or any injury to a child who is not yet walking should draw the attention of the healthcare professional.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
3 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065-44 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014 Spinal injuries are rare in children, but they can happen in victims of violence.33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,1414 Jauregui JJ, Perfetti DC, Cautela FS, Frumberg DB, Naziri Q, Paulino CB. Spine Injuries in Child Abuse. J Pediatr Orthop 2019;39(02): 85-89 Children with disabilities require increased attention, as they are a risk group for violence,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1010 Tiyyagura G, Beucher M, Bechtel K. Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment. Pediatr Emerg Med Pract 2017;14(07):1-32,1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40 are at greater risk of osteopenia than those without disabilities, which may predispose to pathological fractures,44 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590 differential diagnoses of maltreatment.66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014
Orthogonal radiographs of the skull, spine, long bones, hands, and feet are relevant in cases of suspected violence.33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822,1616 Álvarez ID, Latorre IBM, Méndez ÉV El papel del radiólogo ante el niño maltratado. Protocolo de imagen y diagnóstico diferencial. Radiología 2016;58(Supl 2):119-128
17 Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of abuse among young children with rib fractures: A systematic review. Pediatr Emerg Care 2019;35(02):96-103-1818 Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. Child Abuse Negl 2018;76:237-249 However, they do not replace the anamnesis since it is necessary to confirm the compatibility of the report of the trauma mechanism with that evidenced in the image.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1313 Cheong VS, Karunaratne A, Amis AA, Bull AMJ. Strain rate dependency of fractures of immature bone. J Mech Behav Biomed Mater 2017;66:68-76,1414 Jauregui JJ, Perfetti DC, Cautela FS, Frumberg DB, Naziri Q, Paulino CB. Spine Injuries in Child Abuse. J Pediatr Orthop 2019;39(02): 85-89
Age is one of the most important characteristics in distinguishing between accidental trauma and violence. An example is tibia fractures, which are highly suspected in children who are of preambulatory age and may be accidental in young children who are already walking.33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020
The diagnosis of violence in the health sector11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 and notification to the responsible bodies avoids worse outcomes, such as emotional and physical sequelae and even death, especially in cases in which the victim suffers several aggressions over time in a chronic form.11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1010 Tiyyagura G, Beucher M, Bechtel K. Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment. Pediatr Emerg Med Pract 2017;14(07):1-32,1111 Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020
20 Lavin LR, Penrod CH, Estrada CM, et al. Fractures in the Pediatric Emergency Department: Are We Considering Abuse? Clin Pediatr (Phila) 2018;57(10):1161-1167
21 Brasil. Ministério da Saúde. Análise epidemiológica da violência sexual contra crianças e adolescentes no Brasil, 2011 a 2017. Bol Epidemiol 2018;49:1-17
22 Nguyen A, Hart R. Imaging of non-accidental injury; what is clinical best practice? J Med Radiat Sci 2018;65(02):123-130-2323 Luna GL, Ferreira RC, Vieira LJ. Notificação de maus-tratos em crianças e adolescentes por profissionais da Equipe Saúde da Família. Cien Saude Colet 2010;15(02):481-491. Doi: 10.1590/S1413-81232010000200025
https://doi.org/10.1590/S1413-8123201000...
Whereas neglect is the most frequent type of child abuse,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1111 Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775,2323 Luna GL, Ferreira RC, Vieira LJ. Notificação de maus-tratos em crianças e adolescentes por profissionais da Equipe Saúde da Família. Cien Saude Colet 2010;15(02):481-491. Doi: 10.1590/S1413-81232010000200025
https://doi.org/10.1590/S1413-8123201000...
,2424 Krug EG, Dahlberg LL, Mercy JÁ, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002. Available at: https://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2019/04/14142032-relatorio-mundial-sobre-violencia-e-saude.pdf
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it is observed that the incidence of injuries in these cases can be reduced through a preventive approach with parents, guiding them to avoid accident-prone scenarios, including those typical of each age.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020
To monitor, identify, and even prevent cases of mistreatment of children and adolescents, since 2001, Brazil has compulsorily adopted the notification of suspected or confirmed cases that have been attended to in the establishments of the Unified Health System ([Sistema Único de Saúde] SUS). This notification should be forwarded to municipal epidemiological surveillance and a protection agency.2525 Brasil. Portaria n° 1.968/GM/MS, de 25 de outubro de 2001. Dispõe sobre a notificação, às autoridades competentes, de casos de suspeita ou de confirmação de maus-tratos contra crianças e adolescentes atendidos nas entidades do Sistema Único de Saúde. Diário Oficial da República Federativa do Brasil, Brasília, n. 206, Seção 1, p. 86. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt1968_25_10_2001_rep.html
https://bvsms.saude.gov.br/bvs/saudelegi...
From these records, health authorities and managers can assemble the profile of those involved and their impact,2121 Brasil. Ministério da Saúde. Análise epidemiológica da violência sexual contra crianças e adolescentes no Brasil, 2011 a 2017. Bol Epidemiol 2018;49:1-17,2525 Brasil. Portaria n° 1.968/GM/MS, de 25 de outubro de 2001. Dispõe sobre a notificação, às autoridades competentes, de casos de suspeita ou de confirmação de maus-tratos contra crianças e adolescentes atendidos nas entidades do Sistema Único de Saúde. Diário Oficial da República Federativa do Brasil, Brasília, n. 206, Seção 1, p. 86. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt1968_25_10_2001_rep.html
https://bvsms.saude.gov.br/bvs/saudelegi...
to develop relevant public policies to prevent and manage this sad aggravation.
This study, therefore, aims to describe the profile of children with maltreatment notification who present fractures and their related factors in a pediatric orthopedic reference center in Southern Brazil.
Methods
This is a cross-sectional study, with data analysis of children's medical records (ages 0 to 15 incomplete) notified by mistreatment in the emergency room of a pediatric hospital in Santa Catarina from January 2016 to June 2020.
The notifications were selected according to the International Classification of Diseases (ICD-10), with the possibility of outcome in fractures and/or deformities of orthopedic management77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1111 Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775,2626 Platt VB, Back IC, Hauschild DB, Guedert JM. Violência sexual contra crianças: autores, vítimas e consequências. Cien Saude Colet 2018;23(04):1019-1031; availability of information in the medical records; and standardizing terms: "motorcycle accident," "collision," and "car/automobile accident" to "automobile accident." The records that contained more than one item selected for the "type of violence" field were divided into two or more, allowing a more faithful analysis.
Variables related to the victim are categorized into age (age groups), sex (male or female), race (white and non-white), presence or absence of disability/disorder, and the municipality of residence (capital or other). Those related to the perpetrator: number of involved, gender (male or female), suspicion of alcohol use, bond/degree of kinship with the victim (father, mother, stepfather, stepmother, boyfriend, ex-boyfriend, brother, friends, caregiver, friend, unknown, person in an institutional relationship or others, specifying them) were grouped, generating the variable "known" and "unknown."
Concerning violence, a typology was found (neglect, physical, psychological, suicide attempt, and others), being categorized into "neglect," "physical," and "others" (together with the others previously listed), and death as a result of aggression. Automobile accidents with a record in the victim's medical record of the non-use of legally provided safety devices were considered negligence.
In addition to manually verifying the notification forms, an analysis of the records in the patients’ medical records was performed, aiming to investigate the outcome: "presence of fractures." They were categorized in terms of presence (yes or no) based on the orthopedist's clinical and radiological diagnosis, topography (whether in the upper limbs, lower limbs, axial skeleton, or two or more body segments), and the need for surgical intervention.
The data were analyzed using the Statistical Package for the Social Sciences, version 22.0, by descriptive statistics in simple frequency and proportion. Binary logistic regression was employed, using the chi-square or Fisher's exact tests in the crude model (variables with p < 0,20). The selection method was used backward for the adjusted analysis, with results expressed in odds ratio (or) and respective confidence intervals (CI) of 95%. p < 0.05 was considered significant.
In April 2020, a systematized search of the PubMed database (US National Library of Medicine National Institutes of Health) on child maltreatment yielded 182 articles (Table 1 and Fig. 1).
Search Strategy on Child Maltreatment With Bone Fractures, Pubmed: 2015-2020.Source: www.prisma.statement.gov [Data from the author].
The study was approved by the Institutional Research Ethics Committee (Consolidated Opinion 4.203.338/2020).
Results
From January 2016 to December 2020, 276 notifications of suspected or confirmed cases of interpersonal or self-inflicted violence were made, corresponding to a total of 253 children and adolescents. No records confirming or excluding the diagnosis of fractures were found in 6 of the 276 cases, leaving 270 notifications for analysis.
Regarding the characteristics of children and adolescents reported as victims of maltreatment described in Table 1, there was a predominance of males (54.7%), over 10 years of age (30.1%), of white ethnicity (89.4%), without disabilities (94.0%) and who inhabited cities that were not Florianópolis (65.2%). The age of the victim showed a significant difference according to sex. Most of the victims were boys aged 10-15 years (p < 0.05).
Characterization of victims of physical/self-inflicted violence (according to age, ethnicity, presence of disabilities, and the municipality of residence), according to sex, SINAN-HIJG, 2016–2020 (n= 276)
The sex distribution of the perpetrators of the aggression concerning the sex of the victim was statistically significant (p < 0,05). In 57.4% of the notifications, the authorship of these violences was linked to at least two suspects who acted jointly, mostly parents (50.2%), without suspicion of alcohol use in 91.3% of the notifications. Acquaintances predominated (96.0%) (Table 2).
Characterization of perpetrators of ill-treatment (according to the gender of the perpetrator, relationship with the victim, dichotomized relationship, number of perpetrators, and use of alcohol by the perpetrator), according to the sex of the victims, SINAN-HIJG, 2016–2020 (n= 276)
Neglect was the most described typology (53.9%), the beating was the most common means (33.9%), resulting in fractures in 31.5% of cases, and the axial axis was the most affected anatomical segment (40.0%). Regarding the fracture site and sex of the victim, fractures only in the axial skeleton were frequent in males, and fractures in two or more segments predominated in females (p < 0,05). 15 of them (17.6%) required surgical intervention. There were five deaths: two due to gunshot wounds, one due to beatings, one due to automobile accidents, and one due to falls (Table 3).
Typology of cases of maltreatment, its consequences, and outcome "bone fractures" according to the sex of the victims (according to the type of violence, the environment, the presence of fractures, the type of fracture, whether there was consultation with an orthopedist and whether there was a need for surgery or deaths), SINAN-HIJG, 2016–2020 (n= 276)
In the analysis adjusted for sex and age, age of the victim (less than two years) (or 2.48; 95% CI: 1.45 - 4.25), involvement of two or more aggressors (or 2.09; 95% CI: 1.16 - 3.75), the means being traffic/automobile accident, (or 2.65; 95% CI: 1.04–6.75), presence of consultation with orthopedist (or 6.77; 95% CI: 3.66–12.51), and the need for surgical intervention (or 36.72; 95% CI: 8.22–164.03) were statistically significantly associated with increased risk of fractures (Table 4).
Factors associated with the outcome "bone fractures" in victims of maltreatment, SINAN-HIJG, 2016–2020 (n= 270).
Discussion
Male victims, as noted in the literature,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822 were the most affected (54.7%), with a 1.2-fold risk of presenting associated fractures, when compared to females.
The extremes of age (< 2 years and > 10 years) were the groups most likely to suffer aggression. Infants (< 2 years) presented a 2.4 times higher risk of fractures when compared to those older than two years, regardless of sex, corroborating the international literature66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 and differing from that computed by Disque 100 (Dial 100), where school victims were the most listed.99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019 It should be noted that the smaller the child, the more dependent on care the child is, including reaching a health service, with underreporting due to omission of care.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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In the southern region of the country, white ethnicity predominates,88 Brasil. Instituto Brasileiro de Geografia e Estatística - IBGE. Censo Demográfico. Rio de Janeiro: IBGE; 2012,2626 Platt VB, Back IC, Hauschild DB, Guedert JM. Violência sexual contra crianças: autores, vítimas e consequências. Cien Saude Colet 2018;23(04):1019-1031 explaining the disparity between reports of violence in people of this ethnicity (89.4%) in relation to the others, different from the data of the Disque 100, which indicates the brown population as the most affected by mistreatment, followed by white and black.99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019 In this study, having white skin color was associated with a 1.5 times higher risk for fractures related to abuse when compared to other skin colors.
The presence of victims with disabilities was not significant (6.0%), diverging from the literature,11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
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,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019,1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 leading to infer that the failure to seek emergency care for these patients could be related to possible notification errors, the lack of diagnosis of aggression and/or notification and the inability to verbalize victims with disabilities.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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,2626 Platt VB, Back IC, Hauschild DB, Guedert JM. Violência sexual contra crianças: autores, vítimas e consequências. Cien Saude Colet 2018;23(04):1019-1031 In this group, there was no association with fracture risk.
The greater number of notifications from other municipalities (65.2%) than the capital can be justified because the hospital is large and a reference in orthopedics in the State.
Regarding the authorship of the maltreatment, most had at least two aggressors, mainly the father and mother, simultaneously, corroborating with the literature, which maintains the pattern of parents as the main suspects of child maltreatment.11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,44 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590,55 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019,1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40,1717 Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of abuse among young children with rib fractures: A systematic review. Pediatr Emerg Care 2019;35(02):96-103,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 In 91.0% of the cases, the authors of the aggressions were not under suspicion of alcohol use, in line with the literature,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019,1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40 there was no relationship between the use of alcohol by the aggressors and the outcome fractures.
Corroborating national and international research,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,44 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590,55 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822 neglect (53.9%) and physical aggression (39.1%) were the most prevalent typologies, with similar distribution between genders. The high prevalence of the latter may be related to the use of physical force as a form of "education" or disciplinary practice,11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822 where parents who were raised through punishment and physical punishment perpetrate this culturally accepted habit,11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
https://doi.org/10.1590/S1519-3829200100...
,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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regardless of the existence of public policies, such as Law No. 13,010–"Lei do Menino Bernardo" (Bernardo Boy Law)2727 Brasil. Lei n° 13.010, de 26 de junho de 2014. Altera a Lei no 8.069, de 13 de julho de 1990 (Estatuto da Criança e do Adolescente), para estabelecer o direito da criança edo adolescente de serem educados e cuidados sem o uso de castigos físicos ou de tratamento cruel ou degradante, e altera a Lei no 9.394, de 20 de dezembro de 1996. Brasília: Imprensa Nacional, 27 jun. 2014. n. 121, Seção 1, p. 2. Available at: https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/30057416/do1-2014-06-27-lei-n-13-010-de-26-de-junho-de-2014-30057411
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or the Statute of the Child and Adolescent.2828 Brasil. Câmara dos Deputados. Estatuto da criança e do adolescente: Lei n. 8.069, de 13 de julho de 1990, e legislação correlata. 9. ed. Brasília: Câmara dos Deputados, Edições Câmara, 2012. 207 p. (Série legislação; n. 83). Available at: http://bd.camara.leg.br/bd/bitstream/handle/bdcamara/18403/estatuto_crianca_adolescente_9ed.pdf?sequence=10
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The increased risk of these two forms of maltreatment in the occurrence of fractures was 3.3 and 5.0 times higher, respectively, when compared to all the others studied. Understanding the importance of vigilance of parents to their children and especially continuing education about accidents and unintentional injuries.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014
When the means of aggression were evaluated, "traffic accidents" and" beating" responded to more than half of the notifications (54.9%), followed less expressively by electric shock (13.3%), falls (12.9%), and "others," similar to the literature,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,99 Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 signaling for the practice of physical force as an educational disciplinary measure11 Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
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,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822 and the absence of observance of safe transportation.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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,2929 Brasil. Brazilian Traffic Code ([Código Brasileiro de Trânsito] CONTRAN). Law no. Article 64 of April 12, 2021. Available at: https://www.ctbdigital.com.br/artigo/art64
https://www.ctbdigital.com.br/artigo/art...
"Beating" and "traffic accidents" were related to a 2.1-and 2.5-fold risk of causing fractures.
The outcome "fractures" was 2.2 times more frequently observed in the "falls," paying attention to the need for surveillance and supervision, especially of minors who are starting to walk.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,33 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014 Its prevalence (31.5%) was 4.5 times higher than in another national study.1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40
Regarding the anatomical location of the fractures, 40.0% were present only in the axial skeleton, including the skull, a region related to a more severe outcome.22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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3 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065
4 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590
5 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128
6 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014-77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1212 Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822,1515 Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40,1818 Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. Child Abuse Negl 2018;76:237-249,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020 23.5% of the victims presented injuries in more than one segment, being a risk factor for mistreatment22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
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3 Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065
4 Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590
5 Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128
6 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014-77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1111 Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775,1818 Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. Child Abuse Negl 2018;76:237-249,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020, that is, a child with multiple fractures, especially in more than one anatomical site, should be evaluated more closely for this diagnostic suspicion.
Of the patients studied, regardless of gender, children under two years of age had a 2.5 times higher risk of suffering fractures than other age groups, in addition to a 1.7 times higher risk for the same outcome if the violence was perpetrated by acquaintances when compared to those who were assaulted by strangers. Other factors associated with a higher risk of fractures were aggression being committed by two perpetrators or more, victims of automobile accidents, and care provided by an orthopedist—risks respectively 2.1, 2.7, and 6.8 times higher. Considering that automobile accidents are sometimes related to negligence, a great challenge emerges: Safe transportation for children must be established in the safety rules for the transport of children in vehicles.2929 Brasil. Brazilian Traffic Code ([Código Brasileiro de Trânsito] CONTRAN). Law no. Article 64 of April 12, 2021. Available at: https://www.ctbdigital.com.br/artigo/art64
https://www.ctbdigital.com.br/artigo/art...
Fifteen patients (17.7%) underwent orthopedic surgery as part of the treatment, and the presence of bone fracture was related to 16.5 times more need for surgical intervention and 1.5 times the risk of death when compared to the absence of it in the study.
These data reinforce the importance of prevention,22 Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
https://www.spsp.org.br/downloads/Manual...
,2929 Brasil. Brazilian Traffic Code ([Código Brasileiro de Trânsito] CONTRAN). Law no. Article 64 of April 12, 2021. Available at: https://www.ctbdigital.com.br/artigo/art64
https://www.ctbdigital.com.br/artigo/art...
of attention to the signs that may raise suspicions of mistreatment, and the appropriate investigation by the "front line" professional and referral to the specialist when appropriate.66 Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014,77 Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014,1919 Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020
The secondary source of the data is cited as a probable limitation, which was resolved by manually checking the notification forms one by one and checking the victim's hospital records.
Conclusions
Due to the dependence and vulnerability inherent to the life cycle, children are a risk group for various violence, whether accidental or intentional, requiring both family education for prevention and the attention of the assistance professional in the identification and correct notification of this aggravation, with adequate management of cases, avoiding serious outcomes.
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Financial SupportThe authors state they received no financial support from public, commercial, or non-profit sources.
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Work developed at the Joana De Gusmão Children's Hospital/SES, Florianópolis, SC, Brazil.
References
-
1Minayo MCS. Violência contra crianças e adolescentes: questão social, questão de saúde. Rev Bras Saúde Mater Infant 2001;1(02): 91-102. Doi: 10.1590/S1519-38292001000200002
» https://doi.org/10.1590/S1519-38292001000200002 -
2Sociedade de Pediatria de São Paulo. Sociedade Brasileira de Pediatria. In: Waksman RD, Hirschheimer MR, Pfeiffer L, coord. Manual de atendimento às crianças e adolescentes vítimas de violência. 2a.ed. Brasília, DF: Conselho Federal de Medicina, 2018. Available at: https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf
» https://www.spsp.org.br/downloads/Manual_Atendimento_Crian%C3%A7as_Adolescentes_V%C3%ADtimas_Viol%C3%AAncia_2018.pdf -
3Choudhary AK, Servaes S, Slovis TL, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol 2018;48(08):1048-1065
-
4Strouse PJ. Child abuse: we have problems. Pediatr Radiol 2016;46 (05):587-590
-
5Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Interventions to prevent child maltreatment: us preventive services task force recommendation statement. JAMA 2018;320 (20):2122-2128
-
6Weinstein SL, Flynn JM. Lowell and Winter’s pediatric orthopaedics. 7th ed:. Philadelphia: Wolters Kluwer; 2014
-
7Herring JA. Tachdjian’s pediatric orthopaedics: from the Texas Scottish Rite Hospital for Children. 5th ed. Texas: Elsevier Sanders;; 2014
-
8Brasil. Instituto Brasileiro de Geografia e Estatística - IBGE. Censo Demográfico. Rio de Janeiro: IBGE; 2012
-
9Brasil. Ministério da Mulher. Família e dos Direitos Humanos. Disque 100 Direitos Humanos. Relatório Violência contra crianças e adolescentes. Brasília: Ministério da Mulher; 2018/2019
-
10Tiyyagura G, Beucher M, Bechtel K. Nonaccidental Injury in Pediatric Patients: Detection, Evaluation, and Treatment. Pediatr Emerg Med Pract 2017;14(07):1-32
-
11Berthold O, Frericks B, John T, Clemens V, Fegert JM, Moers AV. Abuse as a cause of childhood fractures. Dtsch Arztebl Int 2018; 115(46):769-775
-
12Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2016;89(1061):20150822
-
13Cheong VS, Karunaratne A, Amis AA, Bull AMJ. Strain rate dependency of fractures of immature bone. J Mech Behav Biomed Mater 2017;66:68-76
-
14Jauregui JJ, Perfetti DC, Cautela FS, Frumberg DB, Naziri Q, Paulino CB. Spine Injuries in Child Abuse. J Pediatr Orthop 2019;39(02): 85-89
-
15Pascolat G, Santos CdeF, Campos EC, Busato D, Marinho DH, Valdez LC. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J) 2001;77(01):35-40
-
16Álvarez ID, Latorre IBM, Méndez ÉV El papel del radiólogo ante el niño maltratado. Protocolo de imagen y diagnóstico diferencial. Radiología 2016;58(Supl 2):119-128
-
17Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of abuse among young children with rib fractures: A systematic review. Pediatr Emerg Care 2019;35(02):96-103
-
18Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. Child Abuse Negl 2018;76:237-249
-
19Flynn JM, Skaggs Dl, Waters PM. Rockwood and Wilkins’ fractures in children. 9th ed. Philadelphia:: Wolters Kluwer; 2020
-
20Lavin LR, Penrod CH, Estrada CM, et al. Fractures in the Pediatric Emergency Department: Are We Considering Abuse? Clin Pediatr (Phila) 2018;57(10):1161-1167
-
21Brasil. Ministério da Saúde. Análise epidemiológica da violência sexual contra crianças e adolescentes no Brasil, 2011 a 2017. Bol Epidemiol 2018;49:1-17
-
22Nguyen A, Hart R. Imaging of non-accidental injury; what is clinical best practice? J Med Radiat Sci 2018;65(02):123-130
-
23Luna GL, Ferreira RC, Vieira LJ. Notificação de maus-tratos em crianças e adolescentes por profissionais da Equipe Saúde da Família. Cien Saude Colet 2010;15(02):481-491. Doi: 10.1590/S1413-81232010000200025
» https://doi.org/10.1590/S1413-81232010000200025 -
24Krug EG, Dahlberg LL, Mercy JÁ, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002. Available at: https://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2019/04/14142032-relatorio-mundial-sobre-violencia-e-saude.pdf
» https://portaldeboaspraticas.iff.fiocruz.br/wp-content/uploads/2019/04/14142032-relatorio-mundial-sobre-violencia-e-saude.pdf -
25Brasil. Portaria n° 1.968/GM/MS, de 25 de outubro de 2001. Dispõe sobre a notificação, às autoridades competentes, de casos de suspeita ou de confirmação de maus-tratos contra crianças e adolescentes atendidos nas entidades do Sistema Único de Saúde. Diário Oficial da República Federativa do Brasil, Brasília, n. 206, Seção 1, p. 86. Available at: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt1968_25_10_2001_rep.html
» https://bvsms.saude.gov.br/bvs/saudelegis/gm/2001/prt1968_25_10_2001_rep.html -
26Platt VB, Back IC, Hauschild DB, Guedert JM. Violência sexual contra crianças: autores, vítimas e consequências. Cien Saude Colet 2018;23(04):1019-1031
-
27Brasil. Lei n° 13.010, de 26 de junho de 2014. Altera a Lei no 8.069, de 13 de julho de 1990 (Estatuto da Criança e do Adolescente), para estabelecer o direito da criança edo adolescente de serem educados e cuidados sem o uso de castigos físicos ou de tratamento cruel ou degradante, e altera a Lei no 9.394, de 20 de dezembro de 1996. Brasília: Imprensa Nacional, 27 jun. 2014. n. 121, Seção 1, p. 2. Available at: https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/30057416/do1-2014-06-27-lei-n-13-010-de-26-de-junho-de-2014-30057411
» https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/30057416/do1-2014-06-27-lei-n-13-010-de-26-de-junho-de-2014-30057411 -
28Brasil. Câmara dos Deputados. Estatuto da criança e do adolescente: Lei n. 8.069, de 13 de julho de 1990, e legislação correlata. 9. ed. Brasília: Câmara dos Deputados, Edições Câmara, 2012. 207 p. (Série legislação; n. 83). Available at: http://bd.camara.leg.br/bd/bitstream/handle/bdcamara/18403/estatuto_crianca_adolescente_9ed.pdf?sequence=10
» http://bd.camara.leg.br/bd/bitstream/handle/bdcamara/18403/estatuto_crianca_adolescente_9ed.pdf?sequence=10 -
29Brasil. Brazilian Traffic Code ([Código Brasileiro de Trânsito] CONTRAN). Law no. Article 64 of April 12, 2021. Available at: https://www.ctbdigital.com.br/artigo/art64
» https://www.ctbdigital.com.br/artigo/art64
Publication Dates
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Publication in this collection
17 June 2024 -
Date of issue
2024
History
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Received
04 July 2023 -
Accepted
19 Sept 2023