~LIST TOPICS~

*CHILD ABUSE

*EARLY PREGNANCY

*POVERTY

* DRUG USE

*CLEANLINESS

I choose the topic “CHILD ABUSE”

~INTRODUCTION~

*Child maltreatment is a devastating social problem in American society in 1990 ,over 2 million

cases 0f child abuse and neglect were reported to social service agencies. In the period 1979

through 1988, about 2000 child deaths (ages 0-17) were recorded annually as a result of abuse

and neglect (McClain et al ,1993) ,and an additional 160,000 cases resulted serious injuries

provide in 1990 alone (DARO and McCurdy ,1991) .However tragic and sensational the counts

of deaths and serious injuries provide limited insight into the pervasive long term

social,behavioral and cognitive consequences of child abuse and neglect . Reports of child

maltreatment alone also reveal little about the interactions among individuals ,families,

communities ,and,society that lead to such incidents .

American society has not yet recognized the complex origins or the profound consequences of

child victimization . The services required for children who have been abused or neglected
,including medical care ,family counseling ,faster care, and specialized educationare expensive

and are often subsidized by government funds. The general accounting office (1991) has

estimated that these services cost more than $500 million annually .Equally disturbing ,research

suggest that child maltreatment cases are highly related to social problems such as juvenile

delequency ,substance abuse,and violence, which require additional services and severely

affect the quality of life for many American families .

*SCOPE AND DELIMITATION*

“Child abuse is something takes place in the world ,like GREGORIO and MERCITA they are

desperate to have a kid ,the two jerks are decided to make a child and they named MARIE .The

parents love that MARIE`s need , which is caring and understanding ,but instead they decided

to beat MARIE , abuse her mentally , and in some cases even sexually”

“Scarring thje child for life , because they decided that it was fun to mabuse on an innocent

child that all they wanted was love not to be hated or abused.”

“The causes why the parents abused their child is when they didn`t have a money /financial

problem ,family problem , and being a patientless parents.”

“So that MARIE experience those abusement and she also have trauma that her parents do to

her.”

“(National Society for the Prevention of Cruelty to Children) roles and responsibilities : Provides

support for childen and families in situations such as domestic violence .”

*JUSIFICATIION*

-I choose this topic(CHILD ABUSE) because these is the one or major issue in our society .Child

hood emotional maltreatment an later psychological distress among college students the

mediating role of maladaptive schemas .The abuse child:victim, imstigat0r ,or innocent

bystander .The abusing parent:revisited a decade of psychological research.

*BENEFITS AND BENEFICIARIES*

- Child abuse network provides a collaborative and non- duplicated interagency approach to

process and investigate child abuse cases .The centralized,team approach is designed from the

childs point of view tohel minimize the trauma opf child abuse investigation and promote the

healing process.

- The beneficiaries of child abuse is the DC childrens advocacy center, the DC volunteer lawyers

project the family leadership school.

*GENERAL OR MOTHER QUESTIONS *

~What is research on child maltreatment is currently undervalued and undeveloped?

-Research in the field of child maltreatment studies is relatively undeveloped when compared

with related fields such as child development ,social welfare, and criminal violence.
*FIVE QUESTIONS\ SUB-PROBLEMS *

1. How many cases of child abuse and neglect was reported top social service?

2. Where is not yet recognized the complex origins of the profound consequences of child

victimization?

3. When are the general accounting office has estimated that these services cost more than

$500 million annually?

4. A disturbing number of recent nt reports have concluded that American children in trouble ?

5. When are the first child abuse prevention and treatment act?

*HYPOTHESIS*

~ALTERNATIVES~

-Community partnership for protecting children initiative center for the study 0f social policy

.Describes a community child protection initiative , including underlying principles ,key

strategies and evaluation results.

-Differential response approach in child protective services:

An analysis of state legislative

Provisions (PDF-462 KB) .

National quality improvement center on differential response in child protective services(2010)

Provides a statutory analysis of the 10 major provisions identified in differential response

legislative enactments 14 states .

~NULL~

-Descriptive statistics, including weighted frequencies and means, are tabulated .Multivariate,

ordered logistic regression analyses are conducted using maximum likelihood estimation

techniques is stata/SE 9.2 statistical software.

-Descriptive statistics for the entire sample and for adult IPV perpetrators and victims are

presented in Table 1 . Greater proportions of young adult IPV perpetrators and victims report

experiencing child abuse and adolescent dating violence as compared to the entire sample.

ABSTRACT

Non-accidental injuries in children are an important cause of morbidity and

mortality in this population. Fractures are the second most common clinical

manifestation of child abuse. The fracture of the femur is associated in more than

60% of child abuse in children younger than 3 years. The objective was to review

the literature on child abuse in the major databases and report a rare case of

bilateral subtro chanteric femur fractures associated with unilaterally humeral

fracture in a 28-day newborn. The orthopedic surgeon is often the first physician to

evaluate these children, so a high degree of suspicion, and a physical examination

and a detailed clinical history is mandatory when evaluating a newborn with

musculoskeletal injuries.
Key words: Femoral fractures; Humeral fracture; Child abuse

INTRODUCTION

Greater rising of awareness of child abuse has contributed towards better

understanding of this complex problem. It has been estimated that the annual

incidence of abuse is between 15 and 40 cases per 1,000 children. Thus,

approximately one million children become victims every year and more than 1,200

die as a result of abuse.1

Despite the severity of the problem, it is highly prevalent. In a systematic review

on 32 studies, Kemp et al.2,3concluded that abuse was more common among

children under the age of three years, and that multiple fractures were also more

common among children who suffered abuse.

In Brazil, no data on the incidence of child abuse has been established. However,

according to Ruaro et al.,4recent studies show that among every 1,000 children, ten

are victims of abuse and that of these, 2% to 3% die. Thus, the incidence of

mortality is similar to that due to leukemia. The literature on abuse among

newborns is sparse and there are few studies on children under the age of one

year.

Fractures are the second commonest presentation of this condition and orthopedists

are often the first physician to evaluate these children.5 The objectives of this study

were to conduct a review of the literature on this topic and report on a case, never

previously reported in the literature, of a 27-day-old newborn who was a victim of

abuse, with bilateral subtrochanteric femoral fractures and a unilateral humeral

fracture, and to conduct a review of the literature on this topic.

METHOD

An investigation was conducted in the main databases (Lilacs, Pubmed and

Embase) using the following descriptors: non-accidental injury, child abuse, child

neglect, femoral fractures and humeral fractures.

The inclusion criteria were that the article needed to have been published within the

last 12 years, in the Portuguese, English or Spanish languages, or that they were

regarded as classic studies on the topic. Systematic reviews with and without meta-

analyses were also included. Studies that did not fulfill these criteria were

automatically excluded.

RESULTS

The initial search found 70 studies, which were selected according to their title, in

order to read the abstracts. From this reading, 23 studies that met the inclusion

criteria were selected for reading in full and for discussion of the proposed

objective.

CASE REPORT

A 27-day-old newborn was admitted to hospital accompanied by a young mother of

16 years of age, with a history of fever associated with productive coughing, and
without any other disorders, according to the mother's report. The case was initially

attended by the pediatrics team, who diagnosed pneumonia with criteria of

respiratory insufficiency. The newborn was hospitalized and received antibiotic

therapy in association with noninvasive ventilatory support. In talking with the

mother, it could be seen that she was giving a confused story, without causal links

and inconsistent with the patient's clinical condition. At this time during the

consultation, the mother denied that the child had suffered any traumatic event,

alleging that she had been close to the child at all times. The hospital's social

assistance team was put into action and, concomitantly, the guardianship council.

On the fourth day of hospitalization, the orthopedic team was asked to provide an

interdisciplinary consultation regarding the child's case, because of bilateral edema

on the thighs and because the child was crying a lot if its legs were manipulated.

After detailed orthopedic examination, with imaging examinations, it was

determined that the child presented bilateral subtrochanteric femoral fractures

associated with a unilateral humeral fracture in the left arm (Figs. 1and 2), without

any neurological and vascular deficits in the limbs. There were no cutaneous and/or

ocular lesions. On this day, the mother reported that the child had fallen to the floor

in the bathroom and its legs had hit the edge of the bath, thus contradicting her

story at the time of hospital admission. The father had not been located.

Fig. 1 Radiograph at the time of admission.

Fig. 2 Humeral fracture at the time of admission.

A small plaster-cast splint was immediately applied to the left arm, extending from

the axilla to the palm, and bilateral skin traction was applied to the legs, since the

pediatric team asked for any procedure under anesthesia at that moment to be

postponed until the child's infectious and respiratory conditions had stabilized.

Over this period, serum samples were collected for tests and metabolic and

congenital diseases were investigated. All pathological conditions that form

differential diagnoses with child abuse, such as ontogenesis imperfect, were ruled

out.

On the seventh day of hospital stay, the child was subjected to bilateral plaster-cast

immobilization from the chest to the malleolus, under sedation and analgesia, in the

surgical center.

The child was kept immobilized in the plaster cast for three weeks. The femoral and

humeral immobilizations were removed when it was seen that there was no longer

any crepitation at the foci of the fractures and a voluminous bone callus had formed

bilaterally in the femurs and in the humerus (Figs. 3 and 4). At this time, the

patient was no longer on antibiotic therapy and presented normal pulmonary

functions.

Fig. 3 Radiograph of the arm at the age of three weeks.

Fig. 4 Radiograph of the femurs at the age of three weeks.

The child remained hospitalized for a further week, because of the social problems

and then, after release, was taken to a shelter institution for children abandoned by

their parents.

The child was brought to the outpatient clinic in the second, fourth and sixth

months (Figs. 5, 6, 7 and 8), for follow-up consultations, through which it could be

seen that the child was completely healthy, without anisomelia and/or associated

deformities (Fig. 9). From control radiographs, satisfactory evolution of both the

femoral and humeral bone consolidation was observed.

Fig. 5 Radiograph at the age of two months.

Fig. 6 Radiograph at the age of four months.

Fig. 7 Radiograph of the proximal femur at the age of six months.

Fig. 8 Radiograph of the humorous at the age of six months.

Fig. 9 Photograph at the age of six months, showing absence of anisomelia or significant

deformities.

Currently, the legal procedures for guardianship of the child are underway and a

court hearing to decide on guardianship is awaited.

DISCUSSION

In 1946, Caffey6,7 described an association between subdural hematomas and

fractures of long bones in infants. In a subsequent report, he confirmed that this

process was due to physical abuse. In 1961, the American Academy of Pediatrics

established the expression "battered child", defined as a child who had suffered

non-accidental injuries as a result of attitudes or omissions by its parents or other

adults responsible for the child.8Legally, children are considered to be individuals up

to but not completing 12 years of age and adolescents are considered to be

between 12 and 18 years of age.9

Child abuse can be defined as any action or omission by the adult caregiver or older

adolescent that might result in damage to the child's physical, emotional,

intellectual, moral or social development of the child or adolescent. It can be

classified into four types: physical, emotional (psychological), sexual and neglectful

(negligence through omission or abandonment).10 In 2001, the Brazilian Ministry of

Health determined that notification of any form of violence against children and

adolescents would be mandatory for all healthcare professionals, and that failure to

do so would render the healthcare professional liable to a fine of three to twenty

reference salaries, with doubling of the fine in the event of recurrence.9 It should be

emphasized that in these cases the defense of violation of the duty of confidentiality

resulting from professional practice would be inapplicable, since this would be

communication required by law.4

Fractures are the second largest form of presentation after skin lesions, and

approximately one third of these presentations are seen by orthopedists at the

initial consultation.11 The pattern of non-accidental injuries consists mainly of

metaphyseal lesions, multiple fractures at different stages of consolidation,

fractures of posterior ribs and fractures of long bones in children under the age of

two years.12

Fractures of the long bones in very young children may represent one of the main

pieces of evidence of physical abuse.13 Femoral fractures are associated with abuse

syndrome in 60% of the cases affected children under the age of three years11 and

up to 85% among children under the age of one year.14,15 Bergamaschi et

al.16 studied 35 cases of children under the age of three years who had suffered

diaphyseal fractures of the femur. In 50% of the children reassessed, there were

indications of physical abuse and negligence, such as triggering of femoral

fractures. Anderson reported rates of suspected abuse of 79% and 83% among

children under the ages of two years and 13 months, respectively, when femoral

fractures were present.17 In the present case, the infant was 27 days of age on

admission to hospital, which led us to have a high degree of suspicion and

diagnostic certainty of close to 100%.

The signs suggestive of child abuse include the presence of multiple acute lesions

(ecchymosis, hematoma, excoriation, bites, burns and edema of soft tissues),

previous history of abuse, subdural hematoma, behavioral alterations, presence of

multiple fractures (especially in the femur, tibia and humerus) and/or fractures at

various stages of healing. However, fractures alone frequently occur.18 In the case

reported here, the newborn presented multiple fractures, but all of them were in

the acute phase and there were no skin lesions or subdural hematomas.
According to Pfeiffer, a clinical history or physical examination demonstrating signs

of frequent lesions that are said to be accidental and an unexplainable delay

between the "accident" and seeking medical care are general signs suggestive of

physical abuse.19 In our case, the mother only sought medical care because of the

condition of respiratory insufficiency and fever that the child presented, which led

us to believe that the trauma had occurred some days before the time of hospital

admission.

Dalton et al.11 showed that orthopedists are the main investigators (in absolute

numbers) of physical abuse among children with femoral fractures, followed by

pediatricians. In the present case, the newborn was initially attended by a

pediatrician because of the respiratory condition and secondarily by an orthopedist,

who diagnosed the fractures that led to the suspicion of abuse.

Pandya et al.5,10 studied 1,485 children who were victims of abuse or accidental

trauma. They came to the conclusion that patients under the age of 18 months who

presented fractures of the ribs, tibia, humerus or femur were more likely to have

suffered abuse, while those over the age of 18 months with fractures of the long

bones (femur and humerus) presented greater likelihood of having suffered

accidental trauma. Lane et al.20 reported that black children had higher rates of

non-accidental lesions than did white children of the same age group, but also

reported that those children were more likely to the evaluated and registered due

to suspicion of abuse, thus showing that ethnic difference exist in assessment and

communication of pediatric fractures due to child abuse.20In the case presented

here, the mother and the newborn were not black.

In a systematic review on 32 studies, Kemp et al.21 concluded that fractures

resulting from abuse were more common among children under the age of three

years, and that multiple fractures were also more common in the group of children

who had suffered abuse. They reported that fractured ribs were most likely to result

from child abuse (0.71, with 95% CI of 0.42 to 0.91), and that the likelihood of

humeral fractures resulting from abuse was 0.54 (0.20 to 0.88) and that of femoral

fractures was 0.43 (0.32 to 0.54). They came to the conclusion that during

evaluations on individual fractures, the site, the type of fracture and the child's

developmental stage could help in diagnosing abuse.

Gholve et al.22 reported on a rare case of femoral neck fracture in a three-year-old

girl. They stated that these fractures account for 46% of the fractures of the

proximal femur, but that they account for only 1% of the fractures in children.

Jones et al.12 reported on two cases of growth plate lesions in the proximal femur,

in children who had been victims of abuse, and they drew attention to the need to

think of the possibility that these lesions could be a consequence of abuse, despite

the diagnostic difficulties, given that the center of ossification of the femoral head

appears at the age of four months. Thus, this type of fracture in this age group

should signal that this lesion is not accidental, as in our case.

In diagnosing battered child syndrome, physicians need to be cautious and make

differential diagnoses, particularly with the following pathological conditions:

osteogenesis imperfecta, congenital insensitivity to pain, scurvy, congenital syphilis,

Caffey's disease, multiple fractures of severe rickets, hypophosphatemia, leukemia,

metatarsal neuroblastoma, sequelae of osteomyelitis and septic arthritis.3,18,23-25 In

the case presented here, all of the abovementioned possibilities were ruled out.

Prasad et al.26 demonstrated that children who were victims of abuse presented

worse cognitive function and deficits in motor skills, expression and language

reception during their growth. Healthcare professionals therefore have a social

commitment towards detecting and notifying suspected cases of child abuse, and

should be prepared to identify it. The case presented here has only evolved for 18

months, but apparently does not present any developmental deficit.

Puerperal psychosis is a state of delirium that is frequently hallucinatory, severe

and acute. It appears between the second day after delivery and three months

afterwards, at the frequency of one or two deliveries in every 1,000, and more

often affects primiparous and single mothers. This psychosis does not present any

relationship with the mother's age or with her color.27 In the present case, the

mother was within the period of occurrence of puerperal psychosis; the child was

her first and the father was not present. The mother was sent to the hospital's

psychiatry department for investigation and possible treatment.

It is known that approximately 50% of the children who are victims of physical

abuse who return home are subsequently beaten again. Of these, 20% end up

dying. Therefore, there needs to be a high degree of suspicion in attending children

with fractures or skin lesions that are poorly explained by the trauma mechanism,

like in the present case report, given than there is no pathognomonic fracture in

child abuse cases.20 Physicians who suspect that a case is one of child abuse should

immediately communicate this to one of the following three bodies: the

guardianship council, a police station or the public attorney's office. All of these

institutions have the duty to safeguard and defend the rights of children and

juveniles.

CONCLUSION

Child abuse should always be borne in mind as a differential diagnosis among

children who present fractures that are poorly explained by trauma mechanisms,

particularly femoral fractures in children who cannot yet walk. The present article

reported a rare presentation of this condition; around 30% of such cases are

presented to orthopedists initially. These cases need to be managed by a

multidisciplinary team because of the high risk of recurrence of possible death

among these children.

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1. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop

Surg. 2000;8(1):10-20. [ Links ]

2. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. Landmark

article July 7, 1962: The battered-child syndrome. By C. Henry Kempe, Frederic N.

Silverman, Brandt F. Steele, William Droegemueller, and Henry K. Silver. JAMA.

1984;251(24):3288-94. [ Links ]

3. Kempe CH. Uncommon manifestations of the battered child syndrome. Am J Dis

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4. Ruaro AF MT, Aguilar JAG, Hellu JJ, Custódio MD. Síndrome da criança

espancada. Aspectos legais e cínicos - Relato de um caso. Rev Bras Ortop.

1997;32(10):835-8. [ Links ]

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fractures: child abuse or bone disease? A systematic review. Clin Orthop Relat Res.

2011;469(3):805-12. [ Links ]

6. Caffey J. Multiple fractures in the long bones of infants suffering from chronic

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1990;144(8):875-8. [ Links ]
12. Jones JC, Feldman KW, Bruckner JD. Child abuse in infants with proximal

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Orthop. 2000;20(3):411-3. [ Links ]

14. Schwend RM, Werth C, Johnston A. Femur shaft fractures in toddlers and young

children: rarely from child abuse. J Pediatr Orthop. 2000;20(4):475-81. [ Links ]

15. Forlin E. Maus-tratos na infância e adolescência. Programa de Atualização em

Traumatologia e Ortopedia (Proato) Porto Alegre: Artmed/Panamericana Editora;

2004. [ Links ]

16. Bergamaschi J, Alcântara T, Santili C, Braga S, Waisberg G, Akkar M. Femoral

diaphyseal fractures: an assesmente in children younger than 3 years old. Rev Bras

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18. Dos Santos LM, Stewart G, Meert K, Rosenberg NM. Soft tissue swelling with

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[monogragia]. Curitiba: PUC-PR; 2000. [ Links ]

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21. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K, et al. Patterns of

skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518. Epub

Oct 2008. [ Links ]

22. Gholve P, Arkader A, Gaugler R, Wells L. Femoral neck fracture as an atypical

presentation of child abuse. Orthopedics. 2008;31(3):271. [ Links ]

23. Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the distinction

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1993;45(2):187-92. [ Links ]

24. Paterson CR, McAllion SJ. Osteogenesis imperfecta in the differential diagnosis

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25. Kratz CP, Schweiger B, Kemperdick H, Gobel U. Childhood multifocal skeletal

non-Hodgkin lymphoma is a differential diagnosis of battered child syndrome.

Pediatr Hematol Oncol. 2003;20(8):575-7. [ Links ]

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27. Maldonado MT. Psicologia da gravidez. São Paulo: Saraiva; 2000. [ Links ]

Received: December 03, 2011; Accepted: March 12, 2012

*IN- TEXT CITATION*

CHRISTIAN CW :JAMA .2002 288(13):1603-9

Clin or thop relat res. 2011,469(3);755-8

Kempe CH. 1975 ; 129 (11)1265

Kocher Ms ,KASSER JR. 2000 ; 8(1): 10- 20

Kratz CP Pediatr Hematol ONCOL 2003 ;20 (8) :575-7

Maldonado MT .Kramar LA , Saraiva ;2000

Paterson CR 1989; 299(6713) 1451-4

Prasad Mr. Kramar LA Child . 2005 ;908(1) :82-5

Ruaro AF MT , Aguilar JAG ,Custudio MD 1997 ;32 (10):835-8

William Droegemulier 1984; 251 (24)3288-94

 “REQUIREMENT
IN
RESEARCH FOR LIFE
1 AND 2”

SUBMITTED BY:

JOYLINE T. GUILLERMO

student

SUBMITTED TO:

Mr. Rolando p. sorita

Subject teacher