Children hospitalized due to maltreatment in the ICU of a Public Health Service

ABSRACT Objective: to characterize children hospitalized due to violence in a pediatric ICU in 2011; to relate violence and the mechanisms of trauma with death; to know the contextualization of violence, from the records in the medical records. Method: retrospective cohort, performed in a fi rst aid hospital, Porto Alegre city, in the records of 22 children hospitalized in the ICU due to violence. Quantitative analysis was performed by absolute and relative frequency rates, chi-square and relative risk. Results: 54.5% were boys, 81.8% were white and 50% were up to three years old. Physical violence 50% and neglect 36.4%, family of children (77.3%), highlighting the mother (35.3%). Mechanisms of aggression: fall (22.7%), burns (18.2%). Burns were at high risk for death. Discharge to go home after ICU admission (59.1%). Conclusion: It is considered that the characterization of the cases of violence refl ects the complexity of the theme, mainly, in face of the life histories that surround each case of children hospitalized by this aggravation. Descriptors: Violence; Children; Intensive Care Units; Nursing; Public Health.


INTRODUCTION
This study is part of a research project of the Nursing course of the University of the Sinos River Valley "Children Hospitalized due to Maltreatment in the ICU of a Public Health Service: the nursing team facing the problem".
It is estimated that 10% of children arriving at an emergency health facility are maltreated, mostly at home, hidden and repetitive.Almost 3,500 children die worldwide each year from physical maltreatment and neglect (1)(2) .This is a current and extremely important issue, which is assuming alarming proportions, becoming a serious public health problem (3) .It is noteworthy that the Centro de Referência no Atendimento Infanto-Juvenil (Reference Center for Child and Adolescent Care) in Porto Alegre city recorded a 25% increase in cases of aggression against children and adolescents up to October 2013 (4) .
The Statute of the Child and Adolescent in article 5 provides that "no child or adolescent shall be subjected to any form of neglect, discrimination, exploitation, violence, cruelty and oppression, punished in the manner prescribed by law by any act or omission of his or her fundamental rights" (5) .However, a "wall of silence" usually arises around cases of violence, which results in psychological, emotional and social harm to these victims.In addition, reporting of cases of violence against children is still in deficit, making it difficult to see the extent of the problem (3) .
This violence can occur under different manifestations, in different social groups, such as schools, institutions, among others.However, the highest concentration of cases of aggression occurs in the home itself, where the relationship of power and hierarchy between adults and children is very strong (6) .The main types of violence are physical, sexual, psychological and neglect.These can also occur concomitantly and, in addition to the specific damages of each aggression, added or isolated, cause psychological effects of difficult reversion (7) .It is emphasized "regardless of the presentation form, violence has consequences that will reflect on the development of children from the physical, social, behavioral, emotional and cognitive spheres" (8) .
The relevance of the study is that health professionals who care for children who are victims of violence must be prepared to care for this child and the family that accompanies them.They require individual and integral care by the nursing team, which in addition to treating the lesions, involves the various emotional damages (1) .For this, to know the variables that interfere in this context, can subsidize health professionals in the provision of qualified care to this population.
This study is based on hospitalizations of children in a pediatric intensive care unit (ICU) referring to trauma, from a first aid hospital in Porto Alegre city.It should be emphasized that the indication of hospitalization of the child in an ICU is due to the severity of the physical injuries caused by aggression and/or neglect.Therefore, it is considered this context justifies the importance of the study.
The question of research was constituted by the following question: "what is the characterization of children hospitalized in an ICU, due to aggravations caused by aggression and/or neglect?".

Ethical aspects
The research project followed the norms advocated by Resolution 466/2012 (9) and was approved by the Ethics and Research Committee of the Porto Alegre Municipal Government.

Design, place of study and period
This is a retrospective cohort study performed at the Pediatric ICU of a Hospital de Pronto Socorro de Porto Alegre, an emergency hospital which is reference in trauma care.The study period refers to the year 2011.

Population or sample, inclusion and exclusion criteria
All children up to the age of 12, hospitalized for some type of violence, were included in the year 2011.Data collection was done in the medical records.In the study period, 263 children were hospitalized in this ICU.Initially, 139 participants were excluded because the reasons for hospitalization and the trauma mechanism were not related to the study theme.124 medical records were analyzed, whose reasons for hospitalization indicated the possibility of having been victims of aggression/neglect, such as burns, firearm aggression, among others.Thus, from the records of the medical records, 22 cases of children hospitalized for aggression/neglect were identified.

Study protocol
Data were accessed from a registry system in the unit, in which are inserted data regarding each hospitalization of child assisted.Data were collected using the following variables: age, gender, race/color, place of origin, aggressor, type of violence, place of injuries, aggression mechanism and outcome of hospitalization.We also analyzed the records of health professionals to contextualize the situation of violence that motivated the hospitalization of the child in the ICU.

Results analysis and statistics
Data were organized into an excel spreadsheet and analyzed using the Epi-Info software version 3.4.2and Statistical Package for the Social Sciences SPSS v 22.For the analysis, descriptive statistics were used and the absolute and relative frequencies were calculated.The contextualization of the situation of violence, which motivated the hospitalization, was rescued in the registries and categorized according to the types of violence.

RESULTS
The results will be presented, first, regarding the characterization of children hospitalized as a result of some type of violence in the pediatric ICU under study, in 2011.The contextualization of the violence suffered by children will be presented from the medical records.

Characterization of children hospitalized in a Pediatric Trauma Unit due to violence
In the Pediatric Trauma ICU of the hospital under study, from January to December 2011, 22 children aged between zero and 12 years were hospitalized due to some type of violence.The mean length of hospital stay was 15 days.Tables 1, 2 and 3 present the distribution of participants as to gender, race/ethnicity, age bracket and place of origin; as to the aggressor, type of violence, mechanism of aggression and place of injury; and regarding the type of violence, age bracket and outcome.
It should be noted that in most medical records there was no complete address information, including the neighborhood.Thus, the cities were categorized by regions, among which the metropolitan was the most frequent.The hospital chosen to carry out the study is a reference in trauma care in the capital and metropolitan region, which justifies the demand for more than 85% of the cases coming from these regions.
Regarding the author of the aggression, it is noteworthy that in 77.3% of the cases a relative of the child practiced the violence.Of these, the mother represented 35.3% of the cases; however, when associated with the father or stepfather of the victim, the percentage increases to 58.8%.
In most hospitalizations, physical aggression and neglect were the most frequent types of violence.Of the eight cases of negligent hospitalization, two were children younger than one year of age and six cases of children between the ages of one and three.
In the data of Table 3, regarding the outcome of care, the case characterized as "other" refers to a referral to the Guardianship Council, carried out by the Social Work, described below, in Contextualization of Violence.It should be noted that, among the trauma mechanisms observed, the burn presents a high risk of death RR = 5.0 (95% CI 2.0 -12.32), but there was no relation between the cases of violence and the risk of death RR = 0.33 (95% CI 0.042-2.71).

Contextualization of violence
In the analysis of medical records, it was possible to contextualize violence, based on the records of health professionals, carried out mainly by the psychology and social service team.
It was possible to identify that the aggressor, in most cases, was a family member of the victim.In this context, the case of a one-year-old child, victim of beatings and maltreatment, with hematoma and bruises on the face and burn on the back of the hand, whose aggressor was the mother herself, stands out.According to records of Psychology, the child was taken to the service by an ambulance driven by neighbors, who witnessed the violence.The mother of the child is HIV positive, presenting depression without treatment, besides being an alcoholic.
In another situation, the child was one year and eight months old, hospitalized with traumatic brain injury, due to physical aggression.From his mother's account, the son fell out of the tub during the bath while he was in the care of his stepfather, but denied the possibility of aggression.However, the severity of the lesions did not correspond to the history described by the mother.The records also report that the neighbor's mistreatment was reported, without specifying where and how the information was obtained.The social service was activated and sent a request for an opinion to the guardianship council.
As for the type of neglect violence, common in many cases, there is a record in the medical record of a one-year-old child with second-degree burns on 13% of the body surface in the perineum and root regions of the thighs.According to the Social Service, the mother reported that a charcoal ember fell on acetone and caught fire.In addition, Psychology and Social Work describe in their evolution that the child was not registered in a registry and that the case is "obvious neglect" on the part of the mother.
The fall was the most frequent mechanism of aggression.The contextualization of this type of aggression is reported in the medical record of a child with traumatic brain injury.On record there was information that the mother left the three-month-old child on the edge of the bed while using the computer.The mother went to the health service two days later when he noticed a "lump" in the child's head.
In the medical record of a seven-year-old child with severe head trauma, due to the fall of a cart, there was the report of laceration of the hymen; however, the mother and stepfather denied aggression.The girl's father said that the stepfather runs the car without any care and reports that he suspects the way he and the child's mother described the accident.
In the records of the medical record of a two-yearold child, whose hospitalization was due to burns, there were reports of lesions on the face, scalp and elbows.The Psychology Service reported that the child was taken to the hospital by her stepfather, with a history of hot water burn from the shower.However, the patient told the nursing technician that her stepfather with hot water had beaten her and that she had put her under the shower.The mother said she "fought with her mate" the morning of the incident.The family already has two children fulfilling socio-educational measure and responds to the tutelary council for not enrolling the children in the school.The team realizes that the mother is aggressive with the child in the hospital itself (tell him to shut up, shake, swear).When the child was transferred to another hospital, the Guardianship Council required follow-up by another relative because the mother was not authorized.The stepfather was cold with the situation, and his mother was dull and vulnerable.
Among the cases of aggression in more than one region of the body, there is a medical record of a child with 70% burnt body surface, was one year old and died after 39 days of ICU admission.In this medical record, there was information that the patient was found by her father trapped in the stroller with the house on fire.The Psychology team reported that the mother had inappropriate posture, anxious and impulsive profile.In addition, during the interview there were moments of unrest and anger.The records also report that the parents were 23 years of age and showed little affection with the child during the ICU daughter's follow-up.
In one case that resulted in the death of a 12-year-old child, according to records, the child had been the victim of attempted rape.He had severe head trauma, occipital hematoma and anal laceration.Her family found her unconscious in a jungle.The aggressor was unknown.
In the outcome of care, the case characterized as others, refers to a referral from the Social Service of the institution to the Guardianship Council.The reason for the hospitalization of this child of three months of age was fall.According to the medical record, "the mother of the child does not present Children hospitalized due to maltreatment in the ICU of a Public Health Service Santomé LM, Leal SMC, Mancia JR, Gomes AMF.criticism of the situation".The Public Ministry and Guardianship Council were notified.When questioned about previous hospitalization, also motivated by a fall, the mother claimed that stepfather "threw" boy up and knocked him to the ground.

DISCUSSION
In relation to the age bracket of the child, the highest frequency is between one and three years.This information corroborates the research carried out in the emergency room of the Clinics Hospital of Campinas, with children and adolescents, which identified the majority of cases of violence at ages in which the victim has a lower capacity for self-defense (3) .
In the characterization by gender, there were no differentiations; however, males accounted for 54.5%, as well as the results of similar studies, in which boys are the main victims of violence (10)(11) .However, a study that analyzed the profile of emergency care due to accidents and violence involving children younger than 10 in Brazil, pointed out that in cases of violence, boys were the most frequent, except in the 2-5 year age range in which girls accounted for 59.3% (12) .In another Brazilian study, in which the victims of sexual violence were exclusively characterized, the female gender was the most affected, in a proportion of 2.9 girls for each boy (13) .These results corroborate a study carried out in the Surveillance System of Violence and Accidents, Bahia State, which analyzed the reports of infantile-juvenile violence.In which, the female gender represented 79.8% of the reports of sexual violence, mainly in childhood, with occurrence in the households, perpetrated by a relative and a known male gender (14) .Considering that sexual violence still remains veiled and restricted to the family sphere, researchers suggest the "construction of a training plan on violence and, in particular, on sexual violence, dealing with ways to identify and act in these situations" (15) , in especially in health services.
The greater frequency of white race/ethnicity can be explained by the percentage of 79.2% of the self-declared white population of the city of Porto Alegre (16) .Regarding the author of the aggression, it is noteworthy that in 77.3% of the cases a relative of the child practiced the violence.Of these, the mother represented 35.3% of the cases and when associated with the father or stepfather of the victim, the percentage increases to 58.8%.These data corroborate with published studies (17) , in which the authors show that aggressors are mostly the birth parents (50%), followed by others as foster parents (12%) and stepparents (12.5%).These results show the disruption of the family support system of these children and the compromise in their parents' connivance.Other studies (6) also indicate the home environment as the place where most of the violent events took place, occupying 55.1% of the places of occurrence described in their research, which also included the public highway, school and others; also point out, the family environment as favorable for the occurrence of aggression and aggression against children.In the same way, a research (13) points out that, in addition to the proximity, which facilitates the approach, the trust that parents and stepfathers have to approach more and more, in an insidious process, without the child perceiving the abusive act of the adult.These data indicate, "Home is often not a safe place for children, since aggression can be practiced without the knowledge of society" (13) .The data corroborate with another study that characterized children victims of violence in the records of 322 bulletins of occurrence of the military police of the municipality of Alfenas, MG, in 2011.The results revealed that for 78% of the children the violence occurred in a domestic environment.Being that the mother was the main aggressor, representing 30.8% (18) .In this study, in the context of violence, the case report of a one-year-old child, victim of beating and mistreatment by the mother herself, reflects the seriousness of the situation, the insecurity of the home and the mother's participation in violent acts.
Researchers (17) point out that mothers are almost always present in homes where sexual violence occurs, and their connivance through silence is confirmed by results from other studies.The role of connivance that the mother assumes in the face of violence affirms that, in order to maintain security and stability, the mother agrees to the practice of aggression, not recognizing the violence, for revealing it would represent assuming the failure of her role as mother and wife (13) .In addition, concern about your relationship with the partner and family members after the complaint may justify silence on the part of the mother.In this study, in contextualization of violence, situations were identified in which the mother denied that the aggression had occurred, even after finding that the injuries were due to aggression/neglect.
Regarding the types of violence, it can be observed in Table 2 that physics is the one that occurs most frequently (40.9%).This fact can be explained by the fact that this is the most identified by health care services, considering the lesions and marks left by the aggressor (10) .In the present study, the others variable represented the percentage of 18.2% and refers to situations involving an association of more than one type of violence, totaling four cases: children victims of sexual violence associated with neglect; and the others involved physical violence associated with psychological, sexual and neglect.
In the medical records survey, cases of hospitalization for self-harm were also identified, "understood not only by acts characterized as suicide attempts, but also by risk behaviors" (1) .In this context, the reason for ICU admission was due to exogenous intoxication after ingestion of large quantities of Haloperidol, medication used by the child's father.
In the mechanisms of aggression, described in Table 2, the fall (22.7%) was the most frequent, caused in 80% by neglect, followed by burns (18.2%), also caused, for the most part, by this type of violence.According to the National Association of Emergency Medical Technicians (NAEMT) (19) , approximately 20% of all burns in children involve aggression or neglect.In addition, in this study, different trauma mechanisms were identified, such as hand gunshots, white weapons, various traumas, physical aggression and maltreatment.When employed more than one type of violence, there were associated firearm injuries, burns, falls and physical aggression.
Regarding the damaged area, the region surrounding the head and neck represented the percentage of 27.3%.However, Children hospitalized due to maltreatment in the ICU of a Public Health Service Santomé LM, Leal SMC, Mancia JR, Gomes AMF.
when associated with more than one body site, it accounted for 59.1%.Among the cases of aggression in more than one region of the body, there is a one-year-old child, who died after 39 days of hospitalization, who had suffered burns on 70% of body surface.The records of the health professionals describe the negligent attitude of the parents and this case was detailed in the contextualization of the violence.The consequences of violent acts or omissions create health damage, cause temporary or permanent traumas and disabilities.In addition, physical and emotional distress is often associated (10) .
In the relationship between the type of violence with the child's age bracket, it is emphasized that in most hospitalizations physical aggression and neglect were the most frequent types of violence.Of the eight cases of negligent hospitalization, two were children younger than one year of age and six of them between one and three years old.These findings are similar to those obtained in other studies (20) , in which neglect presented the highest number of cases, followed by physical violence; the most frequent form of neglect was the omission of care, with prevalence in children in the range of up to one year.This type of violence is described as "an omission in relation to the obligations of the family and society to promote the physical and emotional needs of a child" (17) .Physical neglect is defined as the deprivation of needs in medical care, food, shelter, and education (20) .Therefore, the consequences of this omission may be more evident in younger children, who are not able to address their needs, or to supplement them when they are not attended to by their parents.
Between seven and twelve years of age, physical violence represents a percentage of 50%, and in this same age bracket it is noted that, in 37.5% of cases, there was more than one type of violence associated.As, for example, in the case of the twelve-year-old girl, who died after suffering physical and sexual violence, as described in the contextualization of the cases.Physical violence is recorded in all age brackets and the number increases as the age progresses.It is perceived that violence becomes more visible as the child grows and, in addition to neglect, other types of associated violence, including physical violence, appear.The development and growth of children are proportional to the seriousness of the threats and corporal punishments on the part of those responsible, that is to say, as the age advances, the more serious the aggressions are (6) .
Regarding the outcome of hospitalizations of children in the ICU due to violence, the data in Table 3 indicate that 27.3% of hospitalizations evolved for hospitalization in low complexity units, or institution transfer.However, 9.1% of the cases were death, representing the severity of the injuries resulting from the violence.In a study about the profile of care for the victims of external causes, performed in emergency and emergency services of the SUS, most of the cases went up and a small proportion of cases were estimated, with a hospital stay or death outcome (6) .
In the case described in the contextualization of violence, in which the child suffered burns from hot water scalding, reported by the stepfather as an accident in the shower, the two-year-old girl herself told the true cause of the injuries to the nursing team.This case reinforces the importance of investigating the reports of those responsible and understanding the mechanism of trauma, thus facilitating the identification of situations of aggression and/or neglect.It also reflects the need to prepare Nursing for the care of violence victims, since these professionals perform the first care and accompany the hospitalization and evolution of the child.
Professionals need to be qualified to attend hospitalizations for violence, in order to provide comprehensive care to individuals who seek assistance, because of this aggravation.However, it is important that the team assess their own posture and emotional readiness to address and discuss issues related to children violence (1) .The role of nurses in the promotion of nursing team qualifications is highlighted, in order to perform care in the context of the work in which they are inserted.The accomplishment of qualifications in order to equip the team for this type of service strengthens and encourages professionals to face this problem (1) .
However, in the collection of data for this research, it was identified that, in many cases, the nursing team did not record information about violence in patients' records, being restricted only to the description of the lesion and evolution of the condition that motivated the hospitalization.The main information that contextualized the cases attended by violence was the reports of the Social Work and Psychology.This makes it difficult to identify the size of the cases that arrive at the service, besides making it impossible to know about the nursing behaviors directed to each situation.
In general, it is the effect of the violent act on the body that takes the child to a health service, evidencing their fragility in the face of the situation (11) .It is important to reflect on the many violent acts to which the child may have been exposed, before their injuries provoke the need for care and stimulate the visibility of the problem.Results of a study that analyzed reports of violence against children and adolescents from January 2009 to May 2014 at a protection institution in the municipality of Rio Grande/RS and noted that the number of notifications made by the health sector was reduced, thus reinforcing the need for more effective and articulated actions" (20) .
In this perspective, "it is up to the professional to have a critical and sensitive view to analyze each situation, being fundamental a multidisciplinary approach" (11) .Being that the visibility and recognition of children in situations of violence, especially those served in the context of health services, contributes to subsidize the promotion of actions aimed at addressing the problem and the strengthening of public policies (17) .

Study limitations
The limitations of the study are mainly related to the contextualization of violence, considering that retrospective data were taken from records in the medical records.Thus, it is suggested that qualitative studies should be done in a way to broaden understanding of the phenomenon.

Contributions to the Nursing
We understand that the contribution of this type of study is of paramount importance to broaden the body of knowledge of the subject, as well as contribute to the institution of public policies focused on this problem.
Children hospitalized due to maltreatment in the ICU of a Public Health Service Santomé LM, Leal SMC, Mancia JR, Gomes AMF.

CONCLUSION
The characterization of the cases and the contextualization of violence reflect the complexity of the theme, especially in the life stories that involve cases of children hospitalized for aggression.Knowing the characterization of the children hospitalized for this injury, in an Intensive Care Unit, can assist the health professionals in providing qualified care to this population.
In this study, boys accounted for 54.5%, white race/ethnicity, 81.8% and 63.6% were up to three years old.As for the type of violence, physics accounted for 50% and neglect 36.4%.Most of the aggressors were child family member (77.3%), with emphasis on the mother (35.3%).The main mechanism of aggression was the fall (22.7%),followed by burns (18.2%).It should be noted that in the analysis of the outcomes, it was identified that there was no relation between the cases of violence and the risk of death.However, burning caused a high risk of death.In addition, in 31.8% of the children the lesions were located in more than one region of the body.
The mean time was 15 days of hospitalization and the results obtained in relation to the outcome of the visits reflect the severity of the cases of aggression/neglect.The greater percentage of cases occurred with children younger than three years of age demonstrated the fragility of this age bracket, exposed mainly to the neglect of those responsible.This demonstrates the need to face the phenomenon of violence with another perspective, using a holistic approach, not focusing exclusively on the physical consequences of the violence against the child.
The contextualization of the cases of violence described in this study allowed us to illustrate some of the situations that reach public health services.Thus, it was possible to point out the participation of the responsible ones in the abusive acts, besides the vulnerability in which they are exposed within the own home.
In the records of the medical records, carried out by psychologists and social workers, the participation of the nursing team in the identification of most situations of violence was observed.However, little information was found in nursing evolutions, restricted to referrals to other professionals.Therefore, the importance of preparing these professionals for the care of children victims of violence is highlighted.It is also worth mentioning the contribution of the records on this topic, in the context of violence, in the visibility of the seriousness of the problem, and in generating subsidies for more effective actions against violence in children.It was not the object of the study, but it is suggested to carry out research related to the role of nursing in coping with violence and in the complexity of the daily life of this type of care, especially of children hospitalized due to the severity of the injuries.
In this conjunction, it is pointed out the importance of the interdisciplinary work carried out by the professionals of the hospital under study, in view of the evaluations and referrals of Nursing, Social Work and Psychology, as well as the actions to the Guardianship Council and Public Prosecutor's Office, in defense of these children.
It is known that cases of violence and aggression against children who arrive at intensive care services do not represent the majority, since they are still veiled situations and restricted to the home.Although there is recognition that this study is a clipping of some of the situations of violence against children, we understand the relevance of addressing the issue and discuss the participation of nursing in the care and identification of aggressions and neglect.
It is considered that the results of this study reinforce the importance of the discussion on the subject.In addition, they can stimulate reflections for the adoption of actions capable of contributing to the promotion of protective measures for children, as well as addressing violence in the health area.
OBJECTIVE • To characterize children hospitalized as a result of some type of violence according to age, gender, race/ethnicity, length of stay, type of violence, place of injury, outcome of care and aggressor; hospitalized in a pediatric ICU in 2011; • To relate violence conditions and the mechanisms of trauma with death; • To contextualize the violence suffered by children from the records in the records of the ICU under study.
Children hospitalized due to maltreatment in the ICU of a Public Health Service Santomé LM, Leal SMC, Mancia JR, Gomes AMF.

Table 2 -
Distribution of children hospitalized cue to violence in a Pediatric Intensive Care Unit of Trauma in 2011, regarding the aggressor, type of violence, mechanism of aggression and place of the injury, Porto Alegre city, Rio Grande do Sul, Brazil, 2013 Children hospitalized due to maltreatment in the ICU of a Public Health Service Santomé LM, Leal SMC, Mancia JR, Gomes AMF.

Table 3 -
Distribution of children hospitalized due to violence in a Pediatric Intensive Care Unit of Trauma in 2011, regarding the type of violence, age bracket and outcome of hospitalization, Porto Alegre city, Rio Grande do Sul, Brazil, 2013