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Munchausen Syndrome by Proxy (Child Abuse in the Medical Setting), Pediatric


Basics


Description


  • Symptoms of illness in a child that are exaggerated, fabricated, or induced by a caretaker. There is usually no underlying health disorder in the child.
  • Results in harm to the child victim through repeated interactions with the medical care system, including unnecessary tests, medications, and surgeries
  • Known by many names, including the following:
    • "Pediatric condition falsification " 
    • "Caregiver-fabricated illness " 
    • "Medical child abuse " 
    • "Factitious disorder by proxy " 
  • All refer to harm that befalls children through the actions of a caregiver in a medical setting.
  • Symptoms decrease when the child is separated from the perpetrator.

Epidemiology


  • Rare, with no typical presentation. The most commonly described symptoms include apnea, seizures, factitious fevers, feeding and GI problems, failure to thrive, behavioral problems, bleeding, and sepsis.
  • Presenting symptoms may present along a spectrum of severity from mild to fatal.
  • Most victims are <4 years of age, but victims may often be older children.
  • Males and females are equally represented.
  • Symptoms may be present for years before factitious illness is considered and diagnosed.
  • Morbidity is significant; cases may be fatal, especially those involving surreptitious administration of medications, poisoning, or inducing apnea.

Etiology


  • The parent, most commonly the mother, exaggerates, fabricates, or induces the illnesses.
  • The term Munchausen syndrome by proxy refers to specific instances where the caregiver is motivated by a desire for self-aggrandizement. As such, it only defines a subset of factitious illnesses.
  • Medical providers are advised to concentrate on the specific harm done and the patient 's safety rather than on the caregiver 's motives.

Diagnosis


History


Factitious illness should be considered when ‚  
  • Symptoms and signs described are incongruous with patient 's appearance or are seen only when the caregiver is present.
  • Diagnostic tests fail to confirm the diagnosis.
  • Usual medical treatment is ineffective in alleviating the presenting symptom.
  • Caregiver seems unusually knowledgeable or aggressive in suggesting particular medical interventions.
  • "Red flags " :
    • Frequent moves
    • Siblings who have either died or had unusual medical illnesses
    • Seeking care at a variety of facilities
    • Reluctance to accept less severe diagnoses

Physical Exam


  • Examinations are usually normal.
  • When symptoms have been exaggerated, findings are less than expected (e.g., mild asthma or hyperactive behavior).
  • When symptoms have been inflicted, findings are often atypical for the medical condition being considered.
  • Failure to thrive or obesity are common.
  • Patient may have evidence of additional injuries, including old fractures or scars.

Diagnostic Tests & Interpretation


Diagnostic Procedures/Other
  • Workup is dictated by the presenting complaint: EEG for seizures, cardiac monitors for syncope, pneumogram for apnea, etc.
  • When the workup is consistently normal and symptoms are still described, the differential diagnosis should include factitious disorders.
  • If bleeding is the major presentation, identify the blood as the patient 's (as opposed to that of the perpetrator or an animal).
  • A toxicology screen may be helpful for unusual presentations of poisoning.
  • Repeated blood or urine cultures with multiple organisms suggest intentional contamination of the specimen or of the patient.
  • Special care must be taken to prevent the caregiver from tampering with diagnostic testing.
  • If separating the perpetrator from the patient results in disappearance of symptoms, this "test "  may suggest the diagnosis.
  • Covert video monitoring of a patient 's room may demonstrate the perpetrator harming the child.

Differential Diagnosis


Factitious disorders often mimic difficult-to-diagnose diseases: ‚  
  • Apnea/apparent life-threatening event
  • Asthma
  • Seizures
  • Intermittent fevers
  • Genitourinary or GI bleeding
  • Unexplained abnormalities in electrolytes
  • Feeding problems, chronic diarrhea, or vomiting
  • Infections with multiple organisms found in blood or urine culture

Alert
Diagnosis is often delayed and may take months. There are often impediments: ‚  
  • Physicians and nursing personnel may be reluctant to suspect the parent because of their own relationship to the family.
  • It can be difficult to acknowledge that the child has been harmed by well-intentioned but unnecessary medical procedures or investigations.
  • It is often necessary to review records from multiple institutions covering months or years of care. These are often unsuspected and may be difficult to obtain.

Treatment


General Measures


  • Effective care requires that medical providers work closely with other professionals in the community, both to gather information and to ensure the patient 's eventual safety.
  • Child protective services, mental health services, and law enforcement agencies each have a role to play. Evaluations must be multidisciplinary.
  • A variety of interventions may be appropriate depending on the severity of the presentation, from counseling to foster care to criminal prosecution.

Ongoing Care


Follow-up Recommendations


  • Long-term follow-up is necessary for both victim and caregiver.
  • Watch for recurrence of original presentation, or unusual new symptoms, with special attention to the child 's self-image.

Prognosis


  • If undiagnosed, morbidity and mortality may be significant.
  • Victims are essentially taught to be ill, sometimes with lifelong consequences.
  • As there are such diverse presentations, reliable, specific data on long-term morbidity are lacking.

Additional Reading


  • Flaherty ‚  E, MacMillin ‚  H. Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics.  2013;132(3):590 " “597. ‚  [View Abstract]
  • Giurgea ‚  I, Ulinski ‚  T, Touati ‚  G, et al. Factitious hyperinsulinism leading to pancreatectomy: severe forms of Munchausen syndrome by proxy. Pediatrics.  2005;116(1):e145 " “e148. ‚  [View Abstract]
  • Hall ‚  DE, Eubanks ‚  L, Meyyazhagan ‚  LS, et al. Evaluation of covert video surveillance in the diagnosis of Munchausen syndrome by proxy: lessons from 41 cases. Pediatrics.  2000;105(6):1305 " “1312. ‚  [View Abstract]
  • Pankratz ‚  L. Persistent problems with the Munchausen syndrome by proxy label. J Am Acad Psychiatry Law.  2006;34(1):90 " “95. ‚  [View Abstract]
  • Roesler ‚  TA, Jenny ‚  C. Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
  • Schreier ‚  H. Munchausen by proxy defined. Pediatrics.  2002;110(5):985 " “988. ‚  [View Abstract]
  • Sheridan ‚  MS. The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse Negl.  2003;27(4):431 " “451. ‚  [View Abstract]

Codes


ICD09


  • 301.51 Chronic factitious illness with physical symptoms

ICD10


  • F68.12 Factitious disorder w predom physical signs and symptoms
  • F68.13 Factitious disord w comb psych and physcl signs and symptoms
  • F68.11 Factitious disorder w predom psych signs and symptoms

SNOMED


  • 95637005 Munchausen 's by proxy
  • 401316003 Child affected by Munchausens by proxy (finding)

FAQ


  • Q: When should factitious disorders be reported to child abuse authorities?
  • A: When there is reasonable suspicion (note: not certainty) that a child is coming to harm due to the actions of a caregiver. When suspicion exists, it is important to involve community agencies in the investigation.
  • Q: Is it legal to use video surveillance or to separate the parent from the patient?
  • A: Yes, if done properly. When suspicions of factitious illness are high and other laboratory tests are negative, diagnosis may require these measures. Hospital administration and/or risk management should be consulted on how to proceed. Child abuse pediatricians may also provide assistance.
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