AUTHOR INFORMATION

Section 1 of 7

Authored by Jon Donavon Mason, MD, FACEP, FAAP, Assistant Program Director, Associate Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Eastern Virginia Medical School

Coauthored by Michael P Poirier, MD, FAAP, Associate Professor of Pediatrics, Eastern Virginia Medical School; Consulting Staff, Division of Emergency Medicine, Children's Hospital of The King's Daughters

Jon Donavon Mason, MD, FACEP, FAAP, is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, and Medical Society of Virginia

Edited by James Li, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Consulting Staff, Department of Emergency Medicine, Miles Memorial Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical School; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School

Author's Email:	Jon Donavon Mason, MD, FACEP, FAAP
Editor's Email:	James Li, MD

eMedicine Journal, September 15 2005, VOLUME 6, Number 9

INTRODUCTION

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In 1977, Englishman Roy Meadow published the first report of a new form of child abuse. He coined the term Munchausen syndrome by proxy (MSBP) after the syndrome that first had been reported by Asher in 1951. This term is applied when an adult, usually the mother, presents a false history to the physician regarding a child who is not suffering from any of the fabricated symptoms. This history causes the physician to perform unnecessary diagnostic procedures that do not result in any specific diagnosis. MSBP has been called Polle syndrome, named after Baron von Munchausen's only child. In 2002, a new terminology, pediatric condition falsification (PCF), was suggested by the American Professional Society on the Abuse by Children (APSAC).

Today, many reports of such cases are in the literature. Some mothers invent symptoms, and others induce symptoms (eg, using ipecac to induce vomiting, overdosing a child with medication, lacerating the urethra to produce hematuria). Fabricated symptoms are not observed by anyone other than the mother.

In 1995, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) included a definition for factitious disorder by proxy, which is now the accepted psychiatric category for MSBP. The definition includes the following:

1. Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.

2. The motivation for the perpetrator's behavior is to assume the sick role by proxy.

3. External incentives for the behavior, such as economic gain, avoiding legal responsibility, or improving physical well-being, are absent.

For excellent patient education resources, visit eMedicine’s Children's Health Center and Mental Health and Behavior Center. Also, see eMedicine’s patient education articles Child Abuse and Munchausen Syndrome.

WARNING SIGNS OF MSBP

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Children most at risk for MSBP abuse are aged 15 months to 6 years. The emergency physician often is confronted with baffling symptoms. Frequently, the child has been taken to many care providers before the diagnosis is established. In a meta-analysis of early published cases, 75% of morbidity occurred in hospitals. In about 98% of cases, the biological mother is responsible for the event. Victims of MSBP are equally male and female. Warning signs that are suggestive of MSBP include the following:

• Illness is multisystemic, prolonged, unusual, or rare.

• Symptoms are inappropriate or incongruent.

• Patient has multiple allergies.

• Symptoms disappear when parent or caretaker is absent.

• In children, one parent, usually the father, is absent during hospitalization.

• A history of sudden infant death syndrome in siblings may be present.

• Parent is overly attached to the patient.

• Patient has poor tolerance of treatment (eg, frequent vomiting, rash, problems with intravenous lines).

• Parent encourages medical staff to perform numerous tests/studies.

• General health of the patient is inconsistent with results of laboratory tests.

• Parent shows inordinate concern for feelings of the medical staff.

• Seizure activity is unresponsive to anticonvulsants and is witnessed only by parent or caretaker.

SYMPTOMS OF MSBP

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Typical presentations of MSBP include the following:

• Bleeding from Coumadin poisoning, phenolphthalein poisoning, exogenous blood exsanguination of child, and use of colored substances to simulate bleeding

• Seizures

• Poisoning with phenothiazines, hydrocarbons, salt, and imipramine

• Apnea produced via carotid sinus pressure and suffocation. Covert video surveillance in cases of suspected child abuse has demonstrated that in many cases parents were inflicting abuse by suffocation.

• CNS depression produced via drugs (eg, insulin, chloral hydrate, barbiturates, aspirin, diphenhydramine, tricyclic antidepressants, acetaminophen, hydrocarbons)

• Diarrhea and vomiting secondary to ipecac, laxatives, and salt administration

• Fever via falsification of chart records or actual temperature

• Rash from drug poisoning, scratching, caustics, or skin painting

• Hypoglycemia from insulin or hypoglycemic agents

• Hyperglycemia reports (from testing other individuals with diabetes)

• Hematuria or guaiac positive stools produced by traumatic injury to the urethra or anorectal area

DIAGNOSTIC EVALUATION

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The emergency physician must be adept at evaluating patients with varied symptoms and limited or confusing history.

In the case of MSBP, the child may present with a truly life-threatening–induced condition or may be completely asymptomatic with a factitious history supplied by the caregiver. The challenge for the physician is to put the history and physical findings together in a coherent fashion. This is particularly difficult in the child abuse victim, especially when the caretaker may not be giving a truthful history. Involving multiple medical colleagues in the evaluation may be useful.

Physicians can do many tests in the ED to rule out life-threatening conditions, but admission and consultation usually is necessary before the diagnosis of MSBP can be proved.

Emergency evaluation of these cases must be based on symptoms, with specific tests aimed at detecting the potential method by which factitious symptoms are being induced.

Tests that emergency physicians may consider include the following:

• Urine toxicology screening

• Chemistry panels

• Electrocardiogram (ECG)

• Drug levels for suspected poisoning agents (eg, aspirin, acetaminophen, anticonvulsants)

• Cultures

• Coagulation tests

• Head CT scan

THE SPECTRUM OF MSBP

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A study in 1992 suggested that a continuum of parental responses to children exists. At one end of the spectrum is classic neglect, in which the parent disregards symptoms in a child who is truly ill. At the other extreme is the parent who fabricates or generates factitious symptoms in an otherwise healthy child. In between are the parents who are appropriately concerned about a child’s symptoms and who make appropriate efforts to seek care for a child. Parents inflicting MSBP on their children have psychological problems that require professional intervention.

In 1997, Bryk published a description of her own abuse at the hand of her mother and described in detail her prolonged and horrifying story. This instructive article is recommended reading for any medical professional who may come into contact with the victims of this particularly insidious form of abuse.

BIBLIOGRAPHY

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• Asher R: Munchausen's syndrome. Lancet 1951 Feb 10; 1(6): 339-41[Medline].
• Berkowitz CD: Child abuse and neglect. In: Tintinalli's Comprehensive Study Guide. Emergency Medicine, A Comprehensive Study Guide. 6th ed. 2004: 1847-1850.
• Bryk M, Siegel PT: My mother caused my illness: the story of a survivor of Munchausen by proxy syndrome. Pediatrics 1997 Jul; 100(1): 1-7[Medline].
• Eminson DM, Postlethwaite RJ: Factitious illness: recognition and management. Arch Dis Child 1992 Dec; 67(12): 1510-6[Medline].
• Feldman MD, Stuart EJ, eds: The spectrum of factitious disorders. American Psychiatric Press: Washington DC; 1996.
• Fisher GC, Mitchell I: Is Munchausen syndrome by proxy really a syndrome? Arch Dis Child 1995 Jun; 72(6): 530-4[Medline].
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• Meadow R: Munchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977 Aug 13; 2(8033): 343-5[Medline].
• Meadow R: What is, and what is not, 'Munchausen syndrome by proxy'? Arch Dis Child 1995 Jun; 72(6): 534-8[Medline].
• Rogers R: Diagnostic, explanatory, and detection models of Munchause by proxy: extrapolation from malingering and deception. Child Abuse Negl 2004; 28(2): 225-238[Medline].
• Rosenberg DA: Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl 1987; 11(4): 547-63[Medline].
• Schreier H: Munchausen by Proxy Defined. Pediatrics 2002; 110: 985-988[Medline].
• Schreier HA, Libow JA: Munchausen by proxy syndrome: a modern pediatric challenge. J Pediatr 1994 Dec; 125(6 Pt 2): S110-5[Medline].
• Sharif I: Munchausen Syndrome by Proxy. Pediatr Rev 2004; 6: 215-216[Medline].
• Southall DP, Plunkett MC, Banks MW, et al: Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics - Plunkett MC; 100(5): 735-60[Medline].
• Yonge O, Hasse M: Munchausen syndrome and Munchausen syndrome by proxy in a student nurse. Nurse Educ 2004; 29(4): 166-169[Medline].

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Author Information | Introduction | Warning Signs Of Msbp | Symptoms Of Msbp | Diagnostic Evaluation | The Spectrum Of Msbp | Bibliography