Medical child abuse (Munchausen syndrome by proxy)
- Thomas A Roesler, MD
Thomas A Roesler, MD
- Professor of Psychiatry and Behavioral Sciences
- University of Washington School of Medicine
- Carole Jenny, MD, MBA, FAAP
Carole Jenny, MD, MBA, FAAP
- Professor of Pediatrics
- University of Washington School of Medicine
- Section Editors
- Daniel M Lindberg, MD
Daniel M Lindberg, MD
- Section Editor — Pediatric Psychosocial Emergencies
- Associate Professor of Emergency Medicine and Pediatrics
- University of Colorado Kempe Center
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The clinical features, diagnosis, and management of medical child abuse (MCA) with a focus on recognition and care of the affected child will be reviewed here.
Other forms of physical child abuse and neglect are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child neglect and emotional maltreatment".)
Medical child abuse (MCA) refers to a child receiving unnecessary and harmful or potentially harmful medical care due to a caregiver's overt actions including exaggeration of symptoms, lying about the history or simulating physical findings (fabrication), or intentionally inducing illness in their child .
By contrast, acts of omission (failure to provide basic needs for a child such as food, clothing, education, and medical care) are usually labeled as "neglect." Hence, medical neglect indicates a caretaker acting in a way that a child does not receive appropriate health care. (See "Child neglect and emotional maltreatment".)
All of the following terms have been used to describe MCA [2-7]:
- Roesler TA, Jenny C. Medical Child Abuse: Beyond Munchausen Syndrome by Proxy, 1st ed, American Academy of Pediatrics, Elk Grove Village 2009.
- Flaherty EG, Macmillan HL, Committee On Child Abuse And Neglect. Caregiver-fabricated illness in a child: a manifestation of child maltreatment. Pediatrics 2013; 132:590.
- Meadow R, Lennert T. Munchausen by proxy or Polle syndrome: which term is correct? Pediatrics 1984; 74:554.
- Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977; 2:343.
- Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet 2014; 383:1412.
- Stirling J Jr, American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics 2007; 119:1026.
- Schreier HA, Libow JA. Hurting for Love: Munchausen by Proxy Syndrome, 1st ed, The Guilford Press, New York 1993.
- Bools C. Fabricated or Induced Illness in a Child by a Carer: A Reader, 1st ed, Radcliffe, New York 2007.
- Schreier H. Munchausen by proxy defined. Pediatrics 2002; 110:985.
- American Psychiatric Association. Factitious disorder by proxy. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, American Psychiatric Publishing, Arlington 2013.
- American Psychiatric Association. Factitious disorder imposed on self. In: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, American Psychiatric Publishing, Arlington 2013.
- McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child 1996; 75:57.
- Denny SJ, Grant CC, Pinnock R. Epidemiology of Munchausen syndrome by proxy in New Zealand. J Paediatr Child Health 2001; 37:240.
- Warner JO, Hathaway MJ. Allergic form of Meadow's syndrome (Munchausen by proxy). Arch Dis Child 1984; 59:151.
- Guandolo VL. Munchausen syndrome by proxy: an outpatient challenge. Pediatrics 1985; 75:526.
- Orenstein DM, Wasserman AL. Munchausen syndrome by proxy simulating cystic fibrosis. Pediatrics 1986; 78:621.
- Rosenberg DA. Web of deceit: a literature review of Munchausen syndrome by proxy. Child Abuse Negl 1987; 11:547.
- Doughty K, Rood C, Patel A, et al. Neurological Manifestations of Medical Child Abuse. Pediatr Neurol 2016; 54:22.
- Rees P, Al-Hussaini A, Maguire S. Child abuse and fabricated or induced illness in the ENT setting: a systematic review. Clin Otolaryngol 2016.
- Meadow R. Fictitious epilepsy. Lancet 1984; 2:25.
- Rosen CL, Frost JD Jr, Glaze DG. Child abuse and recurrent infant apnea. J Pediatr 1986; 109:1065.
- Hyman PE. Chronic intestinal pseudo-obstruction in childhood: progress in diagnosis and treatment. Scand J Gastroenterol Suppl 1995; 213:39.
- Feldman KW, Hickman RO. The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy. J Pediatr Surg 1998; 33:623.
- Godding V, Kruth M. Compliance with treatment in asthma and Munchausen syndrome by proxy. Arch Dis Child 1991; 66:956.
- Bools C, Neale B, Meadow R. Munchausen syndrome by proxy: a study of psychopathology. Child Abuse Negl 1994; 18:773.
- Meadow R. Munchausen syndrome by proxy. Arch Dis Child 1982; 57:92.
- Sanders MJ, Bursch B. Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS. Child Maltreat 2002; 7:112.
- Schreier H. On the importance of motivation in Munchausen by Proxy: the case of Kathy Bush. Child Abuse Negl 2002; 26:537.
- Sugar JA, Belfer M, Israel E, Herzog DB. A 3-year-old boy's chronic diarrhea and unexplained death. J Am Acad Child Adolesc Psychiatry 1991; 30:1015.
- Mullins ME, Cristofani CB, Warden CR, Cleary JF. Amitriptyline-associated seizures in a toddler with Munchausen-by-proxy. Pediatr Emerg Care 1999; 15:202.
- Souid AK, Keith DV, Cunningham AS. Munchausen syndrome by proxy. Clin Pediatr (Phila) 1998; 37:497.
- Meadow R. Non-accidental salt poisoning. Arch Dis Child 1993; 68:448.
- Coulthard MG, Haycock GB. Distinguishing between salt poisoning and hypernatraemic dehydration in children. BMJ 2003; 326:157.
- Schreier HA. Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. J Am Acad Child Adolesc Psychiatry 2000; 39:668.
- Moszkowicz M, Bjørnholm KI. Factitious illness by proxy presenting as anorexia and polydipsia by proxy. Acta Paediatr 1998; 87:601.
- Rabbone I, Galderisi A, Tinti D, et al. Case Report: When an Induced Illness Looks Like a Rare Disease. Pediatrics 2015; 136:e1361.
- Kosmach B, Tarbell S, Reyes J, Todo S. "Munchausen by proxy" syndrome in a small bowel transplant recipient. Transplant Proc 1996; 28:2790.
- Brown P, Tierney C. Munchausen syndrome by proxy. Pediatr Rev 2009; 30:414.
- Meadow R. Management of Munchausen syndrome by proxy. Arch Dis Child 1985; 60:385.
- 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; 105:1305.
- Byard RW, Burnell RH. Covert video surveillance in Munchausen syndrome by proxy. Ethical compromise or essential technique? Med J Aust 1994; 160:352.
- Spying on mothers. Lancet 1994; 343:1373.
- Foreman DM, Farsides C. Ethical use of covert videoing techniques in detecting Munchausen syndrome by proxy. BMJ 1993; 307:611.
- Morley C. Concerns about using and interpreting covert video surveillance. BMJ 1998; 316:1603.
- Southall DP, Plunkett MC, Banks MW, et al. Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics 1997; 100:735.
- Brown AN, Gonzalez GR, Wiester RT, et al. Care taker blogs in caregiver fabricated illness in a child: a window on the caretaker's thinking? Child Abuse Negl 2014; 38:488.
- Bools CN, Neale BA, Meadow SR. Co-morbidity associated with fabricated illness (Munchausen syndrome by proxy). Arch Dis Child 1992; 67:77.
- Libow JA. Munchausen by proxy victims in adulthood: a first look. Child Abuse Negl 1995; 19:1131.
- Allison TS. Proving medical child abuse: the time is now for Ohio to focus on the victim and not the abuser. J Law and Health 2012; 25:191. http://engagedscholarship.csuohio.edu/cgi/viewcontent.cgi?article=1059&context=jlh (Accessed on September 29, 2015).
- Berg B, Jones DP. Outcome of psychiatric intervention in factitious illness by proxy (Munchausen's syndrome by proxy). Arch Dis Child 1999; 81:465.
- CLINICAL MANIFESTATIONS
- Patient features
- Perpetrator features
- Perpetrator actions
- Spectrum of illness
- - Mild
- - Moderate
- - Severe
- DIAGNOSTIC EVALUATION
- Moderate to severe
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR CONSULTATION WITH A MULTIDISCIPLINARY CHILD ABUSE TEAM
- Moderate and severe
- - Stop the abuse
- - Involve child protection agencies
- - Repair iatrogenic harm
- - Provide family support
- - Legal intervention