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 — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- 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 "Child neglect and emotional maltreatment" and "Physical abuse in children: Epidemiology and clinical manifestations" and "Physical abuse in children: Diagnostic evaluation and management" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)
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.
- 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