The pediatric ED setting can often become quite hectic, with clinical presentations ranging from the pedestrian-versus-motor vehicle accident to the overanxious mother worried about an infant who will not stop crying. But what does one do when a parent’s chief complaint is out of proportion to the child’s physical examination, as in the case of ALTE? Suppose a parent brings in a child and complains of multiple signs and symptoms, but the child appears healthy. Or suppose a child is brought in repeatedly for diagnosis and treatment of a chronic illness that appears unusual to the ED clinician in its presentation. In cases such as these, medical child abuse (MCA) should be considered in the differential diagnosis. By definition, MCA occurs when a child undergoes or receives unwarranted medical care at the hands of a caretaker.1
Medical child abuse has been known by many names over the years, including Münchausen syndrome by proxy (MSBP), factitious disorder by proxy (FDBP), and most recently, pediatric condition falsification (PCF).2 Münchausen syndrome by proxy is probably the most mainstream and well-known nomenclature. Historically, Baron von Münchausen, who is thought to have been a fictitious character, told stories of extravagant adventures. His name was subsequently used to describe a group of disorders (specifically Münchausen syndrome) in which patients fabricate complaints, leading to multiple hospitalizations and invasive tests and procedures.2Roy Meadow first used the term MSBP in 1977 when he described 2 cases of “parents who, by falsification, caused their children innumerable harmful hospital procedures—a sort of Münchausen syndrome by proxy.”3
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV), a diagnosis of MSBP involves 2 components: the child as the victim and the caregiver adult as the perpetrator. The child is then victimized into a sick role.4 The American Academy of Pediatrics has moved away from use of the term MSBP. There are questions regarding the term: should it be used only when the perpetrator is seeking medical care or only when trying to determine the parent’s motivation?2Moreover, who should make the diagnosis of MSBP is controversial. Should it be the pediatrician or a psychiatrist? Should the diagnosis be applied to the parent or the child?2 Finally, if the parent does not fit the DSM-IV criteria of MSBP, does that mean the child has not been abused? Recently, the American Professional Society on the Abuse of Children made an important distinction between the actual abuse caused to a child (ie, PCF) and the motivations behind the abuse (ie, FDBP). Whereas the former focuses on the impact to the child, the latter concerns the psychiatric state of the perpetrator.1
The truth is that clinicians who specialize in caring for children are ill equipped to diagnose the psychiatric state of the patient’s caregiver, whether the label involves MSBP or FDBP. Determining if and how a child has been abused should be their first concern; others can then focus on the motivation of the perpetrator.1 Thus, the term MCA, which is more inclusive and addresses the harm to the child from unwarranted medical care, is a more apt diagnosis for a pediatric patient. The term also clearly indicates that a form of child abuse has occurred.
At 3 am, a mother brings her 4-week-old daughter to the emergency department (ED) with the chief complaint of "stopped breathing." The mother describes the event by stating that the baby was "lying there, turned blue all over, then was not breathing." The mother picked up the baby, who subsequently started breathing again and regained her color. There is no history of recent feeds or reflux prior to the episode. The birth history is significant for a full-term baby, with a normal spontaneous vaginal delivery, poor prenatal care, and urine drug screen results positive for marijuana. Because of the finding on the drug screen, Child Protective Services (CPS) is already involved in the child's life. The mom describes the infant as developmentally appropriate for a 1-month-old and notes that her immunizations are up-to-date. The social history reveals the child lives with her mother, maternal grandmother, and 1-year-old sister. The mother and father are not together. There is smoking in the home but no pets.
On physical examination, the patient's pulse oximetry value is 100%, and she appears comfortable, in no acute distress; the rest of the physical examination is unremarkable. Examination of her skin shows no marks or bruises. Complete blood cell count and complete metabolic panel results are within normal limits for the patient's age, except for a hemoglobin level of 10.2 gm/dL. Results of a chest radiograph are also normal. The patient is admitted for 24-hour observation due to her concerning history of cyanosis, the patient's young age, and mild anemia. The admission diagnosis is apparent life-threatening event (ALTE).
During admission, the patient is placed on a cardiorespiratory monitor, with no apneic events noted. She feeds well and gains weight during her admission. The mother is difficult to contact during this admission, but she is eventually notified to come and pick up her child. Upon discharge, as the mother prepares to leave the hospital room with her infant, she suddenly discuscomes running to the nurses' station, saying her child is not breathing again. The nurse runs into the child's room to find a blue, limp infant. The nurse subsequently initiates the rapid response team and stimulates the infant, who then starts breathing. Pulse oximetry is initially 89%, but it slowly returns to 98% with oxygen via facemask. By the time the rapid response team arrives, the patient has recovered. No chest compressions are required. The infant is then readmitted. A sepsis workup is initiated, and a repeated chest radiograph shows a possible small right lower lobe infiltrate. The infant is started on ampicillin and gentamicin while blood, urine, and cerebrospinal fluid cultures are pending. She is also placed on iron therapy for anemia.
Two days later, results of all studies are negative, the infant remains afebrile, and a 5-channel pneumogram is done to rule out an obstructive versus central process for the baby's continued apneic events. Results of this study are also negative.
The mother is not present during most of her daughter's second admission to the hospital. At time of discharge, the mother is again difficult to contact. When the mother finally arrives, she momentarily leaves the child's room; when she returns, she immediately calls for help, saying the infant is again limp and blue. The nurse enters the room, finds the infant cyanotic and limp, and again calls for the rescue response team. The nurse stimulates the patient, whose oxygen saturation is 84%. By the time the rescue response team arrives, the patient has recovered. The nurses note a drop of blood near the patient's right nares.
A literature review of articles published from 1980 to 2009 was launched using Ovid MEDLINE® (www.ovid.com) and PubMed (www.pubmed.gov). Keywords used in the search were Münchausen syndrome by proxy, medical child abuse, covert video surveillance, falsification of a pediatric condition, pediatric condition falsification, pediatric symptom falsification, and factitious disorder by proxy. Three books (Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment; Münchausen By Proxy Syndrome: Misunderstood Child Abuse; and Medical Child Abuse: Beyond Münchausen Syndrome by Proxy) were used for most of the discussions in this article. Other references included literature reviews, case reports, and a few retrospective studies. In all, more than 20 articles were reviewed, with 8 articles cited in this publication.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available.