Medical Child Abuse In The ED: An Evidence-Based Review
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An Evidence-Based Review Of Medical Child Abuse In The ED

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Practice Recommendations (key points from the issue)
  3. Case Presentations
  4. Critical Appraisal Of The Literature
  5. Epidemiology, Etiology, And Pathophysiology
    1. Profile Of The MSBP Patient
    2. Profile Of The Perpetrator
    3. Profile Of The Family
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Seizures
    2. Bleeding Disorders
    3. Apnea
    4. Vomiting, Diarrhea
    5. Fever
    6. Skin Disorders
  9. Diagnostic Studies
    1. Seizures
    2. Bleeding
    3. Vomiting, Diarrhea
    4. Fever
    5. Dermatologic
  10. Treatment
    1. The Treatment Team
    2. Approaching The Perpetrator
    3. Counseling Of The Perpetrator
    4. Counseling Of The Patient
  11. Special Circumstances
  12. Controversies/Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For The Treatment Of Medical Child Abuse
  16. Case Conclusion
  17. References

Abstract

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.

Practice Recommendations (key points from the issue)

Click here to download a PDF of the Evidence-Based Practice Recommendations for this issue.

Case Presentations

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.

Critical Appraisal Of The Literature

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.

Risk Management Pitfalls For The Treatment Of Medical Child Abuse

  1. Developing intimate relationships with the patient's parents.The emergency clinician should always remain objective when dealing with any family that presents to the ED. This demeanor is especially important in cases where MCA is in the differential. Oftentimes, the mother will use medical jargon, making it seem that everyone is working together for the benefit of her child.
  2. Believing that parents would never fabricate an illness.Physicians are trained to depend on the histories the patient's parents provide.9 With MCA, understanding that the perpetrator will often lie and use deceit just so the child can be placed in the sick role is key.
  3. Continuing to order tests until a diagnosis can be made.Physicians often have difficulty accepting that they are unable to resolve a patient's clinical presentation. Thus, the more uncertain they are, the more tests they order.9 Occasionally, physicians may have to take a step back and ask themselves why they are ordering another test and how much it will benefit diagnosis versus placating their ego as a diagnostician.
  4. Failing to communicate with others.The key to addressing MCA is the multidisciplinary approach. Working alone will often leave the physician feeling overwhelmed and without a tangible diagnosis. It is also important to obtain all of the patient's previous records to decrease duplicity of testing and facilitate the possible diagnosis of MCA.
  5. Disclosing to the suspected perpetrator before gathering enough evidence or consolidating support from auxiliary staff.The whole team should be on the same page, so it does not appear that the primary physician is the only one who believes abuse is occurring. All the medical information should be clear-cut, and no other diagnosis should be plausible.
  6. Not considering the diagnosis in the differential.The physician should ensure that MCA is always in the differential diagnosis. Failure to do so could lead to further harm to the victim.
  7. Incorrectly using the term MSBP.Incorrect use of the term MSBP, which is widely recognized, can be detrimental to the investigation and the search for the true cause of a child's illness. Münchausen syndrome by proxy conjures up a specific profile of the perpetrator and her interactions with the child and health care professionals. When others involved in the multidisciplinary team begin to question if the caretaker fits this profile, the focus on the child may get lost.
  8. Believing that fathers can never be the perpetrators.Fathers have been found to cause 5% of cases of MSBP.7,8 Fathers who are perpetrators are more likely to also have some underlying psychophysiology.
  9. Believing that MCA is rare.Medical child abuse is actually quite common; however, the deception and falsification that accompany the presentations allows many cases to go unreported or unnoticed.
  10. Believing that no one will take these concerns seriously.It is always surprising to learn how many people on the treatment team had suspicions about the clinical presentation and actual diagnosis of a patient. Without bringing the possibility of MCA into the open, however, such a diagnosis will often be missed.

References

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.

  1. Roesler TA, Jenny C. Medical Child Abuse: Beyond Münchausen Syndrome by Proxy. Elk Grove Village, IL: American Academy of Pediatrics; 2009. (Textbook)
  2. Stirling J; American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Münchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Pediatrics. 2007;119(5):1026-1030. (Literature review)
  3. Meadow R. Münchausen syndrome by proxy: the hinterland of child abuse. Lancet. 1977;2(8033): 343-345. (Case report and review of literature)
  4. Ayoub CC, Alexander R, Beck D, et al. Position paper: definitional issues in Münchausen by proxy. Child Maltreat. 2002;7(2):105-111. (Literature review)
  5. Brown P, Tierney C. Münchausen syndrome by proxy. Pediatr Rev. 2009;30(10):414-415. (Literature review)
  6. Schreier H. Münchausen by proxy defined. Pediatrics. 2002;110(5):985-988. (Literature review)
  7. Parnell TF. Guidelines for identifying cases. In: Parnell TF, Day DO, eds. Münchausen by Proxy Syndrome: Misunderstood Child Abuse. Thousand Oaks, CA: Sage; 1998:47-67. (Textbook)
  8. Rosenberg DA. Münchausen syndrome by proxy. In: Reece RM, Christian C, eds. Child Abuse: Medical Diagnosis and Management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009. (Textbook)
  9. Rosenberg DA. Web of deceit: a literature review of Münchausen syndrome by proxy. Child Abuse Negl. 1987;11(4):547-563. (Case report and review of literature)
  10. Meadow R. Münchausen syndrome by proxy abuse perpetrated by men. Arch Dis Child. 1998;78(3):210-216. (Case report and review of literature)
  11. Fisher GC. Etiological speculations. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:39-58. (Textbook)
  12. Rosenberg D. From lying to homicide: the spectrum of Münchausen syndrome by proxy. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:13-37. (Textbook)
  13. MacGregor DL. Neurological manifestations. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:239-246. (Textbook)
  14. Christian C. Hematologic manifestations. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:129-142. (Textbook)
  15. Light JL. Respiratory manifestations. In: Levin AV, Sheridan 2010MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:103-120. (Textbook)
  16. Chuang E, Piccoli DA. Gastrointestinal manifestations. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:121-128. (Textbook)
  17. Mian M, Huyer D. Infection and fever. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:161-180. (Textbook)
  18. Johnson CF. Dermatologic manifestations. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:189-200. (Textbook)
  19. Mian M. A multidisciplinary approach. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:271-286. (Textbook)
  20. Seibel MA, Parnell TF. The physician's role in confirming the diagnosis. In: Parnell TF, Day DO, eds. Münchausen by Proxy Syndrome: Misunderstood Child Abuse. Thousand Oaks, CA: Sage; 1998:68-94. (Textbook)
  21. Day DO, Parnell TF. Setting the treatment framework. In: Parnell TF, Day DO, eds. Münchausen by Proxy Syndrome: Misunderstood Child Abuse. Thousand Oaks, CA: Sage; 1998:151-166. (Textbook)
  22. Day DO, Ojeda-Castro MD. Therapy with family members. In: Levin AV, Sheridan MS, eds. Münchausen Syndrome by Proxy: Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995:202-218. (Textbook)
  23. Hall DE, Eubanks L, Meyyazhagan LS, Kenney RD, Johnson SC, Johnson K. Evaluation of covert video surveillance in the diagnosis of Münchausen syndrome by proxy: lessons from 41 cases. Pediatrics. 2000;105(6):1305-1312. (Retrospective review; 41 cases)
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Publication Information
Authors

Bimpe Adewusi; Leena Shrivasta Dev; Maria D. McColgan

Publication Date

April 1, 2010

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