Munchausen Syndrome by Proxy

Munchausen Syndrome by Proxy (MSbP) was a term coined by Professor Roy Meadows in 1997.¹ Munchausen's syndrome implies a condition in which the patient attempts to simulate an illness by providing a false history or by fabricating evidence, and Professor Meadows proposed that a parent could use a child as a proxy Munchausen patient.²
In 2002, a working party of the Royal College of Paediatrics and Child Health suggested that the condition be known as 'Fabricated or Induced Illness by Carers' (FII).³

This change was proposed because the College felt that the old term focussed more on the motivations of the perpetrator rather than the interests of the child and failed to capture the wide range of presentations and features associated with the condition. Furthermore, the new name afforded an opportunity to address the fact that natural parents were not the only perpetrators. Anyone with parental responsibility, be It long-term such as a foster parent, or anyone providing short-term care such a grandparent or child-minder, could be a perpetrator.

The Department of Health produced guidance in 2002 supplementary to their document Working Together to Safeguard Children in which they recommended the concept of 'fabrication or induction of illness in a child' rather than the use of any specific term.⁴ They wanted to focus thinking on the impact of the condition on the child's health and development, and consideration of how best to safeguard the child's welfare, rather than be drawn into distracting discussions about the best term to use.

The terminology remains confusing, and much of the current literature, including research into epidemiology, still refers to the term Munchausen Syndrome by Proxy.

A two year prospective study was carried out of cases in the UK and the Republic of Ireland notified to the British Paediatric Surveillance Unit categorised as Munchausen syndrome by proxy, non-accidental poisoning, or non-accidental suffocation. The majority of children were aged under 5 years, the median age being 20 months. On 85% of occasions the perpetrator was the child's mother. In 42% of families with more than one child, a sibling had previously suffered some form of abuse. The combined annual incidence of these conditions in children aged under 16 years was projected as being at least 0.5/100,000, and for children aged under 1, at least 2.8/100,000.⁵
A more recent study in New Zealand found an incidence rate for MSbP in children aged less than 16 years of 2.0/100 000 children. The mother was the suspected perpetrator in all cases.⁶

Professor Meadows criteria for defining MSbP was as follows:²

• Illness in a child which is fabricated or induced by a parent or someone who is in loco parentis.
• A child is presented for medical assessment and care, usually persistently, often resulting in multiple medical procedures.
• The perpetrator denies the aetiology of the child's illness.
• Acute symptoms and signs cease when the child is separated from the perpetrator.

The Department of Health working group have furthermore identified three main ways in which carers may induce or fabricate an illness in a child:

• Fabrication of signs and symptoms. This may include fabrication of past medical history.
• Falsification of hospital charts and records, and specimens of bodily fluids. This may include also falsification of letters and documents.
• Induction of illness by a variety of means.

The Royal College of Paediatrics and Child Health have produced a table of the most florid presentations, although almost any disorder can be simulated:³

The differential diagnosis will depend on the presenting symptoms. It will often be difficult during the first encounter to raise more than a suspicion of factitious or fabricated illness, but it should be considered in the list of differential diagnoses wherever appropriate.
The diagnosis may only be made clear when a child presenting with acute illness is admitted to hospital for investigations.
The relationship between older children and carers is complicated and some children may be fabricating illness in order to gain approval of the adult or for other motives, in which case the condition could be considered to be early onset Munchausen per se.⁷ Deliberate attempts by a child to feign illness also borders on the hinterland of malingering. In common parlance, malingering is often used when there is obvious secondary gain (such as school avoidance),⁸ whereas Munchausen is a more clinical term which implies a less obvious and perhaps more deeply rooted psychological cause.

Investigations will depend on the presenting symptoms and signs.
Investigation of a number of common scenarios might include the following:³

Coma, drowsiness and seizures

If glucose estimation suggests hypoglycaemia, check for insulin and C peptide levels. C peptide is a measure of endogenous insulin, and if the level is low in the presence of a high insulin reading, this raises the possibility that exogenous insulin has been given. Test also for oral hypoglycaemics.
Requesting a toxicology screen is unlikely to be helpful, but targeted screening of whole blood for heavy metals, urine for drugs of abuse, serum for hormones and common medications (particularly over the counter preparations) may be contributory.
The sample type will depend on the test, but in cases of suspected poisoning, blood, urine, vomit and stool may all be required.

Salt poisoning

Electrolytes and acid base balance should be ordered on blood and urine, and urine osmolality checked. Fluid balance records and weight must be measured and recorded. Sodium output in a timed urine sample is the gold standard. A sodium/creatinine ratio over 100 is indicative of salt poisoning.

Seizures

If it is possible to see the child immediately after a seizure, a serum prolactin may help to differentiate a true seizure (prolactin rises after a tonic clonic seizure) from a pseudo seizure. However, more commonly, there is a history of seizures which will require repeated EEGs, sometimes with video monitoring.

Apparent bleeding disorders

Arrange coagulation studies and a full blood count. If blood is present in a sample, it may be possible to compare it with the child's blood group. More sensitive DNA tests may be required.

Legal Issues

Laboratory results can become legal evidence and should be handled appropriately. A record of when and where the sample was taken and how it was conveyed to the laboratory should be kept. As few people as possible should be involved in the transfer of the specimen to the laboratory to avoid accusations of tampering.

Video Surveillance

Overt video surveillance may be helpful in corroborating the carer's history (e.g. filming a convulsion in a child in an in-patient setting).³ Covert video surveillance is no longer recommended, except in conjunction with a police investigation.⁴

In the perpetrator - personality disorder,⁹ Munchausen syndrome (approximately 25% of perpetrators have induced factitious symptoms in themselves).¹⁰In the child - sudden infant death syndrome (SIDS),¹⁰ behavior problems (this can include feeding disorders in infants, withdrawal and hyperactivity in preschool-aged children, and adoption of Munchausen syndrome behavior in adolescence¹¹).

There are no formal staging procedures as such but several aspects of the condition can be used to grade severity. These include:

• The severity of harm to the child of the presenting illness - e.g. a life-threatening event
• The degree with which any long-term symptoms.caused chronic disability in the child
• The risk of further harm

The first priority is to exclude organic disease, stabilise the child and treat any presenting symptoms. The child will need to be admitted to hospital if the presenting condition is severe or life-threatening. Hospital admission may also be required if FII is recognised early and it is deemed that the child is at significant risk of harm, or if separation from the carer is required to confirm the diagnosis.

Once FII is suspected a multi-disciplinary approach should be used, involving paediatricians and social services. The police may also need to be contacted. Child protection procedures will need to be invoked, and a strategy meeting held to decide whether to proceed to a formal Section 47 enquiry. This is a section of The Children Act 1989 which precedes possible entry onto the Child Protection Register.¹²

FII invokes strong feelings in clinicians, and there is a temptation to feel anger against the perpetrator. Whilst this is perfectly natural and should be recognised it should not obstruct the opportunity to review the case dispassionately and assess what is best for the future of the child and the family as a whole. FII is a spectrum, and in cases deemed to be 'mild' (e.g. little harm to the child and low possibility of future harm) an open and honest discussion with the child, the perpetrator and the rest of the family may help to rebuild bridges and lead to a more healthy relationship. On the other hand, the situation may be irretrievable, significant future harm may be very likely, and the child may need to be removed to a foster home on a temporary or permanent basis. These decisions need to be taken in a multi-disciplinary setting in the context of the local child protection procedures.

Psychiatric intervention for the child has proven helpful in some cases.¹³ It has proven less successful for the treatment of the perpetrator, possibly because many such individuals have a deep-seated personality disorder.¹⁴
Although the mother is the perpetrator in the majority of cases, the family dynamics need to be assessed. The mother's partner should also be interviewed and involved if possible.

The possibility of abuse of the siblings of the index patient should also be given urgent consideration.¹⁵

Prognosis is dependent upon a number of factors, i.e:³

• The length of the abuse
• The degree of harm
• The degree of psychopathology in the perpetrator
• The relationship between the child and the perpetrator
• The degree of long-term supervision by professionals
• The social environment

Obtaining information about outcomes is difficult, as many children are lost to follow up once family supervision ceases. However, the limited studies available suggest that there are significant emotional problems in adulthood including insecurity, avoidance of medical treatment, posttraumatic stress symptoms and Munchausen syndrome.¹⁶

There is little advice available about the prevention of an initial case of FII. Indeed the condition is so wide-ranging that some authorities believe research in this area would be fruitless.¹⁷ Most work has focussed on the prevention of further episodes of harm. This involves child protection strategy meetings as outlined above, and surveillance of siblings.