Have you seen Medical Child Abuse?

“Medical Child Abuse” is the favored term for what has been called Munchausen Syndrome by Proxy (and “Factitious disorder imposed on another”).  A recent case series with 36 cases (AZ Ali-Panzarella, TJ Bryant, H Marcovitch, JD Lewis. Curr Gastroenterol Rep 2017; 19: 14) provides some of the most extensive information about this troubling condition.  Kudos to my colleague Jeff Lewis and his coauthors for this publication.

The authors conducted a retrospective review of all cases of medical child abuse that were confirmed by video.  During a 20-year period, covert video monitoring was used in suspected cases. This study is important because most of the literature on this topic are single case reports.  Furthermore, there is virtually no published follow-up outcome data available.

Key demographics:

  • All abusers were the mothers
  • Age at diagnosis: 2 months to 17 years, median 2 years. 61% were under 5 years.
  • 91% were Caucasian
  • 72% were Medicaid recipients
  • Only 5 patients were diagnosed on first admission. 13 of 36 (36%) were diagnosed before 1 year of age.

Clinical features:

  • 38% had 5 or more admissions prior to diagnosis (possibly more at other institutions)
  • Median time between first hospitalization and diagnosis was 15 months
  • Primary symptoms in those less than a year: reflux, feeding difficulty, apnea, and seizure-like movements.  These were often induced by partial suffocation, forced feeding and induced vomiting.
  • Older children were reported often as having a past history of leukemia, muscular dystrophy, food allergy, recurrent infections, and mitochondrial disorders.
  • Due to their presentations, the cohort underwent 24 procedures and 9 surgeries (3 Nissen fundoplications, 1 pacemaker, 5 gastrostomy tubes, 3 ENT surgeries)
  • Two-thirds had pediatric gastroenterology involved prior to diagnosis.

Multidisciplinary Process:

  • Setting up covert surveillance and undertaking monitoring requires a team of individuals.  This is well-described in this article -see Table 1.
  • Before monitoring is allowed, a core group has a meeting to determine if monitoring is warranted in each case.
  • During monitoring, “it is critical to have staff observing in real time to allow an opportunity for bedside staff to be notified immediately and intervene in life-threatening events.”

19 references are given with this report.  Two references that are highlighted:

  • Pediatrics 2015; 136 (5): e1361-5.  Describes how induced illness can look like a rare disease
  • Pediatrics 2013; 132 (3): 590-7.  Guides pediatrician in diagnostic evaluation of medical child abuse

My take: Making a diagnosis of medical child abuse is crucial for these children.  This report makes an important contribution to this end.  Institutions that do not have covert surveillance should consider collaboration with institutions that have set up this capability.

Related blog postA Cautionary Tale–Is it Medical Child Abuse?

Monet, Musee L’Orangerie

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