OFFICIAL ABP TOPIC:

Identify the child at risk for caregiver-fabricated illness and evaluate appropriately

BACKGROUND

Caregiver-fabricated illness, also known as medical child abuse or Munchausen syndrome by proxy, refers to a child receiving unnecessary and potentially harmful medical care due to a caregiver’s exaggerated, fabricated, or induced illness in the child. It is a relatively rare but serious form of child maltreatment that occurs in a medical setting. Pediatricians need to be vigilant for signs of caregiver-fabricated illness and prepared to intervene to prevent further harm.

IDENTIFYING CHILDREN AT RISK FOR CAREGIVER-FABRICATED ILLNESS

TYPES OF FABRICATIO IN CAREGIVER-FABRICATED ILLNESS

• Exaggeration: Caregiver overstates or embellishes real symptoms (e.g., reporting diarrhea for several weeks when it has lasted one day).
• Fabrication: Caregiver makes up symptoms that are not present at all (e.g., falsifying medical records, adding blood to urine samples, warming a thermometer to imitate fever).
• Induction: Caregiver directly causes real symptoms or illness (e.g., giving insulin to cause hypoglycemia, adding salt to fluids to cause hypernatremia, causing sepsis by injecting contaminated material).

RISK FACTORS AND RED FLAGS

Suspicion for caregiver-fabricated illness should be raised when:

• Reported signs/symptoms are not congruent with clinical observations or vary widely depending on the observer.
• There is a family history of unusual or unexplained illnesses in siblings.
• Child has many unrelated diagnoses involving multiple organ systems.
• Illness is unexplained, prolonged, rare, or does not respond as expected to treatment despite multiple office visits, tests, and medical interventions.
• Caregiver insists on continued evaluation/treatment despite negative findings and reassurance.
• Signs or symptoms begin only when the caregiver is present.
• Symptoms improve when the caregiver is absent.

DIAGNOSTIC EVALUATION OF CAREGIVER-FABRICATED ILLNESS

KEY QUESTIONS TO CONSIDER

• Are the reported signs and symptoms credible?
• Is the child receiving unnecessary and harmful medical care?
• Who is instigating the evaluations and treatment?

IMPORTANT STEPS IN THE EVALUATION

• Review all previous medical records for inconsistencies, frequent evaluations, or doctor-shopping.
• Interview family members and other providers to corroborate history.
• Observe child’s signs/symptoms in presence and absence of caregiver, looking for discrepancies.
• Perform careful physical exam and consider non-invasive diagnostic studies to evaluate for true pathology; avoid unnecessary invasive tests.
• Consider diagnostic tests for evidence of caregiver-fabricated illness as indicated:
  • Toxicology screening.
  • Drug assays.
  • Blood group typing.
  • Blood/urine electrolytes.
  • Analysis of blood or urine for added substances.
  • Stool testing for laxatives such as phenolphthalein.
  • C-peptide is part of insulin produced by the pancreas but not part of insulin given exogenously.
• Initiate multidisciplinary involvement early, including social work, psychiatry, and child protection teams.
• Consider video surveillance or social media monitoring only as part of coordinated multidisciplinary investigation.

DIAGNOSIS

The diagnosis of caregiver-fabricated illness requires demonstrating that:

1. The child is receiving unnecessary and potentially harmful medical care.
2. The caregiver is the source of the deceptive information/actions leading to the medical care.
3. The caregiver’s motivation is not the primary diagnostic factor.
4. The child’s experience and potential harm should be the central focus, not the caregiver’s intent. True pathology and other forms of maltreatment must also be carefully excluded.

REFERENCES

https://www.uptodate.com/contents/medical-child-abuse-munchausen-syndrome-by-proxy

https://publications.aap.org/pediatrics/article/119/5/1026/70293/Beyond-Munchausen-Syndrome-by-Proxy-Identification