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PubMed1990

Munchausen syndrome by proxy: father as a perpetrator.

We conclude that fathers, as well as mothers and female caretakers, can be the perpetrators in Munchausen syndrome by proxy. Those same fathers may be even more difficult to detect when they do not fit previously described personalities and traits associated with mothers. We do not know if this case was an isolated incident or if some cases go undetected because fathers are not suspected as perpetrators. We hope that the case described in this article will alert the medical community to the possibility of either parent as a perpetrator in Munchausen syndrome by proxy.

Adult↗
PubMed1989

Psychologic morbidity of children subjected to Munchausen syndrome by proxy.

Munchausen syndrome by proxy is being recognized and reported with increasing frequency, which suggests that it is more common and occurs with a wider spectrum of severity than was previously suspected. In past reports, the difficulties of detecting and documenting the syndrome have been emphasized, as well as its physical morbidity and mortality. The psychologic morbidity of Munchausen syndrome by proxy in six children is described. The children reacted with developmentally appropriate behavior problems ranging from feeding disorders in infants, withdrawal and hyperactivity in preschool-aged children, to hysterical disorders and personal adoption of Munchausen syndrome behavior in adolescents. Parental psychologic and behavioral styles, family dynamics, and responses from legal and children's protective services systems make protection of the child within the home difficult, if not impossible. Even with protection from further physical injury, severe psychologic trauma remains likely. Extreme caution is suggested in allowing these children to remain in the family.

Adolescent↗
PubMed1987

Munchausen syndrome by proxy: considerations in diagnosis and confirmation by video surveillance.

Munchausen syndrome by proxy is a form of abuse in which the child suffers from a factitious illness induced by a parent. A case report of an 18-month-old boy who suffered from intractable diarrhea because of the surreptitious administration of laxatives by his mother is presented. The evolution of this case is discussed, as are the legal and ethical considerations in the diagnosis of Munchausen syndrome by proxy.

Child Abuse↗
PubMed1985

Munchausen syndrome by proxy: a new complication of central venous catheterization.

A recent case of supposed gastrointestinal (GI) bleeding in a small child underscored the difficulty inherent in making the diagnosis of Munchausen syndrome by proxy. In this case, an indwelling Broviac central venous catheter was used by the mother to withdraw blood which was then arranged to feign blood loss from her son's upper and lower GI tract. Despite the mother/perpetrator's displaying the classic personality traits of Munchausen syndrome by proxy, diagnosis was not made for many weeks.

Adult↗
PubMed1979

Munchausen syndrome by proxy: definition of factitious bleeding in an infant by 51Cr labeling of erythrocytes.

The Munchausen syndrome by proxy is a phenomenon in which symptoms of a disease are fabricated by some person other than the patient. This report describes and 8-week-old infant with repetitive bleeding episodes, presumably originating from the upper respiratory tract. Extensive investigations, including angiography, several endoscopies under general anesthesia, and reinfusion of the infant's red cells labeled with 51Cr followed by pulmonary and upper airway scanning, failed to reveal the source of bleeding. Within two weeks after initiation of the 51Cr studies, radioactivity of facial blood from two separate bleeding episodes did not exceed background counts. Simultaneous examination of the infant's capillary blood, however, showed moderate to marked radioactivity. The Rh subtype of the facial blood was cc, whereas the infant's type was Cc. These findings indicated that the facial blood was factitious in origin. No further "bleeding" occurred after this information was presented to the parents. This case represents an unusual example of the Munchausen syndrome by proxy. Awareness of this entity can prevent potentially harmful investigations. Documenting its occurrence and sharing the information with parents in a nonaccusatory manner may prevent future harm to the patient.

Diagnosis, Differential↗
PubMed1995

Use of fundal height as a proxy for length of gestation in rural Africa.

Lack of information on the date of the last menstrual period is a common problem in antenatal care in developing countries. The aim of this study was to see whether the fundal height can be used as a proxy for the length of gestation. A graph representing the expected remaining time to delivery was constructed from fundal height measurements in 7790 pregnant women delivered in a rural African hospital from 1970 to 1988. The graph was used to predict the probable week of delivery in 604 pregnant women giving birth to a singleton child in 1989. The mean deviation of the actual week of delivery from the predicted week was -0.6 (s.d. 3.4) weeks. In 270/604 cases (45%) delivery occurred within 2 weeks of the predicted week. Birthweight and perinatal mortality were strongly related to the deviation from the predicted week of delivery. The majority of perinatal deaths (34/50, 68%) occurred in children delivered early. The fundal height, as measured by paramedicals in routine antenatal care in rural Africa, may be used as a proxy for the length of gestation when the date of the last menstrual period is not known.

Birth Weight↗
PubMed1993

Could distance be a proxy for severity-of-illness? A comparison of hospital costs in distant and local patients.

OBJECTIVE: We test the hypothesis that hospital costs, after adjusting for DRG mix, are higher in distant patients than in local patients. DATA SOURCES AND STUDY SETTING: Data were obtained from the Washington State Commission Hospital Abstract Reporting System (CHARS) and included all patients discharged from 15 metropolitan hospitals in the state of Washington during fiscal year 1987 (N = 181,072). STUDY DESIGN: Distant patients were initially defined as those patients residing outside a 15-mile radius of the hospital from which they were discharged; all other patients were considered local. Distance was determined using the patient's residence zip code. Hospital charge, calculated for all patients regardless of payer, served as a proxy for cost and was adjusted using the DRG weight. PRINCIPAL FINDINGS: Average charge (adjusted for DRG weight) was higher for distant patients in all but two hospitals. Overall adjusted charge for distant patients was 15 percent higher (p < .001). This finding persisted when different distances were used to dichotomize distant and local patients. When the 20 most common DRGs were examined individually, little charge difference was found in surgical DRGs that require tertiary center services (tertiary DRGs) and in those DRGs with both moderate and predictable resource use (routine DRGs); the charge difference seemed most prominent in those DRGs with a wide array of possible resource use (heterogeneous DRGs). CONCLUSIONS: Results suggest that patients traveling long distances use more resources and incur higher hospital charges than local patients. This is not accounted for in prospective payment. We postulate that distance might serve in part as a proxy for severity-of-illness.

Catchment Area, Health↗
PubMed1997

Why perinatal mortality cannot be a proxy for maternal mortality.

In recent years, the perinatal mortality rate (PNMR) has been proposed as a proxy measure of maternal mortality, because perinatal deaths are more frequent and potentially more easily measured. This report assesses evidence for an association between these two statistics. This study, based upon data from Matlab, Bangladesh, shows that the maternal mortality ratio (MMR) and the PNMR do not vary together over time, and that the PNMR does not reliably indicate either the magnitude or the direction of change in the MMR from year to year. Statistical analysis shows that the correlation between the PNMR and the MMR is not significantly different from zero. An examination of the major causes of maternal and perinatal deaths indicates that the two measures cannot be expected to vary together. Almost half of perinatal deaths result from causes that do not pose a threat to the mother's life, and almost half of maternal deaths result from causes that do not lead to perinatal death. Monitoring of the PNMR can give an inaccurate picture of maternal mortality and should not be used as a proxy.

Bangladesh↗
PubMed1998

Is use of mechanical ventilation a reasonable proxy indicator for coma among Medicare patients hospitalized for acute stroke?

OBJECTIVE: To ascertain whether use of mechanical ventilation on admission to the hospital is a proxy indicator of coma (i.e., very severe stroke) among acute stroke patients. METHODS: A secondary analysis of data from a medical record review on a nationally representative sample of 2,824 Medicare patients, ages 65 years or older, who were hospitalized for stroke in 1982-1983 or 1985-1986 in 297 acute care hospitals in 30 areas within five geographically dispersed states. RESULTS: Use of mechanical ventilation on the first day of hospitalization was significantly associated with level of consciousness on admission: < 2 percent of noncomatose patients versus 17.5 percent of comatose (p < .001). With a high specificity and high likelihood ratio for a positive test, use of mechanical ventilation on the first day of hospitalization ruled-in coma. It was also significantly associated with severity of illness, prognostic indicators (i.e., admission through the emergency room, admission to intensive care, and having a "do-not-resuscitate" order written during the hospital stay), and with in-hospital death. Adjusting for patient demographics, stroke type, comorbidity, and process of care, early initiation of mechanical ventilation remained significantly associated with both coma and in-hospital death. CONCLUSIONS: A stroke patient's use of mechanical ventilation on the first day of hospitalization is a valid proxy indicator of level of consciousness.

Aged↗
PubMed1996

A mother's complaints of overeating by her 25-month-old daughter: a proposal of anorexia nervosa by proxy.

The following is a report on a case of a 25-month-old girl brought in by her mother with complaints of overeating. The patient was referred to the Psychiatric Clinic of Nagoya University Hospital from the Department of Pediatric Surgery. The mother indicated the patient to have begun overeating before the age of 1 year. However, the patient was of low height and low body weight, and appeared, rather, to have been underfed. The issue was the mother placing severe restrictions on the child's diet, pathologically afraid of the child overeating. The mother seemed to have been suffering from a disorder similar to anorexia nervosa, although not typical. Her fear that her child might eat too much was believed to be a projection of the mentality characteristic of anorexia nervosa on to her child, which would justify labeling the child's condition anorexia nervosa by proxy.

Adult↗
PubMed1999

A case of Munchausen syndrome by proxy presenting as a medical negligence action.

The parents of a child who was transported lifeless to a hospital initiated a medical negligence action. Only after discovery did it become clear that the mother, suffering from a disorder known as Munchausen syndrome by proxy, caused the death of the child. The case presented a number of complex evidentiary and litigation issues likely to be encountered by other medical-negligence defense attorneys.

Adult↗
PubMed2000

[Proxy decision in health questions and advance designations by patients. A practice-oriented review of the legal and ethical problems in treating the incompetent patient].

Except in emergencies, the medical treatment of incompetent patients also has to be based upon an informed consent between the physician and a legitimate legal representative (durable power of attorney). Consequently, the German 'Betreuungsrecht' advices persons to designate in advance such a proxy or surrogate. However, an additional court-decision is demanded, if a medical measure poses significant risks for the future health or the life of the incompetent patient. On the base of the available epidemiologic data we illustrate that neither our medical nor our legal system could realistically cope with the practical consequences of this legislation: The vast majority of our present decisions in such cases is not covered by a legally valid informed consent, which implies possible forensic consequences. This article provides relevant clinical and legal advice on how to protect the legitimate interests of all concerned within the present framework, which should urgently be revised.

Animals↗
PubMed2004

Suffocation and poisoning--the hard-hitting side of Munchausen syndrome by proxy.

Munchausen syndrome by proxy (MSBP) is a severe and difficult to diagnose form of child abuse characterised by the simulation, aggravation or production of symptoms of illness in a child by an adult. MSBP often leads to multiple hospitalisations and has a high mortality and long-term morbidity. This study describes the cases of 5 families with 8 children affected who presented with unexplained neurological or gastrointestinal symptoms or even loss of consciousness. All were victims of poisoning or suffocation by their mothers. Two of those children died and were initially diagnosed as SIDS or natural death, respectively. They were only recognised as MSBP victims after another sibling had fallen ill with similar symptoms. The cases are discussed in consideration of the relevant literature. In addition warning signs of this forensically relevant syndrome and a strategy for the management of suspected MSBP cases are described.

Asphyxia↗
PubMed2006

[When health care professionals become unwillingly involved in child abuse: the Munchhausen-by-proxy syndrome].

Reports on seemingly caring mothers, who at the same time fabricate or provoke clinical symptoms in their children and subsequently expose them to potentially harmful medical procedures, are hardly believable at first sight. Nevertheless the steadily growing number of reports on this kind of child abuse, known as Munchausen-by-proxy syndrome, points to a significant number of undetected cases. The interactional involvement of health care professionals in the abuse tends to impede diagnosis, and, as a consequence of the syndrome, usually leads to violent emotional reactions, which require careful analysis and professional handling.

Child↗
PubMed1993

Munchausen syndrome by proxy: patterns of presentation to pediatric surgeons.

Munchausen syndrome by proxy is an increasingly reported insidious disorder in which illness in a child is fabricated and/or induced by the parent. Over a 5-year period at North Carolina Children's Hospital 10 such children were identified after having presented to the Pediatric Surgical Service. In reviewing this experience, we have identified two patterns of presentation. Apnea, seizures, and cyanosis comprised the pattern most frequently seen in infants. A history of persistent diarrhea and vomiting, although seen in two infants, was the more common pattern in older children. As they got older, four of the infants subsequently were noted to have the childhood pattern of symptoms. The mother was the perpetrator in all cases with the child's illnesses being induced by a number of different mechanisms. The most useful diagnostic tool proved to be isolation of the child from the parent. Resolution of symptoms in parental absence was a consistent finding especially in fabrication cases and was the key to diagnosis. Video telemetry confirmed the diagnosis in two infants and screens for toxins were diagnostic in three others. Awareness of patterns of presentation and parental behavior is critical to establishing an early diagnosis and avoiding needless diagnostic and operative procedures.

Adolescent↗
PubMed1994

Munchausen syndrome by proxy: a study of psychopathology.

Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.

Adolescent↗
PubMed1994

Munchausen syndrome by proxy: unusual manifestations and disturbing sequelae.

Since the initial description of Munchausen Syndrome by Proxy (MSBP) (Meadow, 1977), numerous cases have been reported varying from as simple as the complaint of a nonexistent symptom to those as complicated as altered laboratory tests leading to the false diagnosis of cystic fibrosis (Orenstein & Wasserman, 1986; Rosenberg, 1987). We report three findings previously unreported: esophageal perforation, retrograde intussusception, and tooth loss. Bradycardia has been previously reported associated with suffocation (Meadow, 1984), but in our case may have been caused by carotid artery massage. We also suggest possible induction by the mother of premature rupture of fetal membrane leading to delivery of infected infants.

Bradycardia↗
PubMed1995

Munchausen by proxy victims in adulthood: a first look.

Very little is known about the long-term impact of Munchausen by Proxy abuse on children, as many victims probably are never identified and most have been lost to follow-up soon after termination of protective services supervision. This exploratory study examined the childhood experiences and long-term psychological outcomes for 10 adults, ranging from 33 to 71 years of age, who were self-identified victims of illness fabrication by a parent. Subjects completed a 33-item questionnaire including demographic and open-ended questions and a checklist of PTSD symptoms, supplemented by telephone interviews. Subjects described a range of experiences from poisonings and induced bone fractures to symptom exaggeration. Subjects generally felt unloved and unsafe in childhood; a few were directly aware of their parent's deceptions. They made limited attempts to alert others, with little success. Subjects reported significant emotional and physical problems in childhood, and problems in adulthood including insecurity, reality-testing issues, avoidance of medical treatment and posttraumatic stress symptoms. Most of their siblings were also abused, physically or medically. Some subjects express considerable residual anger towards the abusing mothers, but a surprising degree of sympathy for the fathers who passively colluded or failed to protect. Some of the MBPS parents have continued fabricating their own medical illnesses or harassing their adult children with fabricated dramas even decades later.

Adaptation, Psychological↗