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.