Medical child abuse is a complex and controversial area that is the subject of ongoing debate among child abuse pediatricians. The American Academy of Pediatrics recently defined this clinical entity as “the harm incurred when a caregiver exaggerates, fabricates, or induces symptoms of a medical condition.”1 Initially described in the late 1970s as Münchausen Syndrome by proxy,2 medical child abuse has also been referred to as factitious disorder by proxy and pediatric condition falsification. The term used in this chapter, medical child abuse, is both more inclusive and more specific than previously used terms.3
The scholarly debate surrounding the terminology used to refer to medical child abuse is less relevant for the sleep-deprived hospitalist than the urgent issue of determining whether a patient’s presentation raises concern for maltreatment. Regardless of terminology, there is expert consensus that medical child abuse is a dangerous, even potentially fatal, form of child maltreatment that too often eludes prompt diagnosis.
In evaluating whether a patient may be the victim of medical child abuse, treating physicians must keep three important questions in the forefront. First, is the child’s clinical presentation consistent with an organic disease process? If not, are the symptoms attributable to exaggeration, falsification, or induction by a parent or caregiver? If so, have the non-organic symptoms resulted in the child receiving medical interventions that are not needed and that are potentially or actually harmful?1 Cases of medical child abuse are rarely straightforward, and answering these questions accurately can challenge the even the most seasoned practitioner. This chapter addresses typical features that should raise concerns for medical child abuse and outlines ways in which these concerns can be systematically evaluated. The chapter also addresses the key question of how to prevent ongoing abuse once the diagnosis is made, and how hospital-based physicians can work as part of a multidisciplinary team to intervene to protect the abused or at-risk child.
Because medical child abuse is both under-detected and under-reported, accurate epidemiologic data are difficult to obtain. The age range of affected children spans infancy to adolescence, though cases cluster in early childhood. One study of 451 published case reports estimated an average age of onset at 4 years, and the average length of time to detection of abuse at 21.8 months. Boys and girls were affected in equal proportions, and mothers perpetrated the abuse in roughly 75% of cases. The same study found a 6% mortality rate and a 7.6% rate of serious morbidity in victims. Known siblings of victims were calculated to have a 25% mortality rate, with 61.3% exhibiting symptoms that also raised concern for medical child abuse.4 Accurate population-based figures for incidence and prevalence of medical child abuse are lacking. Recently published data from an Italian hospital in which all pediatric inpatient admissions were reviewed to identify cases of medical child abuse found a prevalence of 0.53% among this population.5
The essential element of every case of medical child abuse is that the patient’s reported or observed symptoms cannot be explained by underlying organic illness alone. Yet because it is by its very nature covert, medical child abuse is often missed. Unlike an asthma exacerbation, which is easily diagnosed by recognizable clinical signs and symptoms and responds promptly to standard treatment, medical child abuse presents along a spectrum of severity and can involve a broad variety of presenting complaints. The term medical child abuse encompasses three main types of presentation, which can occur simultaneously in the same patient1:
Report of exaggerated symptoms or of false symptoms. A parent reports that her infant has a large-volume emesis after every feed, but these symptoms have never been witnessed by a healthcare provider.
Falsification of symptoms. A parent shows a soaked spit-up cloth as proof of patient’s emesis when in fact the parent has simply poured formula directly onto the cloth.
Induction of symptoms. A parent adds ipecac to the infant’s formula to cause intractable vomiting.
When symptoms are exaggerated or falsified, the criteria for diagnosis of medical child abuse are not met until the exaggerated or falsified symptoms result in medical interventions that are not needed and could cause harm to the patient. For example, the pediatrician who evaluates the well-appearing infant with parental report of frequent large-volume emesis may opt to follow clinically without performing any workup, thereby avoiding unnecessary medical care. Conversely, the same patient may see a pediatrician who takes the history at face value and orders an extensive workup. Because the history is not true, no amount of medical intervention will lead to resolution of the vomiting. The apparently intractable nature of the disorder can lead to specialty referrals and multiple studies, formula changes, trials of medication, and even invasive medical technologies such as a gastrostomy tube or a central line for TPN. It is important to remember that in the case of such a patient with reported intractable vomiting, it is likely that the infant has seen both of the above pediatricians in succession, as the parent seeks further interventions and more intensive medical care from a series of medical providers.
In contrast to cases in which a parent or caregiver exaggerates or lies about symptoms that a patient does not have, induction of symptoms occurs when a caregiver intentionally makes a well child ill. In these cases, the patient suffers from actual illness caused by the parent or caregiver, and the harm to the child is clearly evident. The crucial distinction between simple physical abuse and medical child abuse is that in the latter, the perpetrator deceives medical providers by misrepresenting as genuine illness the symptoms that he or she caused.
The literature provides an instructive example of induced symptoms in the case of a girl whose mother beat her legs with a hammer to cause orthopedic injuries. After surgeries were performed to address the injuries, her mother introduced contaminants into the incisions, causing chronic infections. These induced medical conditions led to countless antibiotic courses and surgical procedures over the course of 8 years of treatment by puzzled medical staff.6 The involvement of the medical system in treating induced illness contrasts to the case of a parent who hits a child with a hammer to punish her and then attempts to conceal evidence of this abusive injury when it is detected. Both children are the victims of physical abuse; parental deception of medical providers and the resultant medical interventions make the first example a case of medical child abuse as well.
Pediatric inpatient facilities are ground zero for many cases of medical child abuse, and so awareness of this possible diagnosis in the medically complex hospitalized patient is essential. A patient may have been admitted due to concerns for medical child abuse, and hence the hospitalization may serve both a diagnostic and a therapeutic purpose. More commonly, however, awareness that the possibility of medical child abuse evolves over time as an underlying organic diagnosis remains elusive. These cases are usually highly complex; it is easy to lose sight of the larger clinical picture in the flurry of specialized tests and studies that may be recommended by a host of consultants. As the workup continues and new treatments are trialed, the patient will typically show no response or develop new symptoms. This is because, in the words of one expert, “treatment given for nonexistent illness is seldom successful.”3
The literature on medical child abuse still consists mainly of case reports and case series. Few articles have been published that present rigorously collected data in order to classify common presentations. Table 42-1 presents clinical features commonly associated with cases of medical child abuse, regardless of the reported diagnosis. Although certain characteristics recur, the possibilities are nevertheless infinitely varied. Hence Table 42-1 should be used to rule in rather than rule out suspected cases of medical child abuse. Table 42-2 presents common clinical presentations, which in the absence of verified organic etiology should raise concern for medical child abuse. While no one characteristic or diagnosis is definitive, awareness of common themes can inform the approach to these complex patients.
Presenting History Does not fit typical or common presentation of any illness Exceedingly complex presentation or “worst ever” case3 Multiple diagnoses involving different organ systems12 Symptoms via parental report only Reported diagnosis of underlying organic disease in the absence of medical verification Past Medical History Large volume of medical records Previous involvement of multiple hospitals and specialists History of conflict with prior providers Multiple diagnostic modalities and therapeutic interventions Multiple medications Multiple reported allergies12 Family History Parent or sibling with complex medical history or reported serious illness Death of a sibling from any cause Failure to disclose the birth of a child no longer in parental custody or no longer living3 Hospital Course Other family members marginalized or absent Caregiver rarely leaves bedside Physicians and staff know parent or caregiver by first name Large footprint on the ward or in the hospital Intense involvement of or special relationship with a particular physician to the exclusion of others Strong or polarizing feelings about family, either positive or negative, on treatment team Unexplained setbacks and treatment failures New complaints that arise while patient is hospitalized |
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