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Am Fam Physician. 2008;77(1):97

Guideline source: American Academy of Pediatrics

Literature search described? No

Evidence rating system used? No

Published source: Pediatrics, May 2007

Munchausen syndrome by proxy is a form of child abuse involving both physical abuse and medical neglect. It occurs in the medical setting when a parent or caregiver causes injury to a child by seeking or administering unnecessary and possibly harmful medical treatment for the child. Although Munchausen syndrome by proxy is a rare circumstance, physicians need to consider it when treating a child with seemingly inexplicable findings or failed treatments. For a child whose illness is fabricated by a caregiver, the prognosis may be poor if the abused child is left in the home. The American Academy of Pediatrics (AAP) has identified factors that may help physicians recognize this form of child abuse and has provided recommendations on when to report a case to their state child protective services agency.

Continuing unnecessary medical care may become abusive to the child if the parent or caregiver is consistently misrepresenting or making up symptoms, manipulating laboratory tests, or intentionally inflicting harm on the child to create symptoms. The AAP advises physicians to consider three questions that may help diagnose this condition: (1) Are the history, signs, and symptoms of disease credible?; (2) Is the child receiving unnecessary and harmful or potentially harmful medical care?; and (3) If so, who is instigating the evaluations and treatment? In determining whether signs and symptoms have been fabricated, physicians need to gather relevant information from everyone involved and report concerns to other health care professionals and social service workers. A thorough evaluation of medical charts and clear communication among medical professionals are important in making a proper diagnosis.

The state child protective services agency should be informed if the parent or caregiver is harming the child and will not cooperate with the child's physician in limiting the amount of medical care to an appropriate level. Medical child abuse should be reported in the same way as physical and sexual child abuse if the parent or caregiver continues to harm the child. Care of the abused child may include a multidisciplinary approach that involves primary care physicians, medical subspecialty consultants, dietitians, physical therapists, and social service workers. Treatment considerations include ensuring the child's future safety and allowing treatment to occur in the least restrictive setting possible.

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