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This case may be cited as: Summary: A child starting at the age of six months was diagnosed with ulcerations of the digestive tract. His treatment and complications would persist well into the age of seven. Identification of Munchausen victims is notoriously difficult under the best of circumstances. In this case, the victim was a child admitted to a Massachusetts Hospital for a Central Venous Catheter, line infection. The suspicion, diagnosis and treatment were carried out promptly. The patient was a seven year old child who had been diagnosed with extensive ulceration of the digestive tract at the age of six months. From the very start of the child's "illness" subtle irregularities might have been noted, specifically, the fact that digestive tract ulcers in infants is almost unheard of. "Primary gastric ulcers are rare in childhood, their etiology is unclear and a hereditary predisposition has not been established."2 Treatment at the time consisted of the insertion of gastrostomy and jejunostomy tubes which delivered nutrition directly to the stomach and small intestines respectively. A central venous catheter for parenteral nutrition was also placed. Under normal conditions, this "bypassing" of the upper digestive tract is a temporary measure. Usually within a few weeks to a few months, the tissues and lining of the digestive tract are able to "heal" and normal function can be restored. Once normal function is found to be present, the enteral and intravenous nutrition infusions are usually discontinued in controlled weanings. In this particular case, the alternate nutritional supplementation would continue for over six and a half (6.5) years. This continued despite the child's requests for food by mouth. It was documented that when the child told its mother that it was hungry, her reply was "It will make you sick." Worthy to note is the fact that during this prolonged period of treatment, the child would be admitted frequently for suspected and later confirmed central line infections. This is highly unusual in a patient with no other known predisposing factors for infection. "Infection is a well-recognized complication of all types of catheters. Infections are potentially life-threatening, particularly in patients with neutrophil counts of less than 500 cells/mm. Local infections, including exit site and port pocket, and tunnel infections can occur, as well as systemic infections from colonized thrombi or fibrin sleeves or from intraluminal or extraluminal catheter colonization."3 Examination/evaluation of the child's immune function found no deficits which would make him more susceptible to infection than a normal child in the same situation. "Reported catheter-related infection rates vary greatly, from 2.7% to 60%.47 These differences are likely related to a number of interrelated factors including the immunocompetence of the patient, the number of catheter lumens or types of devices placed, the development of extraluminal thrombosis, the patient's primary diagnosis, and the protocol of catheter care. Furthermore, there are differences in the manner in which catheter infection rates are reported. The most common measure is based on the number of infective episodes per 1,000 days of catheter use."3 Cultures and sensitivities to evaluate the infections would show an "unusual" variety of infecting organisms. The identified causative agents were not, the common bugs one would expect from a typical central line infection. This "irregularity" was noted repeatedly and would later prove significant. "Formerly, gram-negative aerobes from the gastrointestinal tract (i.e., Escherichia coli, Klebsiella, Pseudomonas aeruginosa) caused most infections. Today these cause 25% to 33% of infections, while gram-positive aerobes from the skin (i.e., Staphylococcus aureus, S. epidermis, and streptococcus species) are implicated in more than 50% of all infections.43,44 Candida species are isolated 5% to 7% of the time. Coagulase-negative cocci, which are normal skin flora, have a high pathogenic potential when introduced through catheter insertion or other procedures that violate intact skin."3 Care of the child's central venous catheter lines and parenteral nutrition was performed by licensed nursing personnel using standard protocols, procedures and precautions. Despite this, the infection rate noted was found to be seven times what would normally be expected for a patient receiving Total Parenteral Nutrition (TPN). "Another risk factor for infection may relate to the primary diagnosis and the medical indication for catheter placement. Some studies document a greater number of catheter-related infections in patients whose catheters are placed primarily for TPN or chemotherapy than in patients whose catheters are placed for antibiotic therapy."3 On the admission of November 1996, a central line infection was again identified and treatment initiated. The treatment administered would turn out to be life-threatening. A transfer to the Pediatric Intensive Care Unit (PICU) was indicated and performed. In the PICU, the child's medical history was closely examined. The prolonged parenteral/enteral nutrition and frequent admissions for central line infections were noted and scrutinized. Interviews with the parents led to suspicions that the mother may be contributing to the child's illness. This suspicion was reinforced when the suggestion was made to "wean" the child off the alternative nutrition in controlled trials. The mother objected to the notion strenuously. Despite repeated attempts to explain to the mother that this treatment may no longer be needed, the mother would not give her consent for the controlled trials. Following this, the mother raised further suspicions by refusing from that point on to cooperate with the doctors' treatment plans or requests for previous medical records. At this point, a formal complaint/inquiry was initiated by a Pediatric fellow and the diagnosis of "Munchausens's by proxy" established. "The term "Munchausen Syndrome by Proxy" (MSBP) was coined in a 1976 report describing four children who were so severely abused they were dwarfed. In 1977, Meadow described a somewhat less extreme form of child abuse in which mothers deliberately induced or falsely reported illnesses in their children. He also referred to this behavior as MSBP."4 Once their suspicions were documented and a working diagnosis established, treatment was initiated and the lack of consent of the mother overruled by the Department of Social Services of Massachusetts. The child's multiple medication regimen was completely discontinued. Weaning of the parenteral nutrition was begun, oral feedings were initiated and well tolerated. Visitation privileges of the mother were restricted and a 24 hour watch/observation protocol initiated. When the mother learned of the physicians new treatment plan, she objected strenuously and vocally. She stated that "she regretted bringing the child to that facility for treatment." She repeatedly told the child at every opportunity that "he was going to be sick," over and over again. This behavior was documented and communicated to the State's Child Protective Services Division. Once the weaning was initiated, the child's progress was swift. No need to continue the previous feedings or medication regimens was demonstrated. The child was placed in the protective custody of his Aunt and Uncle in a foster home setting. He would remain there for three years while legal proceedings were taking place. It is pertinent to note that in the first three years of this custody arrangement, no medical problems or concerns were documented. From the body of evidence collected during the child's stay, it was clear that the mother was unfit to care for her child. Arrangements were made for the child to be put up for adoption. The laws in effect at that time required parental consent before an adoption could be completed. Again, the boy's mother strenuously objected to the notion of her child being taken away from her and put up for adoption. The department of Social Services would petition the Juvenile Court of Boston to waive the parental consent requirement. This petition was granted based on the large body of evidence detailing the mother's past history of caring for the child. The mother would appeal this decision. Questions to be answered: 1. Was there sufficient evidence present to support a working diagnosis of Munchausen's Syndrome By Proxy. 2. In view of the length of the child's intensive treatment and the "irregular" nature, why wasn't it picked up sooner during the six and a half years duration of therapy. Why were the "red flags" not noted by the doctors and nurses engaged in the child's care. On appeal, the decision to waive the parental consent was affirmed by the appellate court. The mother's behavior during the child's treatment was judged to be consistent with Munchausen's Syndrome By Proxy. Contributing to this decision were the following: a. The original presenting situation, gastric ulcerations in a six month old child. A condition almost never seen in the normal developing infant in the absence of congenital abnormalities which this child did not have. b. The fact the mother refused to allow her child to be weaned off the treatment regimen even after it was explained to her that it may no longer be necessary. c. The repeated affirmations throughout the hospital stay by the mother to the child that "he would get sick" without his treatments. d. The history which would show a pattern of consulting multiple physicians and bringing the child to multiple facilities for treatment. Each time offering little or no prior medical history. e. The high incidence of central line infections despited skilled nursing care given. The fact that the organisms found were not the typical infecting bugs found raised further suspicion. Proving a case of Munchausen's syndrome is notoriously difficult in most instances. Some tell-tale signs that may raise initial suspicions include: 1. A history of switching physicians and treatment facilities frequently. 2. Multiple admissions frequently for the same or similar conditions. There are some signs and symptoms of the disease that health care professionals can be aware of and look out for. "Warning Signs of MSBP: Children at risk for MSBP abuse are aged 15 months to 6 years. The emergency physician often is confronted with baffling symptoms. Frequently, the child has been taken to many care providers before the diagnosis finally is established. Warning signs that are suggestive of MSBP include the following: Illness is multisystem, prolonged, unusual, or rare. Symptoms are inappropriate or incongruent. Patient has multiple allergies. Symptoms disappear when parent or caretaker is absent. In children, one parent, usually the father, is absent during hospitalization. History of sudden infant death syndrome in siblings is noted. Parent is overly attached to patient. Patient has poor tolerance of treatment (eg, frequent vomiting, rash, problems with intravenous lines). General health of patient clashes with results of laboratory tests. Patient shows inordinate concern for feelings of the medical staff. Seizure activity is unresponsive to anticonvulsants and is witnessed only by parent or caretaker."5 Nursing, healthcare professionals and social workers are required by law, to report actual or suspected cases of child abuse. Elder and other types abuse are slowly starting to fall under protective legislation. Munchausen's Syndrome By Proxy as illustrated above is one of the more difficult types of abuse to pick up on. When in doubt, just as you would with a patient you suspect is going downhill, examine and assess a bit more closely. It may save a life. Related Link Sections:
Munchausen Syndrome By Proxy, Psychiatric & Mental Health Resources
Abuse, Abuses, Abusive, Direct Patient Care, 452 Distinct Websites
Central Venous Catheters, Central Lines:
Gastric, Peptic, Duodenal Ulcers, Ulcerations, Gastrointestinal Disease:
Infectious Diseases, Infection Control, Direct Patient Care, 472 Distinct Websites:
Intravenous & Infusion Therapy Links :
Pediatric Cardiology:
Pediatric Intensive Care Units, PICU:
Pediatric Nurses:
Pediatric Organizations: Related Clinical Nursing Cases:
June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
July 18, 1999: Good Samaritan Laws & Acts. Do They Cover Nurses Volunteering Nursing Care When A Citizen Goes Anaphylactic.
June 20, 1999: Organ Donation Informed Consent, Is A Single Parent's Sufficient? References: 1. 41 NLRR 4 (September 2000) 2. Vanderbilt Medical Center. Tuesday, 16 June 1998. Gastroenterology: Primary Gastric Ulceration. Retrieved March 12, 2001 from the World Wide Web: http://www.mc.vanderbilt.edu/peds/pidl/gi/gastulcr.htm 3. Rita Wickham, MS, RN; Sandra Purl, MS, RN; and Diane Welker, MS, RN. August 1996. Medithesis. "Long-Term Central Venous Catheters: Issues for Care." Retrieved from the World Wide Web March 20, 2001 from the World Wide Web: http://www.meditheses.com/997-962.htm 4. Asher-Meadow. No Date Given. "What Is MSP?" Retrieved from the World Wide Web, March 12, 2001: http://www.bcpl.net/~agravels/Whatis.htm 5. Mason, Jon Donovan. February 12, 2001. Emedicine.com. "Munchausen's Syndrome By Proxy." Retrieved April 5, 2001 from the World Wide Web: http://www.emedicine.com/emerg/topic830.htm http://www.nursefriendly.com/nursing/clinical.cases/2001/051301.htm This page was created on Tuesday, May 13, 2001
Last updated by Andrew Lopez, RN on March 23, 2017
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