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MUNCHAUSEN SYNDROME BY PROXY
Definition
Munchausen Syndrome by Proxy is a form of child maltreatment in which an adult falsifies
physical and/or psychological signs and/or symptoms in a victim, causing the victim to be
regarded as ill or impaired by others. The falsification includes but is not limited to the
following forms of deception:
 Fabricating the presence of signs or symptoms, such as fever, seizures, hematuria,
hematemesis, and hematochezia
 Directly causing conditions, such as by administration of milk of magnesia or Syrup
of Ipecac, smothering a child to produce apnea or seizures, and injecting feces into
IV tubing to produce polymicrobial bacteremia
 Creating a false appearance of signs and symptoms, such as by repeatedly pricking a
child with a pin to simulate a rash
 Coaching the victim or others to misrepresent the victim as ill
The child may also have a valid illness.
Terminology
For many professionals familiar with the original descriptions, a diagnosis of Munchausen
Syndrome by Proxy (MSBP) implies that the motivation of the parent is to obtain attention
or comfort in the medical environment. In order to avoid the connotation of suspected
motivation, non-mental health providers can use the term Pediatric Condition
Falsification (PCF). Mental health providers assess the motivation of the parent, and their
appropriate diagnostic term is Factitious Disorder by Proxy (FDP). Thus, terminology can
be summarized as follows:
MSBP
(Medical and =
mental health term)
PCF (preferred term for use by most physician, since it does
not imply a motivation for the behavior) plus FDP (for mental
health professions, who assess motivation)
Non-physicians cannot diagnose PCF or MSBP, since a child's medical information is an
integral part of these diagnoses. Physicians can diagnose FDP, but working with a
psychologist or psychiatrist can give a more complete and credible picture.
The Perpetrators
The perpetrators in 95% of cases are the mothers. Their fabrications tend to be quite
realistic, or the physician would not be mislead, and often they have medical experience.
Approximately, 50% have had Munchausen’s Syndrome.
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The motivation of the parent may be to:
 Obtain attention or comfort as the devoted parent of a "sick" child
 Manipulate a system by child maltreatment false reports
 Keep a child dependent, such as by not attending school
 Seek help (parent overwhelmed)
 Relieve unwarranted health concerns, as in the vulnerable child syndrome
 Wish to covertly manipulate authority figures
Those mothers who seek admission to the hospital for its nurturing milieu tend to remain at
the child’s bedside, forming close relationships with the physicians and nurses.
Other Family Members
Older siblings of the victim commonly have a history suggesting they were victims of the
disorder, until the mother transferred the falsification to the younger child. Sometimes,
older siblings died under suspicious circumstances.
The fathers are generally in the home but not closely involved with the children. They do
not appear to know of the fabrication and have difficulty believing it.
Why this Disorder is Physical Abuse
As a result of the parent’s fabrications or actions, a physician orders painful and sometimes
risk-associated tests and procedures, as well as repeated hospitalizations. Some of the
children die as a result of the parent’s actions.
Formulating a Suspicion of the Disorder
Objective medical evidence includes the following:
 Finding an unexpected drug in child’s blood, urine, or stool
 Finding the mother’s blood in child’s vomitus, urine, or stool
 Observation of parent in the act of inducing illness
 Findings consistent only with an induced illness
Non-objective medical evidence includes the following:
 Persistent or recurrent illnesses for which a cause cannot be found
 Discrepancies between the history and medical findings
 Symptoms and signs that do not occur when a child is away from the mother
 Symptoms, signs, or hospital course that do not make sense
 A differential diagnosis consisting of disorders less common than Munchausen
Syndrome by Proxy
 Persistent failure of a child to tolerate or respond to medical therapy without clear
cause
 A parent less concerned than the physician, often comforting the medical staff
 Repeated hospitalizations and vigorous medical evaluations of a child without
definitive diagnosis
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A parent who is constantly at the child’s bedside, excessively praises the staff,
becomes overly attached to the staff, or highly involved in the care of other patients
 A parent who welcomes medical tests of her child, even when painful
The diagnosis can be so difficult to establish that many hospitals have instituted patient
covert video assessment to protect the child and document a parent’s actions.

Management
A reasonable suspicion of the disorder should be reported to the Child Maltreatment Hotline.
Conclusion
Munchausen Syndrome by Proxy/Pediatric Condition Falsification is a complex pediatric
disorder requiring a collaboration of physicians, nurses and social workers in its
identification and management. Although difficult to recognize, recognition and
management is essential to minimize painful tests and procedures and maintain safety of the
child.