PC2042: Why Can't I Grow? Munchausen Syndrome by Proxy in a 5 Week Old Infant

Introduction: Munchausen syndrome by proxy (MSP), more recently known as Factitious Disorder Imposed on Another, is a serious form of abuse that is characterized by deliberate fabrication or induction of illness in another. The exact prevalence of MSP is unknown due to the deception component of the diagnosis but is estimated to be 1%. There is an average age of 48.6 months at time of diagnosis and an average time from onset of symptoms until diagnosis of 21.8 months. Notably, 7% of diagnoses have been made post-mortem.

Case Description: A 1.5-month-old infant was brought to the Emergency Department by his mother due to concerns for failure to thrive after leaving AMA from an outside hospital where he had been admitted since he was 10 days old. Extensive evaluation at the outside hospital, revealed only mild GERD and laryngomalacia. As the patient surpassed 1 month of age and still had not regained his birth weight, the care team became concerned about parental feeds and placed staff in the room to observe feeds; during that time, the patient started gaining weight. The patient’s mother became uncomfortable with this arrangement and refused supervision, after which the patient lost weight and struggled with weight gain. CPS was contacted and the mother requested a transfer to our facility for further evaluation. We accepted the transfer, however the mother left AMA to drive to our institution with the patient. Upon admission to our facility the patient was placed under video surveillance (VS) due to concerns for MSP. On day 2 of admission, the mother was observed inserting her fingers into the patient’s mouth and holding them there until the infant vomited on three separate occasions. The mother was removed from the bedside by law enforcement and CPS assumed custody; the patient has since tolerated full feeds with appropriate weight gain.

Discussion: Barriers to diagnosis and intervention include a failure to consider MSP as a diagnosis, a reliance on parents to provide accurate information, the recognition of patterns of presentation and parental behaviors associated with this abuse, and difficulty in obtaining conclusive proof needed for legal action and intervention. In our case, thorough communication of the outside facility’s previous workup was key in eliciting suspicion for MSP and persistent advocacy was necessary to overcome administrative reluctance to establishing VS. As a result, this patient was diagnosed at an age not previously reported in the literature.

Conclusion: This case highlights the importance of communication and advocacy in our practice as pediatricians. In patients whose reported symptomology remains inconsistent with clinical evaluation despite evaluation and treatment, MSP should be considered and acted upon. This case also brings up important ethical and legal questions that require further exploration.