Watch Out for 'Caregiver-Fabricated Illness' in Kids, AAP Warns

Healthcare professionals should be on the lookout for "caregiver-fabricated illness" in children, according to a new report released by the American Academy of Pediatrics.

The review, which is published as a Clinical Report in the September issue of Pediatrics, was developed by the AAP Committee on Child Abuse and Neglect to raise awareness and to give a broader understanding of the condition, which carries a 6% to 9% mortality rate.

Traditionally known as Munchausen syndrome by proxy, caregiver-fabricated illness describes an instance in which a parent deliberately induces health problems in a child. The newly suggested diagnostic name, the report authors note, will place the emphasis on the child, where it belongs, instead of on the motivation of the caregiver.

Although this form of child abuse is considered to be quite rare, co-lead author Harriet L. MacMillan, MD, professor in the Departments of Psychiatry and Behavioral Neurosciences and of Pediatrics at McMaster University in Hamilton, Ontario, Canada, told Medscape Medical News that "it is probably more common than we realize."

"In this report, we're saying that caregiver-fabricated illness is a serious form of maltreatment. And we want to make sure that pediatricians and others working with children know about it and know to look out for it," said Dr. MacMillan, who was also the American Academy of Child and Adolescent Psychiatry liaison to the AAP subcommittee.

She noted that although there is no typical presentation for this condition, pediatricians and other healthcare professionals should be suspicious whenever a young patient has a persistent or recurrent illness that cannot be explained or does not seem credible.

"It really comes down to conducting a very careful history and physical examination, with an emphasis on communication with all healthcare providers who have seen the child," she said in a release.

"It's important that we are thorough in seeking comprehensive information…while adhering to privacy legislation."

Name Debate

Although the condition has been known widely as Munchausen syndrome by proxy, several alternative names have been suggested for it in the past few years. These have included pediatric condition falsification, factitious disorder by proxy, and medical child abuse.

The current report is an update of one released in 2007 by the AAP subcommittee in which it called this form of maltreatment "child abuse in the medical setting."

"Just as the name has been under debate, the definition has been controversial, partly because early definitions often included the offender's motivation," write the authors.

"Caregiver-fabricated illness in a child is best defined as a maltreatment that occurs when a child has received unnecessary and harmful or potentially harmful medical care because of the caregiver's fabricated claims or signs and symptoms induced by the caregiver," they write.

In addition to urging clinicians to be on alert for the condition, the new report asks for an agreement among the field on appropriate terminology and discusses possible approaches for assessment, diagnosis, and interventions.

Past literature reviews have noted that the most common symptoms include bleeding, diarrhea, apnea, vomiting, rash, and central nervous system depression. Cases of caregiver-fabricated emotional and behavioral conditions, including psychosis and attention-deficit/hyperactivity disorder, and allegations of sexual abuse have also been reported.

Don't Delay Reporting

In addition, the National Poison Data System reported receiving 1437 calls from 2000 to 2008 that were coded as "malicious" exposures to pharmaceuticals in children younger than 7 years. The most common of these were ethanol, laxatives, and benzodiazepines.

"Although fabricated illness in a child is relatively rare, best estimates suggest that health professionals will likely encounter at least 1 case during their career," write the authors.

"The reported incidence is approximately 0.5 to 2.0 per 100,000 children younger than 16 years," they add.

The authors note that "any reasonable suspicions of child abuse" should be reported to child protective services, which is mandated by state laws. However, a past review study showed that only one third of this type of suspected abuse has been reported.

"This is the type of condition where it is essential for clinicians to review medical records and speak with other healthcare providers to have complete information in conducting their assessment," said Dr. MacMillan.

"But if clinicians suspect this, then it's important that they report it and not wait until they have absolute certainty of the condition. Because doing that means we're going to be missing some cases."

Serious Condition

"To me, this article gave very good information, but it doesn't really have anything new other than changing the name again," Maureen Claiborne, MD, pediatrician and specialist in child abuse pediatrics at Children's Hospital of Georgia in Augusta, told Medscape Medical News.

"The trend recently has been to get away from the Munchausen syndrome by proxy identification and to focus on the injury to the child. And they've been doing that for the past couple of years," she added.

Dr. Claiborne, who was not involved with this report, noted that although she prefers the "child abuse in the medical setting" name, "the purpose behind the name is most important and I'll use whatever is the consensus."

She added that encountering the condition is not common for most pediatricians. And although she has dealt with cases at her own hospital, the overall number has been very low.

"It's not something that even child abuse pediatricians see frequently. For us, some of the cases were verified and others were ones we researched to see if we felt like that was what it actually was," said Dr. Claiborne.

She also agreed with Dr. MacMillan that erring on the side of caution is best when it comes to evaluating any possible abuse in children.

"For years we tried to save the family for the child. And we know now that many times when we've sent the child back, it's been a seriously wrong or fatal decision. So I think you really have to be very careful and willing to look at what's going on," she said.

"With Munchausen, we looked at the injury to the child and at the motives of the caregiver. I think it's important to take the focus off the motives. It doesn't matter. Just focus on the child."

She added that the current report "is excellent in trying to bring awareness to the general pediatrician and help them to look at what they need to look at in order to not miss a case that might come by."