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Cover page of the Journal of Health Sciences


 
 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 178-182

Fabricated or factitiously induced illness in a neonate: A case report and review of literature


1 Department of Paediatrics, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Psychiatry, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication18-May-2018

Correspondence Address:
Hafsat Umar Ibrahim
Department of Paediatrics, Bayero University, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_80_17

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  Abstract 


Fabricated or factitiously induced illness (FII) is a form of child abuse in which a caregiver imposes an illness on a child for some attention or gains. These gains could be financial or psychological. It is also known as Munchausen Syndrome by Proxy. In our clinical setting, the patient load is usually high and documentation is not adequate. Most cases could go unnoticed or undiagnosed due to work pressure. The case highlights a neonate with multiple admissions due to induced, imposed, and exaggerated illnesses by a mother, to get financial and psychological attention from the husband. She was found to have severe depression and background borderline personality disorder after a psychiatric evaluation. A high index of suspicion and communication between health-care providers including documentation helps in early detection of these children with FII. The need to further investigate and rule out risk factors in caregivers and child cannot be overemphasized.

Keywords: Fabricated, induced illness, Munchausen Syndrome by Proxy


How to cite this article:
Ibrahim HU, Mohammed A, Takai MG, Usman F, Farouk ZL. Fabricated or factitiously induced illness in a neonate: A case report and review of literature. Indian J Health Sci Biomed Res 2018;11:178-82

How to cite this URL:
Ibrahim HU, Mohammed A, Takai MG, Usman F, Farouk ZL. Fabricated or factitiously induced illness in a neonate: A case report and review of literature. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2020 Feb 28];11:178-82. Available from: http://www.ijournalhs.org/text.asp?2018/11/2/178/232699




  Introduction Top


Fabricated or induced illness (FII) also known as Munchausen's Syndrome by Proxy (MSBP) is a form of child abuse in which the perpetrator is the caregiver of the child, usually the mother.[1],[2] The victim (child) is usually under 5 years. This involves convincing the child and health-care professionals that the child is ill, exaggeration of symptoms, or even induction of symptoms of illness.

It is a covert and potentially lethal form of child abuse that is difficult to recognize and deal with, hence, the importance of increasing the awareness of health-care professionals about it. A high index of suspicion is required to identify this condition.[3],[4],[5]

Roy Meadow in 1977 coined the term ™MSBP to describe a form of child abuse in which the caregiver (generally the mother) causes or simulates illness in the child for psychological gain.[6]

Later in 1994 and 2000, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and DSM-IV-TR, respectively, used the term “factitious disorder” by proxy to describe a psychiatric illness of the perpetrator who fabricates or inflicts illnesses on her/his victims.[2],[4],[7] In 2013, DSM-V used the term “Factitious Disorder Imposed by Another” instead of MBPS.[8]

In the United Kingdom, MSBP is now termed FII, although MSBP is still widely used in other countries.[9],[10] There are four diagnostic criteria for diagnosis of FII, namely:[8]

  1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
  2. The individual presents the child to others as ill, impaired, or injured
  3. The deceptive behavior is evident even in the absence of obvious external rewards
  4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.


The harm to the victim is also described as pediatric condition falsification. Most of these caregivers have some form of unresolved psychological and behavioral problems such as self-harm, drug or alcohol abuse, have experienced death of another child, and have a borderline personality disorder or benefit financially or emotionally from the child's illness.

It is a condition that should be suspected when physical signs do not tally with the history given or explanations are not consistent, the child has had multiple admissions or been to various hospitals for treatment of unexplained illness without improvement or when there are >2 unexplained sibling deaths or sudden infant death syndrome in infancy or childhood.[11]

Presentations are varied, FII may be chronic or episodic with periods of relative peace in between presentation.[12] It could be as simple as fabricating illness or as complicated as manipulation of test results such as putting sugar in urine to simulate diabetes to deliberate induction of symptoms with drugs or poison.[4],[13]

Many cases go unreported or undetected; therefore, a high index of suspicion is required to make this diagnosis. The child may be made to play a sick role, and multiple hospital admissions are common. The perpetrator may be a health worker or conversant with medical setting in most cases.


  Complications Top


Children of parents with MSBP are at risk of injury, repeated admissions, and even unnecessary invasive procedures. Mortality could be as high as 6%–10% in this form of child abuse, especially if it is chronic.[14],[15]


  Management Top


The management includes acute management and long-term management.

Any suspected cases should be reported to social services, police, and appropriate child protection agencies. In low- and middle-income countries, with poorly organized child social services (where available), this might be difficult.

The first priority is to protect the child. This will involve removal of the child from the caregiver where possible, and supervision where total removal becomes difficult. While on admission, restricting access of the abusive parent from the ward while other issues are sorted out might temporarily suffice. Identification and treatment of any psychological problem in the parent should be done. This can be difficult as most will deny and refuse to accept there is a problem. This is more so in those with personality disorder.

In Nigeria in the early 1990s, Ifere et al. reported a case spanning over 8 years. He had various admissions in several hospitals across the country and was exposed to various invasive procedures.[16] The case report was one of the few case reports of the condition from Nigeria. This paucity of reports of FII from Nigeria could be due to difficulty in the detection of cases possibly due to work pressure. Poor documentation and reporting systems in our environment, in addition to poor inter-discipline communication among health-care professionals, could be other factors responsible for few literature reports from Nigeria. We aim to report a case from Nigeria involving a neonate highlighting the challenges in making the diagnosis and the management of FII in our environment.


  Case Report Top


We report baby MA, a male neonate who was first seen at our facility at 4 h of age. The baby was referred from a private clinic where he was delivered through emergency cesarean section indication being placenta previa type II. The mother of this neonate had antepartum hemorrhage before surgery at term. The neonate was referred to our hospital on account of respiratory distress and foaming from the mouth with grunting. At the time of presentation to our facility, the mother was still at the referral hospital, and detailed information regarding pregnancy was not available. A family member (a health-care worker at another hospital) was contacted who gave the history. It was the first pregnancy of a 19 year old primi para, booked at 2 months of gestation. She was a student of a high institution, the second wife in a polygamous family setting of two wives and three children. The father was a businessman. The referral letter from the birthing hospital had inadequate information surrounding the delivery, and the Apgar scores were not documented.

On examination, the neonate weighed 2.5 kg, estimated gestational assessment using the modified Ballard charts was 36 weeks, and an occipito-frontal circumference was 33.5 cm. He was in respiratory distress, grunting with use of accessory muscles of respiration. He had a respiratory rate of 52 cycles/min and SPO2 of 85% in room air. He was conscious and had optimal primitive reflexes. A diagnosis of aspiration syndrome with differential diagnosis of early-onset neonatal sepsis with pneumonia in a near-term baby was entertained.

The baby was admitted and resuscitated. Investigations done revealed: normal random blood sugar of 4.9 mmol/L, raised mini ESR of 3 mm, low packed cell volume (PCV) of 38%, normal serum electrolyte, urea, creatinine, Ca 2+, and phosphate levels. A chest radiograph showed few pulmonary infiltrates. He was placed on intranasal oxygen at 1.5l/min (the oxygen saturation improved to 95%) and placed on empirical broad-spectrum antibiotics and intravenous fluids as par protocol of the Special Care Baby Unit (SCBU). He had top-up transfusion to raise PCV to 45%. Blood culture did not grow any organism. His condition improved on this treatment and mother was transferred from the referral hospital on the 2nd day of life. Additional history revealed no maternal risk for sepsis and baby was put to breast to initiate feeding.

The patient remained stable, breastfeeding was established, and it was adequate. He was discharged home on the 6th day of life. On the 3rd day of discharge from the hospital (9th day of life), the mother brought him for a follow-up visit. There was no new complaint, and he was examined and found to be in good health.

At the age of 20 days, the baby was rushed to the SCBU by the mother. There was a history of poor suck and abnormal body movements few hours before the presentation. He was said to be in good health and under the care of a 14 year old aunt while his mother was asleep when symptoms occurred suddenly. The aunt had fed the baby with evaporated milk; she reported being afraid to wake his mother up to feed him. The mother appeared agitated; she denied that she did not want to be woken up to feed the baby. She could not provide adequate explanations of the events leading to the onset of the convulsion or fast breathing. The old case note was not available at the time for details of the previous admission.

On examination, he was found to have tachypnea, with SPO2 of 98% in room air, there were no crepitations. A diagnosis of possible aspiration of feeds and possibility of child abuse was made. He was then admitted and placed on intravenous antibiotics and close monitoring pending investigation results. PCV was 41%, mini ESR of 2 mm/h, and random blood sugar was 7.9 mmol/L.

Results of chest X-ray showed patchy opacities suggestive of bronchopneumonia while echocardiography showed no structural abnormality. While on admission, the patient did not show any sign of illness. There were no convulsions observed, the respiration remained normal, and he was breastfeeding adequately. The patient was then discharged home after 2 days on admission.

Three hours after, he was discharged; the baby was rushed back into the SCBU with difficulty in breathing and abdominal distension. Other family members accompanied the mother of the baby to the hospital. They kept urging the mother to reveal what had happened to the infant. The mother refused to give an account of events surrounding child's symptoms and appeared agitated. This further increased our suspicion of FII and based on this, the baby, who had exceeded the unit's age cutoff, was allowed in the unit until mother's medical issues were sorted out. The father of the baby who was contacted for further information refused to come for the meeting, but a phone conversation with him revealed a history of family disharmony, violent outbursts in the mother and that she had often neglected to feed or take care of the baby. It also revealed that they were divorced.

A joint clinical conference with the psychiatrists, the social welfare, hospital legal unit, the neonatal team, the mother's parents, and other extended family members was held. Some family members disclosed that the mother was manipulative and had a strained relationship with family members.

The psychiatric review revealed that in the last 17 days the mother had been having a daily low mood, decreased energy, decreased enjoyment, frequent crying spells, early morning wakefulness, excessive guilt feelings, hopelessness, and decreased interest in the baby. Premorbidly, she was described as an impulsive person. She responds to minor disappointment with severe outbursts of anger. She often threatens to commit suicide. She had several episodes of deliberate self-lacerations in the past.

Based on the findings of the psychiatric evaluation, the mother was diagnosed with severe depression without psychotic features and comorbid borderline personality disorder. The risk assessment also revealed the baby was at risk of infanticide.

The mother was to be admitted to the psychiatry ward and to be on medication while the child was placed under the custody of the maternal grandmother and nurses in the clinical setting.

Following the joint meeting, the patient's mother and ex-husband signed discharged against medical advice form and refused to stay in the hospital. The baby was stable and was, however, discharged to the grandmother after being immunized; he was booked for a 1-week appointment for follow-up which was kept. At follow-up, he was found to be healthy with no problem.

One week after the discharge, at the age of 36 days, the infant was brought to the Emergency Pediatric Unit by the mother with a complaint of regurgitation of feeds and difficulty in breathing. The mother had opened a new hospital file for the infant and was seen and treated as an entirely new patient, with no mention of the previous admissions. The infant was found to have a normal physical examination, and the mother was reassured and counseled on feeding.

The social welfare unit of the hospital traced the family through a relative 4 months later. The baby was said to be doing well, but efforts to contact the family after that were unsuccessful.

Limitations in Management

  • Poor social welfare services
  • No functional established child protection agency/body
  • Refusal of the patient to undergo psychiatric treatment and lack of legal enforcement for treatment.



  Discussion Top


The victim in this case was a neonate and, hence, it was a bit difficult to make the diagnosis at first. Neonatal presentations are not common, with the average age at diagnosis of FII commonly being 39 months. This was because all history was obtained from the perpetrator (the mother) who was good at manipulating the symptoms to suit her needs for attention. This was typical of FII presentations, where the perpetrator is able to deceive the medical staff to suit her/his intent.[1] This infant had multiple presentations to the hospital, the mother interfering with the history and his condition and no other explanation for the recurrent respiratory distress. This is in keeping with one of the Rosenberg criteria for the diagnosis of FII that is multiple hospitalizations and tampering with the child or the medical situation.[17] History regarding the father and social setting of this child was not accurate at the initial presentation of this infant. This shows the importance of having a high index of suspicion and putting extra effort to take further history when the presentation is not as expected for clarification.

The psychiatrists were involved in the management of this case; this enables the managing team to have an insight into the bigger picture of the case and the potential danger posed by the caregiver's mental ill health which is a major risk factor for FII.[18] A multidisciplinary team was involved in the evaluation of this case, as supportive confrontation is the initial modality of treatment recommended.[19] The symptoms of this child appears to have occurred when the mother was in full conscious state of mind. This is in keeping with FII where the harming of the child is said to occur when the perpetrator is in the nonpsychotic state.[17] The involvement of the hospital management legal department, the social welfare department, and the extended family were helpful in organizing a plan of action for the management of this patient.

The dramatic improvement of this infants condition when the grandmother was made the primary caregiver, with the relapse of symptoms as soon as the infant returned under the sole care of the mother is another typical presentation of FII, where separation of the victim and perpetrator leads to abatement of symptoms.[20] Although the refusal of the patient's mother to be admitted for full treatment was a major challenge in this case, the family were made aware of the potential danger to the child and herself. Involvement of the family also made them more vigilant in observing her behavior and nurturing of the child.

The unusual family circumstances of the victim coupled with the lack of functional child protection services was another limitation. Ideally, the child could have been kept in custody of child protection services or even foster home pending, when the mental illness of the mother was treated and certified fit to take on the care of her child if a family member could not be assigned. Involvement of the grandparents in the care of this infant was in the hope that there will be extra vigilance on the mother, thereby decreasing further risk to the infant. However, the financial circumstances of the grandparents make them unable to take over the care of the infant totally. The absence of the father further enhances the vulnerability of this infant. Although the father of this infant knew that the mother had been neglecting the infant, he apparently did not do enough to protect this infant. There have been reported cases of FII where there may be a nonabusing parent residing with the victim while the abuse is going on, or the father may support their spouses and some may be accomplices in the abuse.[20],[21] The nonperpetrating father is known to be distanced from the hospital [20] as seen in this case. Marital disharmony is reportedly common in the families of victims of FII.[20]

The lack of an integrated computerized medical record system within the hospital and even the state delayed diagnosis. An integrated computerized system may ease detection of multiple hospitalizations and probably aided in making an early diagnosis.

Lack of functional child protection agencies and legal enforcement to ensure the mother gets appropriate medical care, left this infant at risk and led to the fourth presentation of this patient to the hospital. Health-care providers could not enforce the recommended psychiatric admission of the mother. This highlights some of the difficulties encountered in the management of this condition in our environment.

The family was eventually lost to follow-up. This is commonly encountered in cases of FII.[17],[20]


  Conclusion Top


This case has shown that a high index of suspicion, communication, and collaboration between health-care providers including documentation helps in early identification and management of children with FII. It has also highlighted the need for involvement of family and other support systems when dealing with a suspected case, to help diagnose and make management plans for these children. It has also shown the lack of functional child protection services in our environment when faced with immediate decisions regarding child protection and safety.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Stirling J Jr.; American Academy of Pediatrics Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in a medical setting. Pediatrics 2007;119:1026-30.  Back to cited text no. 1
    
2.
DSM IV American Psychiatric Association. Diagnostic & Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Publishing; 1994.  Back to cited text no. 2
    
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Kay J, Tasman A. Essentials of psychiatry 2nd ed. Ch. 55. Hoboken, NJ West Sussex England, Wiley 2006.  Back to cited text no. 3
    
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Lasher L. Munchausen syndrome by proxy definition, maltreatment behavior and comments 2006.  Back to cited text no. 4
    
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Zaky EA. Factitious disorder imposed on another (Munchausen Syndrome by proxy), a potentially lethal form of child abuse. J Child Adolesc Behav 2015;3:4.  Back to cited text no. 5
    
6.
Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977;2:343-5.  Back to cited text no. 6
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7.
DSM-IV-TR. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text GH Revision. Washington, D.C.: American Psychiatric Publishing; 2000.  Back to cited text no. 7
    
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.  Back to cited text no. 8
    
9.
NHS Choices. Fabricated or Induced Illness. Available from: http://www.nhs.uk/conditions/fabricated-or-induced-illness. [Last accessed on 2011 Dec 23].  Back to cited text no. 9
    
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Bass C, Jones D. Psychopathology of perpetrators of fabricated or induced illness in children: Case series. Br J Psychiatry 2011;199:113-8.  Back to cited text no. 10
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Brannon GE, Abdulhamid I, Poirier MP. Factitious Disorder Imposed on Another; 2015.  Back to cited text no. 11
    
12.
Sigal M, Gelkopf M, Meadow RS. Munchausen by proxy syndrome: The triad of abuse, self-abuse, and deception. Compr Psychiatry 1989;30:527-33.  Back to cited text no. 12
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Criddle L. Monsters in the closet: Munchausen syndrome by proxy. Crit Care Nurse 2010;30:46-55.  Back to cited text no. 13
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Sheridan MS. The deceit continues: An updated literature review of Munchausen syndrome by proxy. Child Abuse Negl 2003;27:431-51.  Back to cited text no. 14
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Christie-Smith D, Gartner C. Understanding Munchausen Syndrome by Proxy Special report: Highlights of the 2004 institute on Psychiatric Services. Psychiatry online.org 2005.  Back to cited text no. 15
    
16.
Ifere OA, Yakubu AM, Aikhionbare HA, Quaitey GE, Taqi AM. Munchausen syndrome by proxy: An experience from Nigeria. Ann Trop Paediatr 1993;13:281-4.  Back to cited text no. 16
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Schreier HA, Libow JA. Munchausen by proxy syndrome: A modern pediatric challenge. J Pediatr 1994;125:S110-5.  Back to cited text no. 17
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Waller DA. Obstacles to the treatment of Munchausen by proxy syndrome. J Am Acad Child Psychiatry 1983;22:80-5.  Back to cited text no. 18
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19.
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Morrell B, Tilley DS. The role of nonperpetrating fathers in Munchausen syndrome by proxy: A review of the literature. J Pediatr Nurs 2012;27:328-35.  Back to cited text no. 20
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21.
Awadallah N, Vaughan A, Franco K, Munir F, Sharaby N, Goldfarb J, et al. Munchausen by proxy: A case, chart series, and literature review of older victims. Child Abuse Negl 2005;29:931-41.  Back to cited text no. 21
    




 

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