Munchausen Syndrome By Proxy (MSBP), first described in 1977, takes its name from Baron von Munchausen, an 18th century teller of exaggerated tales. In adults, the condition is Munchausen Syndrome (first described in 1951) and involves individuals who, for personal gratification, fabricate illnesses to extreme degrees resulting in unnecessary hospitalizations, surgeries, and procedures. When an illness is feigned and the child is subjected to such "treatments" for the parent's/caretaker's gratification, it is by proxy and thus MSBP. Studies show that most victims are under the age of six years (range = weeks to 11 years). The child's illness may be simulated or actually produced. Simulated illnesses represent approximately 25% of cases. In these cases, the histories are fabricated, or an illness is simulated by the perpetrator altering the child's specimens and thus laboratory tests. In the remaining 75%, the perpetrator produces an illness by inflicting it. These cases are much more dangerous. The infliction may be in the form of poisoning, smothering, injection of substances, etc. Common presentations are: repeated illness unresponsive to treatment, apnea and/or seizures, and urogenital track "problems". The children with urogenital tract "problems" are often sexually abused and the perpetrator is "allowed" to focus on the genitals in order to "treat" the child at home.
Perpetrators are usually the mother; rarely the babysitter or father is the perpetrator. A large number have some type of medical background or experience. The perpetrator appears concerned, cooperative, friendly, and supportive of the healthcare that the child is receiving. The perpetrator is not critical of the healthcare and the lack of cure/improvement of the child's condition. The perpetrator is even able to witness the care of the child including painful procedures and multiple surgeries (a sort of sadism). The gratification that the perpetrator receives is support, approval, and a form of great attention. Many of these perpetrators are depressed, isolated, and emotionally distant.
The diagnosis is difficult and requires careful investigation, interview and confrontation, and legal preparation. Such investigation requires: exclusion of all other medical entities that would explain the child's condition; video monitoring if possible of the infliction of illness; interviews with child, parent, and potential witnesses; obtaining any evidence such as poisons or medication used to inflict illness on the child; and obtaining all past medical records of the child. The prevalence of MSBP is most likely underestimated. The reported mortality is as high as 10%.

Suggested Readings:

1. Rosenberg D. Web of Deceit: A literature review of Munchausen Syndrome by Proxy. Child Abuse and Neglect. 1987;11:547-563.
2. Meadow, R. Suffocation, recurrent apnea, and sudden infant death. J Pediatrics 1990;117:351-357.
3. Bools C, Neale B, Meadow R. Munchausen Syndrome by Proxy: A study of psychopathology. Child Abuse Negl 1994;18(9):773-788.
4. Meadow R. Munchausen syndrome by proxy abuse perpetrated by men. Arch Dis Child 1998;78(3):210-216.
5. Shannon DC. Murder and video surveillance. Pediatrics 1998;102(1 pt 1) 160.
6. McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child 1996;75(1):57-61.