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Münchausen Syndrome by Proxy (MSBP) is a psychiatric disorder characterised by the adoption of bizarre behavioural-patterns by caregivers in which diseases or disorders are fabricated in individuals, usually children, for purposes which span feelings of superiority derived from deceit of persons deemed superior to the caregiver, or attention seeking. The patient under discussion was a 6 year old male brought to the hospital by his mother with complaints of repetitive and unceasing passing of stones per urethra. Upon inspection of stone specimens brought in by the parents and physical examination, the stones in question were observed to be common stones, with no reason to suggest a urolithiatic origin, leading to the suspicion of MSBP. Further questioning of both the mother and father revealed more information regarding the cause of her child's illness and strongly suggested that the stones were being physically inserted into the child's urethra by the mother--often in the father's absence--after administration of sedative-hynotic drugs.

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La presente investigación se desarrollo en el Hospital de Pediatría Juan P. Garrahan. La investigación se centro en analizar un fenómeno complejo tanto en su diagnóstico como en su tratamiento el Síndrome de Munchausen por poder. El Hospital de Pediatría Juan P. Garrahan, presenta un número elevado de casos con síndrome de munchausen, la cual constituye una forma de maltrato infantil. Aquí se simula o se produce enfermedad en un niño sano, por par te de quien lo cría, que es quien debería protegerlo y ampararlo. El objetivo final de un equipo interdisciplinario frente a este tipo de casos es, hacer un trabajo minucioso con el paciente, familia nuclear, red ampliada y personas significativas, con los recursos profesionales que correspondan, al contexto del paciente, a la red institucional (contra referencia), a fin de que ese niño no vuelva a sufrir ninguna forma de daño intencional. Como obstáculo para el tratamiento y seguimiento de estos niños y sus familias, en la práctica profesional de este Servicio Social, se observa escasa cantidad de equipos profesionales y centros especializados para tal fin, como así también interrogantes acerca de los resultados de las estrategias de intervención de las instituciones a las cuales se derivan estos niños y sus grupos familiares.

The present study was conducted at the Pediatric HospitalJuan P. Garrahan. The study focuses on the phenomenonof Munchausen by proxy syndrome, a complex syndromeboth in its diagnosis and treatment. At the Pediatric HospitalJuan P. Garrahan a high rate of cases of Munchausen by proxy syndrome, a form of child abuse, is found. In this syndrome the parent or caretaker, who is supposed to protectthe child, deliberately makes the child sick or simulates anillness. The main aim of an interdisciplinary team managingthese cases is to closely work with the patient, the close and extended family, and persons important to the child withthe necessary professional resources in an institutional net-work (counter referral) to protect the child from further intentional harm. In the practice of the Social Service of this institution, the main obstacle in the treatment and follow-up of these children and their families is the scarcity of professional teams and centers specialized in the syndrome as well as uncertainty about results of interventional therapies at the centers these children and their families are referred to.

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The parental investment hypothesis provides a parsimonious explanation for a wide range of sexually dimorphic traits and behaviors across countless species. In the human context, the hypothesis posits that in light of the differentially greater parental investment that human females provide to their offspring, they should be much more vested in the wellbeing of their children. Munchausen Syndrome by Proxy (MSbP) occurs when a caregiver feigns or causes a medical condition in a dependent (typically a child). In the great majority of cases, the biological mother is the perpetrator, which is thus deeply surprising from an evolutionary perspective. I propose that for a small sample of women (e.g., those suffering from specific personality disorders and who do not possess the necessary support from their husbands/partners), the parental investment hypothesis is usurped or subverted in the service of their narcissistic need for attention (especially from high-status male physicians). Hence, in the same way that infanticide can be explained from a Darwinian perspective (despite it being at first glance incongruent with kin selection theory), MSbP appears to be equally amenable to an evolutionary analysis. One can test the hypothesis by demonstrating that the sex-specificity of the disorder holds true irrespective of cultural setting and epoch. Furthermore, one can look at single-parental families (as a means of controlling for the otherwise differential access to children in dual-parent homes) to show that within this controlled environment, mothers will remain the greater perpetrators of MSbP.

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PURPOSE: To report a case of Munchausen syndrome by proxy, which manifested as recurrent bilateral keratoconjunctivitis in an infant. DESIGN: Interventional case report. INTERVENTION: The patient underwent numerous diagnostic studies, including two endoscopies, skin biopsy, conjunctival pH measurement, and a skeletal survey. She underwent daily eye examinations until the corneal and conjunctival epithelial defects resolved. MAIN OUTCOME MEASURE: Resolution of cutaneous, mucosal, corneal, and conjunctival epithelial defects. RESULTS: A punch biopsy of the right postauricular area was performed, and pathology subsequently determined that the findings seemed to be the result of an exogenous injury. The conjunctival pH was 8.0, consistent with exposure to an exogenous, caustic agent. The acute ocular lesions resolved. CONCLUSIONS: Munchausen syndrome by proxy can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough and methodical evaluation.

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The difficulties in diagnosing Munchausen Syndrome by Proxy Abuse (MSbPA) are examined. The perpetrators of MSbPA are usually the victim's primary care giver. The warning signs of MSbPA include unexplained, prolonged and extraordinary illness with the signs and symptoms only being evident when the suspected perpetrator is present. Confrontation, exclusion and covert video surveillance are all possible routes to gaining further evidence. The problems associated with covert video surveillance are explored.

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Five children (3F:2M), in the age group 1 years to 11 years, with Munchausen syndrome by proxy are reported from the Sultanate of Oman. They were seen over a four years period from 1996-1999. In all these children, the mother came up with history of uncontrolled epilepsy. Carbamazepine was the most common antiepileptic drug used. One of these children remained hospitalized elsewhere for nearly 9 months, as a case of uncontrolled status epilepticus. It took 18 months to 6 years (mean 2.8 years) to establish the diagnosis and the mother was the offender in all. The main lead to diagnosis, was the disparity between history and clinical presentation to hospital. The carbamazepine levels were several times above the upper limit of therapeutic range. Munchausen syndrome by proxy very much exists here, but is possibly less recognized and needs immediate attention to formulate policies to identify and manage these children. It is necessary to create awareness even in the medical community, to recognise this problem. There is an urgent need to develop a child protection council at the national or regional level.

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This article discusses a presentation of Munchausen Syndrome by Proxy. It is believed this factitious disorder was precipitated and grew out of the context of a postpartum depression. To our knowledge, no such case has been reported in the past and implications for new exclusion criteria defining a fictitious disorder are raised. Furthermore, reintegration of the perpetrator back to family is discussed and suggestions are made for follow-up.

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This article provides an overview of Munchausen syndrome by proxy. It examines current definitions and looks at the varied clinical presentations. The characteristics of the perpetrators are described with a view to aiding early identification and intervention.

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The literature on Munchausen Syndrome by Proxy (MSP) is reviewed to assess the extent of existing knowledge and the incidence of this syndrome among health care workers. Although use of this diagnosis appears to be increasing and broadening, it was not until the Beverly Allitt case in the United Kingdom in 1993 that this syndrome was used to explain the behaviour of a health care worker who harmed people in his/her care. However, a review of available details of previous health care workers accused of murder reveals that five shared some of the distinctive features of MSP. Although care must be taken when applying diagnoses, in view of the risk of morbidity and mortality which MSP poses for the people involved, it is important that health care workers become more informed and involved in understanding and detecting MSP.

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The awareness and involvement of pediatric nurses in the type of child abuse known as Munchausen syndrome by proxy (MSBP) was explored in this study. A questionnaire assessing knowledge about and extent of involvement in the identification of MSBP cases and demographic information was completed by 320 registered nurses (RNS) employed at a children's hospital. Fewer than half of the subjects (47%) responded that they had heard of MSBP. Those who had heard of MSBP demonstrated only a moderate level of knowledge of the signs and signals of the syndrome. Thirty-four percent of those nurses who had heard of MSBP had been involved in the detection of cases. Findings suggest that it might be important for pediatric hospitals to include information about MSBP in their own required classes or in-house seminars.

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