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BACKGROUND

TERMINOLOGY

Medical child abuse is a complex and controversial area that is the subject of ongoing debate among child abuse pediatricians. The American Academy of Pediatrics recently defined this clinical entity as “the harm incurred when a caregiver exaggerates, fabricates, or induces symptoms of a medical condition.”1 Initially described in the late 1970s as Münchausen Syndrome by proxy,2 medical child abuse has also been referred to as factitious disorder by proxy and pediatric condition falsification. The term used in this chapter, medical child abuse, is both more inclusive and more specific than previously used terms.3

The scholarly debate surrounding the terminology used to refer to medical child abuse is less relevant for the sleep-deprived hospitalist than the urgent issue of determining whether a patient’s presentation raises concern for maltreatment. Regardless of terminology, there is expert consensus that medical child abuse is a dangerous, even potentially fatal, form of child maltreatment that too often eludes prompt diagnosis.

In evaluating whether a patient may be the victim of medical child abuse, treating physicians must keep three important questions in the forefront. First, is the child’s clinical presentation consistent with an organic disease process? If not, are the symptoms attributable to exaggeration, falsification, or induction by a parent or caregiver? If so, have the non-organic symptoms resulted in the child receiving medical interventions that are not needed and that are potentially or actually harmful?1 Cases of medical child abuse are rarely straightforward, and answering these questions accurately can challenge the even the most seasoned practitioner. This chapter addresses typical features that should raise concerns for medical child abuse and outlines ways in which these concerns can be systematically evaluated. The chapter also addresses the key question of how to prevent ongoing abuse once the diagnosis is made, and how hospital-based physicians can work as part of a multidisciplinary team to intervene to protect the abused or at-risk child.

EPIDEMIOLOGY

Because medical child abuse is both under-detected and under-reported, accurate epidemiologic data are difficult to obtain. The age range of affected children spans infancy to adolescence, though cases cluster in early childhood. One study of 451 published case reports estimated an average age of onset at 4 years, and the average length of time to detection of abuse at 21.8 months. Boys and girls were affected in equal proportions, and mothers perpetrated the abuse in roughly 75% of cases. The same study found a 6% mortality rate and a 7.6% rate of serious morbidity in victims. Known siblings of victims were calculated to have a 25% mortality rate, with 61.3% exhibiting symptoms that also raised concern for medical child abuse.4 Accurate population-based figures for incidence and prevalence of medical child abuse are lacking. Recently published data from an Italian hospital in which all pediatric inpatient admissions were reviewed to identify cases ...

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