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• W2016242514 abstract "Munchausen syndrome by proxy (MSBP) is a form of child abuse in which a caretaker fabricates or induces illness in a child. A variety of methods have been used for this purpose, including suffocation (1,2), poisoning (3,4), and various types of trauma (5). Although recent technological advances have made it possible to improve the health care of many children, these same tools have also led to new presentations of MSBP (6,7). The use of gastrostomy tubes is not uncommon in children who are victims of this form of abuse, because failure to thrive is a frequent symptom. The use of the gastrostomy tube as a means of assault, however, has been reported only once previously, when the tube was used to poison the child (8). It is possible that this form of abuse, especially in a child with multiple medical needs, could easily go unrecognized. This is the case of a child who was uniquely vulnerable, because of static encephalopathy and the presence of a gastrostomy tube. CASE REPORT This 2-year-old girl with a history of a seizure disorder and static encephalopathy was admitted to a local hospital with respiratory distress secondary to aspiration pneumonitis. She was treated with oxygen and antibiotics and continued receiving maintenance doses of antiepileptic drugs. On the third hospital day, the physician noted that her mental status was depressed. A random phenobarbital level was obtained that was 90 μg/mL (normal range, 20–40 μg/mL). The phenobarbital was held, and because of the patient's decreased level of consciousness, she was transferred to our institution for further management. The patient's medical history was significant for perinatal asphyxia, which left her with severe motor and developmental delays. In addition, she had a history of vomiting and failure to thrive, which led to a diagnosis of gastroesophageal reflux (GER). After numerous hospital admissions and feeding regimens, a gastrostomy tube was placed when she was 12 months of age. In the following year she continued to have multiple admissions to a number of hospitals for a variety of diagnoses, including aspiration pneumonia, phenobarbital and carbamazepine toxicity, seizure exacerbation, and continued GER with failure to thrive. She was admitted to the intensive care unit because of her depressed level of consciousness. She still needed oxygen; however, oxygen saturations, measured by pulse oximetry, remained stable during the night. Another phenobarbital level, obtained approximately 6 hours after admission, had shown continued increase to 135 μg/mL. The following morning, shortly after her mother's arrival at the bedside, oxygen saturation suddenly decreased, requiring assisted bag mask ventilation. She recovered from this episode, and approximately an hour later, a similar episode occurred. This time, her mother was witnessed placing her hand over the child's nose and mouth and watching the monitor until the oxygen saturation fell. The mother was seemingly unaware that her actions had been seen. Because of concern that the eye-witness account alone would be insufficient documentation, permission was obtained from the hospital administration to place the child under covert video surveillance. The patient was moved into an isolation room but remained in the pediatric intensive care unit (PICU) with continuous cardiorespiratory monitoring to ensure her safety. During this time, the mother's affect remained flat. She verbally expressed interest in her child's condition but appeared emotionally removed. Except for one brief appearance, the father was not present during this hospital stay. The mother and the maternal grandparents repeatedly inquired about surgical intervention for the GER. The medical staff was pursuing that option, because the child's neurologic condition made her susceptible to feeding difficulties and reflux with resultant aspiration pneumonitis, requiring frequent and prolonged hospital admissions. During the next 3 days, the patient made slow improvement, and no further episodes of oxygen desaturation occurred. The videotape, however, revealed her mother pumping air into the patient's gastrostomy tube until the patient vomited. The mother would access the gastrostomy tube, connect it to a 60-mL syringe, and pump 1 to 2 L of air into the patient's stomach. She would then quickly disconnect the tubing and syringe, hide it, and call the nurse into the room to notify her of the emesis. The diagnosis of MSBP was made, and the child was removed from the mother's custody. No further episodes of emesis were documented in the next 2 months of the hospital stay. The patient tolerated gastrostomy tube feedings without difficulty and gained weight well. Her seizures were controlled by routine doses of antiepileptic drugs, without any evidence of toxicity or difficulty with subtherapeutic levels. The child was placed in medical foster care, and the mother was charged with misdemeanor child abuse. DISCUSSION Munchausen syndrome by proxy is a form of child abuse in which a caretaker lies about or induces illness in a child. First described by Meadow (9) in 1977, MSBP has become increasingly recognized as a potentially harmful, sometimes lethal, form of abuse. Although there are no typical presentations of MSBP, some symptoms are more common, such as vomiting, diarrhea, failure to thrive, apnea, allergies, and infections. In our patient, as in most incidences, the perpetrator was the mother. In classic descriptions of MSBP, the mother appears to be medically knowledgeable and to enjoy the hospital environment, often offering support to the staff caring for her child (10). In other instances the mother may be emotionally distant and remain unusually calm in the face of serious illness in the child (11). The clinician must have a high index of suspicion in a child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent and inexplicable. The mother of our patient did not fit the classic description of an MSBP mother. She was from a rural area, uneducated, and emotionally distant. However, it is not possible to make a diagnosis of MBPS based on characteristics of the caregiver alone (12). It is defined as occurring when a patient is intentionally brought to medical attention without any identifiable source of secondary gain, which generally results in multiple medical procedures. The child's symptoms resolve when separated from the mother. Our patient had had numerous hospital admissions in her 2 years of life, during which she had undergone multiple medical procedures, including the gastrostomy tube placement, and she was about to undergo surgery again for a Nissen fundoplication. She had erratic antiepileptic drug levels unexplained by any pharmacokinetics, culminating in a phenobarbital level of 135 μg/mL. It remains our belief that the only explanation for her phenobarbital toxicity was poisoning by her mother. Other than hospital personnel, she alone had access to the child. In retrospect, it seems that she used her lack of sophistication to manipulate the medical staff into believing that she was simply incapable of properly caring for her daughter, when she had been inducing symptoms and lying about it all along. Our patient was uniquely vulnerable to her perpetrator because of her neurologic condition and the presence of a gastrostomy tube. The literature contains a number of case reports in which the victims of MSBP had gastrostomy tubes placed during the course of their prolonged illness; therefore, it is not an uncommon occurrence (13–16). In the series of patients described by Lacey et al. (13), 5 of the 10 children who were treated in the pediatric surgical service had a Nissen fundoplication, and 3 of those had gastrostomy tubes placed. The use of a gastrostomy tube to perpetrate MSBP, however, is a newly described entity. Knapp et al. (8) published the case of a 17-month-old child who had a gastrostomy tube placed for vomiting and failure to thrive. Her mother was caught using the tube to poison her with acetone. In this day of advanced medical technology it must be considered that the methods we use to treat children may put them at risk for this form of child abuse. Feldman and Hickman (17) studied the use of central venous catheters in victims of MSBP. They found that 17% of the MSBP patients had central venous catheters placed. Of the children who had central venous catheters, 13% died, and 56% had catheter-related sepsis. The deaths were directly attributable to the catheters. They concluded that the medical staff had unintentionally collaborated in harming those children by performing an unnecessary procedure and providing the perpetrator with an easy route to further injure the child. No similar study has been undertaken on gastrostomy tubes. However, based on the findings in this case as well as the case previously cited, it can be concluded that a gastrostomy tube that is placed in a victim of MSBP provides another opportunity for the perpetrator to inflict injury. Munchausen syndrome by proxy is a potentially fatal form of child abuse that can be very difficult to recognize. This is especially true in the case of children who have pre-existing medical problems complicating the clinical presentation even further. We must keep in mind that the tools we use to treat children, such as placement of central venous catheters and gastrostomy tubes may be placing our patients at greater risk for inflicted injury." @default.
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• W2016242514 title "Use of a Gastrostomy Tube to Perpetrate Munchausen Syndrome by Proxy" @default.
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