Munchausen Syndrome by Proxy

Evaluating for Suspected Child Abuse: Conditions That Predispose to Bleeding

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding or bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, it is important for pediatricians to consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising or bleeding and should be considered when evaluating for abusive injury.

Fabricated or induced illness in the oral cavity in children. A systematic review and personal experience

Introduction

Münchausen syndrome by proxy (MSBP) describes a pattern in which a caregiver induces a disease in a child. The symptoms may manifest in the oral cavity.

Material and methods

PubMed was researched for articles between 1990-2014, presenting manifestations of MSPB, following PRISMA 2009 guidelines, and an in-house case of MSBP with oral manifestations was presented.

Review

Among 66 articles presenting MSBP symptoms, four included descriptions of oral lesions in five children. They included: tooth loss, ulcerations and ulcers on oral mucosa, scars due to old, healed lesions, bleeding, black tongue, polysialia, and discolouration and swelling in the lips. Münchausen syndrome by proxy with participation of the mother was diagnosed in four cases.

Case

A 13-year-old girl was hospitalised because of a non-healing ulcer of the septum, loose and lost mandibular teeth, skin lesions, and suspected immunodeficiency. She had been hospitalised numerous times at other facilities. Consultations and diagnostic tests did not confirm an organic disease. The patient and her mother agreed to undergo all examinations, and some symptoms ‘went away’ during the examinations. The behaviour of the patient and her mother during hospital stays, ambulatory care, and the psychiatric observations all pointed towards MPSB. They refused further treatment at the present facility.

Conclusions

A dentist should take into account the potential ‘fabrication’ of symptoms in a child by the latter or by a caregiver. Consultations with a paediatrician or psychiatrist enable a diagnosis and treatment.

Evaluating for suspected child abuse: conditions that predispose to bleeding

Child abuse might be suspected when children present with cutaneous bruising, intracranial hemorrhage, or other manifestations of bleeding. In these cases, it is necessary to consider medical conditions that predispose to easy bleeding/bruising. When evaluating for the possibility of bleeding disorders and other conditions that predispose to hemorrhage, the pediatrician must consider the child's presenting history, medical history, and physical examination findings before initiating a laboratory investigation. Many medical conditions can predispose to easy bleeding. Before ordering laboratory tests for a disease, it is useful to understand the biochemical basis and clinical presentation of the disorder, condition prevalence, and test characteristics. This technical report reviews the major medical conditions that predispose to bruising/bleeding and should be considered when evaluating for abusive injury.

Evaluation for bleeding disorders in suspected child abuse

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.

A preliminary screening instrument for early detection of medical child abuse

OBJECTIVE

The goal of this research was to develop a screening instrument for early identification among hospitalized children of medical child abuse (MCA).

METHODS

We developed a preliminary screening instrument for the early identification of MCA. Items were chosen based on published characteristics of MCA, including caregiver, patient, and illness information. Each item in the instrument was scored with 1 point if positive. This instrument was tested by reviewing the hospital charts of child protective services-confirmed MCA patients and comparing the results with charts of children with admissions for apnea, vomiting/diarrhea, and seizures who were not diagnosed with MCA. Nineteen cases and 389 controls were used for analysis. We used receiver operating characteristic curves, starting with items most highly associated with MCA in our sample. Predictive values and strengths of association were assessed by using chi2 and Fisher's exact tests, as appropriate.

RESULTS

From an initial 46 questions, we determined that 26 items showed a statistically significant difference between cases and control patients. From these, an instrument with 15 items maximized the area under the receiver operating characteristic curve, and a score of > or =4 had a sensitivity of 0.947 and a specificity of 0.956 (P<.05) in detecting MCA.

CONCLUSIONS

This chart review screening instrument identified differences in characteristics of children, caregivers, and illness during hospitalization that may allow for earlier detection of MCA and referral for further assessment to the multidisciplinary team.

[Parent's perspective on child rearing and corporal punishment]

OBJECTIVE

To describe parents' current perception of corporal punishment associated to child rearing and its practices.

METHODOLOGICAL PROCEDURES

There were studied 31 family members whose children were warded due to child abuse complaints (12) and not warded (19) at a health care unit and a local social service unit in the city of Belo Horizonte (Southeastern Brazil) in 2006. Data was collected through semi-structured interviews and speech analysis was performed grouped by subjects and categories. ANALYSIS OF DISCOURSE: There was limitation of the respondents' speeches based on their production means. There was a diversity of conceptions on child rearing and its practices and corporal punishment was reported by all parents, even among those who expressed strong disapproval of this practice. Speeches were characterized by heterogeneity and polyphony with emphasis on the tradition speech, the religious speech and the popular scientific speech. Respondents did not express concepts of legal interdiction of corporal punishment or its excesses.

CONCLUSIONS

The culture of corporal punishment of children is changing; tradition approving it has weakened and prohibition has been slowly adopted. Reinforcing legal actions against this practice can contribute to speed up the process to end corporal punishment of children.

Citrin deficiency: a novel cause of failure to thrive that responds to a high-protein, low-carbohydrate diet

The proband was born at 36 weeks, appropriate for gestational age, to nonconsanguineous white parents. There was no evidence of hyperbilirubinemia or intrahepatic cholestasis in the neonatal period, and she had normal newborn screen results. She presented with 3 episodes of life-threatening bleeding and anemia. The diagnostic evaluation for her bleeding diathesis revealed an abnormal clotting profile with no biochemical evidence for hepatocellular damage. She was incidentally noted to have severe growth deceleration that failed to respond to 502 kJ/kg (120 kcal/kg) per day of protein-hydrolyzed formula. An extensive diagnostic workup for failure to thrive, which was otherwise normal, included plasma amino acid analysis that revealed hyperglutaminemia and citrulline levels within the reference range. Testing of a repeat sample revealed isolated hypercitrullinemia. No argininosuccinic acid was detected. Her ammonia level and urine orotic acid were within the reference ranges. Subsequent plasma amino acid analysis exhibited a profile suggestive of neonatal intrahepatic cholestasis caused by citrin deficiency with elevations in citrulline, methionine, and threonine. Western blotting of fibroblasts demonstrated citrin deficiency, and a deletion for exon 3 was found in the patient's coding DNA of the SLC25A13 gene. On the basis of the experience with adults carrying this condition, the patient was given a high-protein, low-carbohydrate diet. The failure to thrive and bleeding diathesis resolved. When compliance with the dietary prescription was relaxed, growth deceleration was again noted, although significant bleeding did not recur. This is the first report of an infant of Northern European descent with citrin deficiency. The later age at presentation with failure to thrive and bleeding diathesis and without obvious evidence of neonatal intrahepatic cholestasis expands the clinical spectrum of citrin deficiency. This case emphasizes the importance of continued dietary control and growth monitoring in children with neonatal intrahepatic cholestasis caused by citrin deficiency and identifies a new metabolic entity responsible for failure to thrive.