Munchausen syndrome by proxy: an outpatient challenge

Munchausen syndrome by proxy: an outpatient challenge

Selected Abstracts from Pediatrics seem to be quantifiable, easil y ascertainable behavior patterns that could alert pediatric health profe ssionals t...

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Selected Abstracts from Pediatrics seem to be quantifiable, easil y ascertainable behavior patterns that could alert pediatric health profe ssionals to the existence of more pervasive disturbances in child and family.

KLEIN, N., HACK, M., GALLAGHER, J . & FANAROFF, A. A. (1985), Preschool performance of children with normal intelligence who were very low-birth-weight infants. 75:531- 537. Children who were very low-birth-weight infa nts « 1,500 g), beneficiaries of modern neonatal intensive care, are now of school age. To evaluate their school performance 80 children born in 1976 who had very low birth weight (mean birth weight 1.2 kg, mean gestat ional age 30 weeks) were examined at age 5 years. Sixty-five children were neurologically intact and had normal IQ (2::85) on the Stanford-Binet; 5 children were neurologically abnormal and 10 had IQ below 85. Of the 65 children with normal intelligence and no neurologic impairments, 46 were single births and enrolled in preschool. These 46 children were matched by race, sex, and family background with classmate control children who had been born at full term. Outcome measurements included the Siosson Intelligence Te st , the Woodcock-Johnson Psycho-Educational Battery (including subsca les of Picture Vocabul ary , Spatial Relations, Memory for Sentences, Visual Audi tory Learning, Quantitative Concepts, and Blending ), and the Berry Developmental Te st of Visual -Motor Integration . No significant differences in IQ were found between children who were very low-birth-weight infants and control children ; however, children who were very low-birth-weight infants performed significantly less well on the Spatial Relations subtest of the Woodcock-Johnson and on the Visual -Motor Integration test. Similar results were found for nine sets of twins and their control children. Recognition of these perceptual and visual-motor problems may permit appropriate earl y remedial intervention and prevent the compounding of these difficulites.

This study assessed the types, circumstances, frequency, and health consequences of trauma suffered by juvenile delinquents at a secure residential training school. A review of 369 medical records of 387 teenagers, aged 10-17 years, admitted to one such facility between 1978 and 198:! was made . Of the 369 students, 191 students (52%) suffered 391 separate trauma incidents serious enough to require a health care provider's attention. Circumstances surrounding the injuries included sports (36%), fight s (20%), self-inflicted injuries (13%l, suicide attempts (9%), incidents related to vocational studies (8%), and hor seplay (3%). The most comm on types of injuries were musculoskeletal trauma, scratches, brui ses and lacerations, and fractures. The usual site s of injury were the extremities, head, or neck . More than 50% of trauma incidents required a physician's attent ion init ially or in follow-up ; 28% of the injured were referred to an off-campus facility; 21% necessitated radiologic or laboratory studies; 4% required hospitalization ; and one student died . The average trauma rate for teenagers in this setting was 1.2 injuries per person per year; the average rate of hospitalizations for trauma was 0.04 hospitalizations per per son per year. These data call for futher studies of trauma morb idity among adolescents in th is and other sett ings and for innovative trauma prevention strategies.

GUANOOLO, V. L. (1985), Mun chausen syndrome by prox y: an outpatient challenge. 75:526- 530.

BILLMIRE, M. E. & MYERS, P . A. (1985), Serious head injury in infants: accident or abu se? 75:340-342.

Primary health care providers are well aware of the physical findings that suggest a child has been intentionally maltreated. Practitioners must also be aware of a more subtle form of child abuse in which the parent victimizes the child by presenting fictitious medical history that initiates a sequence of unnecessary diagnostic and therapeutic interventions. A 4'/2-year saga of such a case, an example of Munchausen syndrome by pr oxy in the outpatient setting, is reported.

The medical records and computed tomography (CT) scan s of all children less than 1 year of age admitted to the hospital with head injury over a 2-year period were reviewed. Sixty-four percent of all head injuries, excluding uncomplicated skull fracture, and 95% of serious intracranial injuries were the result of child abuse. The occurrence of intracranial injury in infants, in the absence of a history of significant accidental trauma, such as a motor vehicle accident, constitutes grounds for an official child abuse investigat ion .

WOOLF, A. & FUNK, S. G. (1985), Epidemiology of trauma in a population of incarcerated yout h. 75:463-468.

Lozon, B., WOLF, A. W. & DAVIS, N. S., Sleep problems seen in ped iatric practice. 75:477-483. LIFSCHITZ, M. H., WILSON, G. S., O'BRIAN SMITIl, E. & DESMOND, M. M. (1985), Factors affect ing growth and intellectual funct ion in child ren of drug add icts . 75:269-274 .

T o determine whether sleep problem s commonly seen in pediatric practice, such as conflicts at bedtime and night waking, are associated with more pervasive disturbances in the child or family, two groups of healthy ch ildren were st udied. Interview data from a pilot sa mple were examined to identify factors that might be import ant in sleep problems, and then the results were validated with data from the second sample. The two samples included 96 white children between 6 months and 4 years of age. In each group, approximately :10% had a sleep problem hy the criteria that night waking involving parents or bedtime struggles occurred 3 or more nights a week for the month preceding the interview, accompanied by conflict or distress. Five experiences dist ingui shed children with sleep problems from those with out: an accident or illness in the family, unaccustomed absence of t he mother during the da y, maternal depressed moodts), sleeping in the parental bed, and maternal att itude of ambivalence toward the child. These experiences cor rectly classified 100% of pilot and 83% of validation sample children as having a sleep problem or not . The similarity of findings in the two samples attests to the potential importance of sleep problems as an early childhood symptom. Bedtime conflicts and night waking

The effects of maternal heroin and methadone use on head growth and neurodevelopmental performance was studied in preschool children of untreated heroin addicts (N = 25), women receiving methadone therapy (N = 26), and a drug -free comparison group (N = 41l who had been followed from birth. The mean birth head circumference of both groups of drug-exposed infants was significantly below that of the comparison group; however , the only factors determined by multiple regre ssion analysis as associated with head size at birth were maternal nutrit ional status and birth weight. By preschool age, head size did not differ significantly among group s. The factors associated with postnatal head growth were birth weight, int rapart um risk score , and race . Data show an increased incidence of low-average and mildly retarded intellectual performance in the drug-exposed children. Regression analyses dem onstrated that amount of prenatal care , prenatal risk score, and home environment were most predictive of intellectual performance and that the degree of maternal narc otic use was not a significant factor . 1) 1:\