Drug-perpetrated Munchausen by proxy syndrome: When we dare and why we dare to care

The term Munchausen syndrome by proxy (MSP) refers to a situation in which one or both parents by procuring or inventing symptoms or illness that their children do not have. As a consequence children can be exposed to continual medical examinations, tests and analyses, including surgery that can severely injure or, in extreme cases, provoke death. Usually, the victim is a young child, and the perpetrator is the mother, usually the person child is almost exclusively entrusted, placing her in the best position to simulate illness. Difficulty in making a diagnosis is motivated by the low prevalence of cases, unspecific nature of the symptoms, difficulty of reconducting the overcure back to a criminal case and tracing it back to the care giver.

Starting from a case series, a diagnostic algorithm useful for prompt MSP identification has been developed.

A detailed examination of four cases is given, all with a common feature: drug administration to perpetrate MSP.

Biological fluids have been sampled and analyzed for drugs to which symptomatology could be traced.

In all presented cases a late MSP diagnosis was possible on the base of results from toxicological analyses. Although analytical results are often diagnostic, a delay in sample collection, related to improper diagnostic algorithm, is frequent. Only an integrated approach, based on collaboration among multiple professionals, among which the role of the medico-legal expert and toxicologist stands out, can ensure the achievement of a rapid diagnosis and the protection of the victim.