Munchausen Syndrome by Proxy: a pediatrician's observations.

Munchausen Syndrome by Proxy (MSP) is a disturbing diagnosis that should be considered when persistent signs and symptoms defy adequate explanation despite extensive testing. Insistence by a parent (often mother) that more, and particularly invasive investigations be pursued, should serve as a warning sign that MSP might be present. The primary care provider who has an existing, over-time, relationship with the child and family is in an important position to raise the question of MSP because this professional may be able to recognize larger dynamics at play between child and family that are less apparent to subspecialists who are focused on a narrow aspect of the evaluation. A confounding element to identifying MSP can also be at play when parent(s) have become proficient in the jargon and technical communication with which professionals on the healthcare team are most comfortable. This easily occurs in cases of MSP both because frequent hospitalizations offer ample opportunity for the articulate and inquisitive parent to pick up the ways of "medical-speak," and because the World Wide Web provides countless and effortlessly accessible sources of disease related information (albeit not always accurate or relevant to the diagnostic dilemma in question). An additional complicating factor in posing a risk for MSP is the child with a chronic illness, or one whose neonatal course has served to label the child as vulnerable.