Feldman K W, Hickman R O
Department of Pediatrics, University of Washington School of Medicine and Children's Hospital & Medical Center, Seattle, USA.
J Pediatr Surg. 1998 Apr;33(4):623-7. doi: 10.1016/s0022-3468(98)90329-3.
The aim of this study was to determine what percentage of childhood central venous catheters (CVC) are placed in victims of Munchausen syndrome by proxy (MSBP) and to evaluate the clinical indications and complications of CVCs in MSBP.
Study design was by retrospective chart review. Data were obtained from the regional children's hospital and regional child abuse consultation network. Patients in the MSBP series were all children who on consultation were determined to be victims of MSBP, from 1974 through 1996. Patients in the central catheter series were all children who had central venous catheters placed 1991 through 1995, excluding children whose catheters were placed for cancer chemotherapy or for chronic renal failure. Consultation records of MSBP cases were abstracted noting the clinical characteristics of victims and perpetrators. Hospital procedure codes were reviewed for children who had CVCs placed. Those who had discharge diagnostic codes that commonly require CVC placement were not reviewed, but charts of children with diagnoses not usually requiring CVCs were evaluated. Descriptive statistics and chi2 and Fisher's Exact test were used for comparisons.
Sixteen of ninety-three (17%) of MSBP victims had central lines, including two deaths caused by assault through the lines. Line sepsis occurred in 9 of 16 (56%) patients. Primary reasons for CVC were for administration of medicines that can normally be administered orally or subcutaneously (7) or for severe nutritional depletion (8). All but one of the children had symptoms of multiple organ system involvement. Siblings had frequently been victimized. The mean age of symptom onset was 19 months, yet the mean age at diagnosis was delayed until 82 months. All perpetrators were the mother. Fathers were usually physically or emotionally unavailable. Nearly one third of mothers had prior medical training and one third had themselves been victims of prior physical or sexual abuse. Ten of fifteen mothers previously exhibited Munchausen behavior themselves. Of children at our institution who had central venous catheter placement, 8 of 709 (1.1%) were MSBP victims.
CVCs are frequently placed in MSBP victims for physiological problems, malnutrition, or failure to respond to normal treatments. Surgeons should consider requesting systematic evaluation for MSBP in patients seeking CVC placement for diagnoses not usually requiring CVCs lest they become unintentional collaborators in abuse of these children.
本研究旨在确定代理孟乔森综合征（MSBP）受害者中放置儿童中心静脉导管（CVC）的比例，并评估MSBP中CVC的临床指征和并发症。
采用回顾性病历审查的研究设计。数据来自地区儿童医院和地区儿童虐待咨询网络。MSBP系列中的患者均为1974年至1996年期间经咨询确定为MSBP受害者的儿童。中心导管系列中的患者均为1991年至1995年期间放置中心静脉导管的儿童，不包括因癌症化疗或慢性肾衰竭而放置导管的儿童。提取MSBP病例的咨询记录，记录受害者和施虐者的临床特征。对放置CVC的儿童的医院程序代码进行审查。那些有通常需要放置CVC的出院诊断代码的儿童不进行审查，但对诊断通常不需要CVC的儿童的病历进行评估。使用描述性统计、卡方检验和费舍尔精确检验进行比较。
93名MSBP受害者中有16名（17%）有中心静脉导管，其中包括2例因通过导管攻击导致的死亡。16名患者中有9名（56%）发生了导管败血症。放置CVC的主要原因是用于通常可口服或皮下给药的药物（7例）或严重营养消耗（8例）。除1名儿童外，所有儿童均有多器官系统受累的症状。兄弟姐妹经常成为受害者。症状出现的平均年龄为19个月，但诊断的平均年龄延迟至82个月。所有施虐者均为母亲。父亲通常在身体或情感上无法提供支持。近三分之一的母亲曾接受过医学培训，三分之一的母亲曾遭受过身体或性虐待。15名母亲中有10名此前曾表现出孟乔森行为。在我们机构放置中心静脉导管的儿童中，709名中有8名（1.1%）是MSBP受害者。
CVC经常被放置在MSBP受害者身上，用于解决生理问题、营养不良或对常规治疗无反应的情况。外科医生应考虑对因通常不需要CVC的诊断而寻求放置CVC的患者进行MSBP的系统评估，以免他们在无意中成为虐待这些儿童的帮凶。
