The Munchausen Syndrome by Proxy, as described in 1977 by Meadow, are comprised today in the “Factitious disorders”. Munchausen by proxy syndrome is a type of severe abuse that is caused by the parent of the child. The incidence of recurrence is quite high. There are patients who travel through hospitals to adapt illness stories, which is why unnecessary and numerous medical or surgical interventions are applied and this is called Munchausen Syndrome. The disease is usually performed by a mother with a personality disorder. They are very talented in deceiving healthcare personnel. They enjoy the child's apparent illness and enjoy the interest and sympathy of the healthcare staff. It is very important to start treatment as early as possible. If the diagnosis becomes definite, psychiatric treatment should be started. The purpose of this article is to carry out a review of Munchausen syndrome by proxy.

Keywords: child abuse, Munchausen Syndrome by proxy, psychopathology

The World Health Organization defines the child abuse, whether intentionally or unintentionally made by an adult and negatively affecting the child's health and physical and psychosocial development.¹ Munchausen by proxy was first described in 1977 by a professor of pediatrics Roy Meadow.² Meadow describes parents who make their child ill as "Munchausen syndrome by proxy".³ Munchausen syndrome by proxy is a very severe and special form of child abuse. The incidence of recurrence is quite high.⁴ There are patients who travel through hospitals to adapt illness stories, which is why unnecessary and numerous medical or surgical interventions are applied.⁵ Munchausen syndrome by proxy is also ana important issue for forensic sciences, especially in cases of poisoning. Everyone who takes action at this point must be very careful.⁶ There are more difficult cases to distinguish from poisonous cases. A case report has mentioned a 27-year-old middle school graduate. This woman was charged with killing her own child and two other children. The woman was sent to the Forensic Psychiatric Observation Department of the Council of Forensic Medicine for evaluation of criminal responsibility. The same woman was caught by the hospital’s camera when she closed her three month-old daughter's mouth. It was learned that the woman had been abused by her mother when she was a child.⁷ The exact cause of Munchausen syndrome by proxy is not known, but researchers believe that both biological and psychological factors play a role in the development of this disorder. One theory is that early parental loss or abuse in childhood leads to Munchausen syndrome by proxy. Some researchers suggest that major stress, such as marital problems, can lead Munchausen syndrome by proxy.⁸

Munchausen syndrome by proxy, also known as "medical child abuse", was inspired by the German Baron Munchausen who lived in the 18th century who adapted the stories about his experiences on his travels.⁹ He has been recognized throughout Europe since the publication of Baron's Tales.¹⁰ The Munchausen Syndrome by Proxy, as described in 1977 by Meadow, are comprised today in the “Factitious disorders”.¹¹

Diagnosing Munchausen by proxy syndrome is a rather difficult task for a healthcare professional. Current symptoms can also occur in the course of any disease. The substance that the child's mother or caregiver uses to poison the child can mimic many diseases. For all of these reasons, it is either time-consuming or impossible to diagnose correctly. Recently, there have been more Munchausen by proxy cases reported.¹²

Meadow and Rosenberg changed the criteria for diagnosis as follows:¹³

1. The disease must have been made up by parents or by those who replace the parent.
2. Symptoms are often presented to require more than one recognition. The parent does not accept the etiology of the child's illness.
3. Disease indications and acute symptoms end when the child leaves the parent.

Morley insisted that the Munchausen syndrome by proxy diagnosis must be based on sound medical practice that begins with a careful history, perhaps spending hours in gathering a clear understanding of the mother’s concerns and actions. The physician’s suspicions should be expressed to the mother simply by presenting the information gathered thus far with their implications.¹⁴

Previous studies show that for the most part, in the Munchausen by proxy cases, the best result is achieved if the child and mother or caregiver are separated for a long time. During this time, children should be carefully monitored. When the children who stayed with their parents were examined, it was the result that their situation got worse.¹⁵ Munchausen syndrome by proxy is a form of child abuse played out in the medical setting. Most people presume that the Munchausen syndrome by proxy diagnosis is proposed after someone discovers a mother’s or caregiver’s clever strategy for keeping her child sick. In most cases, however, the suspicion of Munchausen syndrome by proxy takes root within the quiet context of confusion about the cause, the severity, or persistence of a child’s symptoms.¹⁶ The most common method is to mislead the health staff. Other methods include poisoning drugs and other substances and counterfeiting the child’s samples. In mild cases, mothers speak only of indications that are not actually true, but in other cases the situation is more severe. In severe cases, mothers can even cause deaths from serious physical harm to their children.¹⁷ The most common symptoms were hemorrhages (44%), (42 %), loss of consciousness (19%), apnea (15%), recurrent diarrhea (11%), recurrent vomiting (10%) and redness (9%).¹⁸ The disease is usually performed by a mother with a personality disorder.¹⁹ They are very talented in deceiving healthcare personnel. They enjoy the child's apparent illness and enjoy the interest and sympathy of the healthcare staff. Psychiatric intervention is often not possible because they cannot be accessed. Rehabilitation is not possible if the child continues to stay in the family after Munchausen by proxy is diagnosed. Abuse continues in patients and siblings. In a cohort of 119 cases, 40% of poisoned children and 50% of children at risk of suffocation were found to have been subjected to abuse.²⁰ Pediatric follow-up is very important. It was found that 17% of the children allowed to go home even if there was no physical damage, were abused.²¹

Pediatricians are primarily concerned with the detailed medical story that children's mothers or caregivers tell themselves. But if Munchausen by proxy is the case, this most important tool is unfortunately invalid. Doctors sometimes resort to expensive and inadequate treatment because of the misconception of the mother. That is why Munchausen by proxy represents a modern pediatric challenge.⁶ It is almost impossible to know the frequency of this population, but there are still some statistical surveys.²² According to Davis and colleagues, the prevalence of Munchausen by proxy in the UK is 0.5 in 100,000 children under 16 years of age.²⁰ When these mothers were examined, it was determined that they were exposed to sexual abuse during childhood. Bipolar disorder accompanying the narcissistic personality disorder, hysterical personality disorder and sadomasochistic behaviors are also seen in syndromed mothers. Munchausen by proxy is a very important method of abuse in which the child is sacrificed.²³ There are some features for correct diagnosis. Disease identification is difficult, repetitive and long-lasting. The work being done is in line with the fact that mothers are very eager to keep their children in the hospital. Health workers have declared that their mothers or caregivers have accepted all methods of treatment that they would implement in their children without worrying.²⁴

Munchausen syndrome by proxy is very rare when compared with other types of child abuse. Studies found out that the incidence of Munchausen syndrome by proxy is 0.4/100.000 among children aged below 16 years and 2–2.8 per 100,000 among children aged below 1 year.²⁵ In a study of 139 child abuse suspicions in Turkey it is included in the file. It was clear that 94 of them were child abuse. Munchausen syndrome by proxy was only observed in two cases. However, it is believed that the actual incidence of Munchausen syndrome by proxy is higher than this rate and there might yet be undiagnosed cases.²⁶ Professionals from many areas works with each other in order to keep an eye on the unusual situation in such cases.²⁷ The perpetrator is clearly a mother with mental disorders. The average diagnosis rate is around 3.25 years. Munchausen by proxy cases had mortality rates between 6% and 10%. In this case, affected mothers can be collected in three groups: active inducers, help seekers and doctor addicts. Active inducers exaggerate their children's illnesses. Help seekers are using children to escape the problems of social life in the home and in the environment. Doctor addicts are more dangerous and more paranoid than the.⁷ The purpose of this paper was to carry out a review Munchausen syndrome by proxy.

It is very important to start treatment as early as possible. If the diagnosis becomes definite, psychiatric treatment should be started.²⁴ Other adults around the child should be careful about frequent illness or accident.²⁸ The child should stay in a different place during both the child's treatment and the mother's psychiatric treatment.²⁹

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