A mother brings her 2-year-old son to the Emergency Department. They have previously presented 10 times over the past six months and on each occasion have been discharged. He has previously been investigated for multiple episodes of rectal bleeding, and no cause found. Investigations have included routine blood tests, a negative radionuclide scan for Meckel’s diverticulum and a negative endoscopy. Five weeks ago, he presented with mum being concerned about the possibility of a chest infection but was discharged without treatment, and mum had been reassured. Today he has presented having had several alleged episodes of nausea and vomiting at home. He has not been eating or drinking and has been spiking fevers. He appears undistressed and has had no witnessed vomiting episodes in the department. His observations today are: temperature: 36.5°C, heart rate 100 bpm, SaO2 100% on air, RR 25, capillary refill time <2 seconds.

1. What is the most likely diagnosis?
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The most likely diagnosis, in this case, is Meadow syndrome, which was formally known as Munchausen syndrome by proxy. In this syndrome, the caregiver fabricates the appearance of health problems in another person, typically their child. This can include injuring the child or altering their test results and then presenting the child as being sick or injured.

2. What are the main features that support this diagnosis?
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Features that would support a diagnosis of Meadow syndrome include:

  • Reported symptoms or signs only appear or reappear when parent or guardian present
  • Reported symptoms only observed by parent or guardian
  • Symptoms do not respond to treatment or medication
  • History of illness which seems unlikely, e.g. a large amount of blood loss without a drop in haemoglobin or change in physiological data
  • Parent or guardian seeking multiple clinical opinions despite a definitive opinion already being given
  • Persistent disagreement with a clinical opinion by parent or guardian
  • Significant compromise of the child’s normal activities by frequent presentation, e.g. school absenteeism
  • Child using aids to daily living that are apparently not necessary, e.g. wheelchair usage

3. What is the main risk factor for this diagnosis?

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The parent having suffered negative event or trauma during their childhood is the principal recognised risk factor for this condition. For example, the death of a parent or having been a victim themselves of child abuse or neglect.