646 Deborah A. Lee

Munchausen syndrome by proxy in twins

DEBORAH A. LEE

Department ofPaediatrics, Preston Hospital, North Shields

SUMMARY A family is described in which twininfants had repeated admissions for apparenthaemoptysis. It was proved that the mother wassimulating these episodes and she eventually in-jured one of the children with a pin. The motherhas subsequently shown some evidence of a Mun-chausen tendency in herself.

The spectrum of child abuse is ever widening withthe recognition of the more obscure types of injury.Meadow (1977) described a child whose symptomswere fabricated by her mother, causing numerousinvestigations. He called this Munchausen syndromeby proxy. A further family is described in whichthere were similar occurrences.

Case report

Twins, a boy and a girl, weighing 2 * 5 kg and 1 * 9 kgrespectively were born at 36 weeks' gestation byspontaneous vertex delivery. There were no im-mediate problems at birth. The boy was allowedhome with his mother after 5 days. The girl waskept in the special care nursery for 3 weeks duringwhich time parental visiting, although encouraged,was infrequent.Both parents, previously married, were known to

the Social Services Department because each hadhad children who were suspected, but not proved,to have been nonaccidentally injured. These childrenare now in the custody of the other remarriedpartners.During the first 4 months, despite intensive

support, there were 5 admissions for relativelyminor illnesses. Then, on consecutive evenings, bothtwins were admitted with a history of havingvomited blood. No cause was found for this andthey were subsequently discharged. The same eveningthe girl was readmitted and the boy the next night,again having vomited blood. On this occasion,blood-stained bibs were produced. Aspiration ofstomach contents showed no evidence of blood andagain no cause was found for the bleeding. Thenext day, while the mother was feeding the boy inhospital, she reported that he was again bleeding.Blood was present on his clothing and on themother's nursing gown. Thorough examination

showed no bleeding points on the child. Motherand baby were known to have different bloodgroups so the clothing was sent for forensic analysis.At this stage it was thought that the mother wasprobably simulating the bleeding by injuring her-self, and this was confirmed at a much later dateby the forensic tests. However, the twins wereallowed home in the knowledge that the mother had'an escape route' when under pressure. The nextevening both twins were readmitted, again havingvomited blood and no cause was found.A few days later while the mother was momentarily

alone with the twins, blood appeared on the girl'schin. A nurse heard the baby crying, immediatelyexamined her, and found a small bleeding point onher lower lip. He also saw a nappy pin that wasalmost hidden in the mother's hand. The twinswere wearing selfadhesive disposable nappies whichdid not require the use of pins. The mother sub-sequently admitted injuring her child with the pin,was charged with assault, and found guilty. Sheconsistently denied falsifying any of the previousepisodes. The children were then both placed in thecare of the local authority.

Discussion

Although it was recognised from before birth thatthe twins were at risk of child abuse they appearedto thrive and develop normally. The repeatedadmissions were accepted as a means of helping thefamily, although during admissions the parentsrarely visited, and there was always delay in dis-charging the twins. In retrospect, we suspect thatthe mother felt unable to cope with both twinsfrom early in their life, but could not admit this toher cohabitee. She found a means of escape byinjuring herself and gaining relief from the childrenwithout showing her inadequacy. We think she mayhave deceived her entire family as several membershad been present in the room on occasions when thebleeding had occurred. Why she should eventuallyinjure one of the children is open to speculation,particularly as she had no concept of different bloodgroups and was therefore unaware that her falsifica-tion could be proved.

This case report differs from those previouslydescribed in that the sole gain to the mother was of

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Munchausen syndrome by proxy in twins 647

relief from the children. The mother showed noprevious Munchausen tendency, but since the twinshave been taken into care she has presented to herdoctor with a history of haemoptysis and also witha bleeding lesion on her breast which was extremelyslow to heal.

Reference

Meadow, R. (1977). Munchausen syndrome by proxy. Thehinterland of child abuse. Lancet, 2, 343-345.

Correspondence to Dr Deborah A. Lee, Department ofChild Health, Royal Victoria Infirmary, Queen VictoriaRoad, Newcastle upon Tyne NEI 4LP.

Change of reference styleFrom January 1980, the Archives will change itsstyle for citing references and will follow the numbersystem. We are making this change in order toconform with the 'Vancouver style' of uniformrequirements for manuscripts submitted to bio-medical journals.

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International Steering Committee of Medical Editors.Uniform requirements for manuscripts submitted to bio-medical journals. Br MedJ 1979; 1: 533-535.

2 Lancet. The Vancouver style. Uniform requirements formanuscripts submitted to biomedical journals. Lancet1979; 1: 429-430.

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in twins.Munchausen syndrome by proxy

D A Lee

doi: 10.1136/adc.54.8.6461979 54: 646-647 Arch Dis Child 

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