title: The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Pediatrics, University of Washington School of Medicine and Children's Hospital & Medical Center, Seattle, USA.
authors.forename: K W
authors.initials: KW
authors.lastname: Feldman
authors.forename: R O
authors.initials: RO
authors.lastname: Hickman
mesh_terms: D000328:Adult; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000706:statistics & numerical data; D002649:Child Abuse; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D016735:Munchausen Syndrome by Proxy / Q000453:epidemiology / Q000628:therapy; D012189:Retrospective Studies