Child abuse related to medical dilemma when a pediatric age group exposed to nonessential invasive medical interventions and investigation due to family exaggerate their condition and put unbelievable medical story and fabricate their child medical issues or even induced the disease for the child with plan for these action due to psychological problems. A 6-year-old male and his sister 5 years old was frequently consulted to hematology clinic due to symptoms bleeding from the ear eyes and nose and hematuria. The patient wasn’t give a history of skin bruising in response to minor injury. The history  of their family was unremarkable and all other family relative otherwise normal. The diagnosis of Munchausen syndrome was made by exclusion of other possibilities of unusual site of bleeding, normal all bleeding profile and from mysterious story of presentation.

Munchausen syndrome was first described in in the fifth decade of previous century   byuAshar in a different patients discovered this disease and made doctors to perform not urgent, not beneficial  medical operation and invasive intervensions. Mun-chausen- syndrome -by -proxy (MSBP) is a specific form of medically abuse of the children first described by Meadow at the seventh decade of previous century.

Child abuse related to medical dilemma when a pediatric age group exposed to nonessential invasive medical interventions and investigation due to family exaggerate their condition and put unbelievable medical story and fabricate their child medical issues or even induced the disease for the child with plan for these action due to psychological problems [2]

The Association of psychiatric science in America have uses these terminology of fabricating medical disease  impact on other person , and use it to the parents involved in this fabrication  rather than the abnormally medically abused child [2]. the approximate occurrence of these medical condition is nearly less than two for each one hundred thousand for those children below sixteen [4]. Other features associated with MCA in these studies include The mother is usually the perpetrator. The child is most commonly younger than five years of age. True medical illness or disability is present in the child in many cases.Complexity of the medical presentation is notable; in one study, almost 75 percent of the children had multiple symptoms reported by the caregiver. [4]

A six year old male was frequently visited to hematology center clinic with the due to symptoms of bleeding from the ear eyes and nose and hematuria, his mother was house wife and denied any education and their father 25 solider near the Syrian boundaries comes to their family every 20 to 30 day.He was delivered by caesarian section with prolong admission  to neonatal care unit for weeks due to jaundice and birth asphyxia he is a member of 3 kids in the family of healthy father solider 25 years old and 23 years old mother  10 years old child healthy ,they are relative. and 5 years old female diagnosed as leukemia (as the mothers say by history)  but I see paper of jak II mutations without name and another paper of the pediatrician that he wrote (known case of bleeding tendency)  ENT specialist other papers for his sister wrote (recurrent otitis media and recurrent ear bleeding) since one years and ,relative and no family history of the disease She had first an episode of bleeding below when he is about 1 year age and the the condition repeated many times reach to more than five times per week .

                                                                                                                                 Figure 1

One of pediatrician after presentation suggest OGD and he did it under GA and was normal.

The symptoms bleeding from ears and bloody tears occurs, and tear mixed with blood had occurred in the previous two months with no any related cutaneous or bleeding from other site. 

His bleeding vaguely present and merely was seen by mother in the family and no other family member. The pateints visited different centers in the different cities and many hospitals in Baghdad, Najaf with hematology parameter and biochemical investigations were normal. no history of easy skin or subcutaneous ecchymosis or petechial rash. The mother claimed that the he has an attacks of mouth bleeding during dental eruptions and other nonspecific attack of bilious or green color vomiting diagnosed by pediatric surgeon as intestinal ileus and no need for surgical intervention after many U/S by different dates and even barium enema was done. he is not circumcised till now. and. The family history was otherwise normal.

The patient on tegretol anti-epileptic tegrtol (twice daily) for his cerebral palsy and  convulsion in early life.The physical examination of the patient was shows hypertonia and generalize rigidity and global developmental delay, there were no signs of subcutaneous related hemorrhage . She was hospitalized many time for further evaluation and received un countable amount of cryoppt and plasma infusion. Full blood parameter plus smear, and analysis of liver function and renal function was normal were in normal limits. Hepatitis screen and other virology was negative.

GUE pus cell ++ , RBCs 2-3

RBS 97

One of the CBC at 17.5.2022 shows WBCs 13.8, Hb 10.5, platelet 509 

MCV 68 RBCs 4,49

Bleeding time was 2 minute (2-7). PT & PTT was normal

PT 18(13-20)

PTT 37 (20-40).

Fibrinogen 340    (150-400)

Vonwilbrand factor 109%    (60-200%).

Factor XIII was normal.

The analytic tests and lab results with clinical finding weren’t goes with diagnosis vonWillebrand factor disease or factor thirteen deficiency problems but this information’s was not enough to explain all her symptoms. Depending on the conflicting information about the bleeding tendency one of the pediatrician decided to give him cryo or plasma with each visit and asked her mother referred to hematology clinic or special center for confirmatory test .

Hence a diagnosis of Munchausen syndrome was made by exclusion of other possibilities of unusual site of bleeding and from this mystery story.

Any general family doctor or pediatrician should be aware about the suspicion of medical child abuse after facing a bleeding disorder disease like skin bruising or bleeding from any part of the body and should be regards these symptoms to be abnormal either due to congenital bleedindind disorder or part of battered baby syndrome and should be assessed carefully by history and full examination. Medical child abuse and disease due to hematological bleeding tendency cannot occur at the same time even it is possible . For that reason, the medical information  shoud be integrals with full sequences of the bleeding events and nature of precipitating factor and the severity of the attacks in related to level of the activity .[5]Our patient was consult to many doctors and different hospitals for complaints of bleeding from unusual sites, had undergone many investigations, even invasive investigations and all results are normal and organic etiologies were investigated and excluded.  So one of the doctors tell them the laboratory investigation goes with factor XIII deficiency but these symptoms could not be explained by fibrin stabilizing factor.[6]He had no history of delay umbilical cord splitting or abnormal bleeding from the umbilical cord stump. If the condition is not treated, affected individuals may have episodes of excessive and prolonged bleeding that can be life-threatening

In fabricated or induced illness, a child is harmed due to caregiver behavior and actions, carried out to convince mainly doctors that the child’s physical and/or psychological health is more impaired than in reality. Harm is caused directly by the caregivers(s) and also often indirectly by doctors’ responses. [7]

The cardinal features of maunchosen by proxy are illness fabrication by caregiver, persistently ill child subjected to multiple diagnostic procedures and up to 90% of physically abused children have cutaneous manifestations which is absent in those patients. Biological mothers (76.5%) are depicted to be major perpetrators similar to our case. [8] 

Perpetrator nearly more than ninety fivepercent are from the mother sides,which represent the female principle of caring their child although cases of conspiracy  with others may be founded , including the father or other male members in the house which take part directly or indirectly [9,10]

The primary motive may be to gain attention and manipulate physicians. These problems are common in Congenital anomalies, intellectual disability, cerebral palsy (mental retardation) or other handicaps, or chronic or recurrent illnesses. [11]

Medical abuse in children are nearly rare incomparism with other types of battered baby problems . Turkish hospitals data shos one hundred forty patients were examined for suspected child abuse and near ninety five were evaluated as child abuse cases and an additional only two of those patients were diagnosed with medically related problems.However, it is known that the actual incidence of MSBP is higher than this and there might yet be undiagnosed cases. [12] Bleeding from unusual multiple sites such as ears and bloody nipple discharge also reported in other study [13]

Specialize psychiatry clinic is necessary  in cases. Specialist in childhood disease and childhood psychiatry specialist form a multidisciplinary team  and their job together to maintain  treatment commitment  of the patient and the family. Because, as we see in our case, these patients unfortunatly refuse uncooperate with medical staff and refuse therapy related to psychaitry. The best methods for treatment is by urgent diagnosis if there’s non recognize and illogical medical information, the purpose is prevention of more injury to the child in future and avoid change the severity of abused child from mild ondtion to moderate or more even severe case.

Family doctors or health personnel’s should tell the family that the patient condition is not goes with medical information’s was given and clinical examination was done [2]. It is usually beneficial to ask the family; why they are giving the inaccurate information’s. Mild cases usually not require invasive investigation and can manage easily by health care provider. In moderate to severe cases it need special balanced approach  of medical evaluation, which include the child protection services, and understanding the caregiver enviroments. Family doctor and child abuse specialist should guide this multidisciplinary evaluation and treatment. The general advice to the doctor facing such cases should include; firstly  cancel scheduled but unnecessary medical intervention or surgery, take out unnecessary cannula, centraline or any vascular access and stop the medications that can have the worst potential side effects such as cancer or seizure medications if not required. [14]

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with global scientific researches.