Foamy discharge on the scalp of the infant: munchausen syndrome by proxy.

Sir,

Munchausen syndrome by proxy (MSP) first described by Meadow is a rare disorder in which there is intentional production or feigning of physical or psychological signs or symptoms in another person (usually a child) who is under the individual's care (usually mother).[1] This may lead to unnecessary painful investigations and treatment on the child. Although a form of child abuse, there are characteristics of the syndrome that sets it apart from other types of child abuse.[2] The victims are usually under the age of 6 years.[1] Usually there is a history of family dysfunction with the father uninvolved and emotionally distant and mother having few social outlets.[2] Features of MSP may be seen in one-third of patients, and the rest may have depression or personality disorder.[3] This syndrome almost always involves a mother abusing her child by seeking unneeded medical attention for the child. She usually welcomes painful and invasive tests in the child and grows anxious if the child improves.[1] In case of unusual symptom or sign presentation in a child, this is an entity which requires consideration by the clinicians.

A 22-year-old mother of an infant 10 months old came to the Skin and VD out patient department with complains of foamy discharge coming out of the scalp of the infant since 3 months [Figure 1]. There was no history of fever, or trauma. The child was born by normal vaginal delivery without any birth complications. On examination, the child appeared normal, afebrile, active with regular milestones of development. She had consulted a local practitioner several times, but he failed to come to any conclusion and referred the case to a medical college for diagnosis and treatment.

Figure 1

Foamy discharge coming out of the scalp of the infant

Local examination of the frontal portion of the scalp showed the presence of foamy liquid, which kept reappearing after about 15-20 min after wiping that area with cotton. No signs of inflammation like erythema, vesiculation or oedema were visible over the affected area. During examination the mother was unwilling to leave the infant alone, and was very anxious and apprehensive. She also refused to admit the infant to be kept under observation. Microscopic examination of the foamy liquid did not show the presence of any cells or microorganism except for a few crystals like substances. Other investigations like complete blood count, routine examination of stool and urine, culture of the foamy liquid, X-ray of head and CT scan of the brain did not reveal any abnormality. Serum sodium, potassium, urea, and creatinine were within normal limits.

As all the reports were within normal limits and the appearance of the foam could not be explained, the mother was interrogated thoroughly by the nursing staff on the next visit. After much coaxing, she admitted that she had been applying baby shampoo on the scalp of her child and fabricating it before the clinician. She also revealed that her husband was in the army and comes home once a year and she used to stay with her in-laws. She was not interested in household work, and she did this to avoid work and stay with her child who was thought to be suffering. She cried during the confession, and feared that she would be severely punished for her actions. She was then referred to the psychiatric department for psychotherapy.

The term Munchausen syndrome was coined by Asher in 1951, to describe patients who consistently produced false symptoms or stories about themselves to obtain needless hospital investigations and treatments. Meadow in 1977 described another form of syndrome called as MSP where parents, usually the mother make their children undergo harmful hospital procedures by fabricating symptoms.[1] Commonest presentation of MSP reported in most literatures include any form of bleeding, seizures, central nervous system depression, apnea, diarrhea, vomiting, fever and rash.[45] The motivation for the parent's behavior is to assume the sick role by proxy. This case presented with a less harmful and unusual symptom of foam appearing on the scalp. It was difficult to identify the cause of the foam from the scalp and the mother was not ready to hand over the infant to any medical personnel for she feared that her trick might be caught. But as all the investigations were within normal limits and the complaint was very unusual, the mother was interrogated and she confessed about the fact that she had been applying baby shampoo on the scalp of the infant very cleverly.

The essential criteria for MSP are illness fabricated or produced by a parent in the child to assume sick role by proxy and get medical attention. In this case, the mother when confronted expressed her feeling of loneliness in the absence of her husband and the lack of any social outlets. Here the mother's behavior appears deliberate, but as the dividing line between conscious and unconscious gain is not clear, the case was diagnosed as MSP and referred to the psychiatry department for psychological interventions.

In such unusual presentations the diagnosis of MSP, though rare should be kept in mind to avoid performing invasive procedures on the child.