A 4-month-old female patient was admitted to the Hospital de Niños "Dr. Pedro de Elizalde" on May 16, 2005 derived from Hospital Santojani, in which he was hospitalized since May 13, 2005.
During her stay in the day care center she presented an episode of apnea that resolved with manual stimulation.
The evolution was favorable until at 48 h she presented two episodes of apnea, with 5 minutes difference between them, which were repeated in the recovery room and required intubation and respirator.
It was not possible to verify whether these episodes were in the sole companion of the mother or in the presence of a professional.
In the nursing controls it is noted that, that same day in the morning, the mother withdrew oxygen to the child without medical indication.
It was found that in February 2005 he had been assisted at the Hospital GandÃ©rez due to constant crying, food refusal and sweating for 1 hour.
Subsequently, an episode of respiratory pause with color changes in the face and distal extremities, accompanied by hypertonia.
On that occasion, a polysomnographic study was carried out in which "pneas with indices within normal parameters" and pHmetry with pathological gastroesophageal reflux were found.
The diagnosis was "gastroesophageal reflux", antireflux treatment was indicated, and the mother was involved in a cardiopulmonary resuscitation course.
With the derivation of the Santojani Hospital, he was admitted to the Elizalde Intensive Care Unit and extubation was decided with good tolerance; then he was transferred to the pediatric ward.
Two days later the patient developed an episode of apnea without bradycardia requiring bag-mask ventilation.
Subsequently, a tonic-clonic seizure is triggered initially focal and then generalized that overcomes with diazepam; it is transferred to the ICU.
Patient studies: • Cardiac: clinical examination, normal ECG and Holter. • Neurological: clinical examination, EEG and brain ultrasound normal.
Polysomnography: apnea of 140 sec mixed, with bradycardia associated, after an episode of whitening with mild stimulation.
It should be noted that during the polysomnographic recording, the technique is absent for a few minutes to request a baby's bottle; when she returns, she finds the mother on the child's head".
The mother's hands were on the child's face, without trying to stimulate her.
Then she is seen by an ICU doctor who notes her recovery.
During this episode, the respiratory pause described above is recorded. • Gastroenterological: series gastroduodenal: no anatomical changes, with gastroesophageal reflux III, chamber: reflux without normal microaspirations gamma bottom or lumen.
The following laboratory tests were performed: blood count, erythrocyte sedimentation rate, blood glucose, uremia, creatinine, hepatogram, muscle enzymes, calcium, phosphorus and magnesium in blood, coagulation profile, thyroid hormones and total thyroid acid.
All results were normal.
An episode of desaturation occurred a posteriori in the ICU room, which occurred when the child was on the mother's arms and she embraced her intensely.
In view of the risky attitudes observed in the mother regarding the mode of care that she proposed to her daughter, her oppositionist attitude, demonstrated hostility and the patient with persistent consultation Violence whose results did not justify the family consultation.
As a result of this intervention, it was decided to immediately call CONNAF hospital caregivers to establish the monitoring, control and protection of the patient during hospitalization, to prevent the mother from managing her daughter discretionally.
The family group living with the child consists of a 29-year-old Argentinian mother from a southern province with incomplete secondary education and the 39-year-old Uruguayan father who works as a street vendor.
Both account for the death of another son of the lady with a previous partner in 1999; link the fatal outcome to a clinical picture similar to that of the patient.
The medical history of the deceased sibling, according to the records of the Central Military Hospital manifest normal were two hospitalizations; the first, in August 1999, at 45 days of life, due to bronchiolitis and apnea, included a study.
The second, one month later, due to vomiting and diarrhea, with two episodes of apnea on the same day, the last of longer duration.
The patient was transferred to the ICU where it was stated that the episode was not after ingestion or crying.
Subsequently, a new episode of prolonged apnea requiring mechanical ventilation was recorded, where a large amount of milk was aspirated from the endotracheal tube.
Keep connected to the ventilator for 5 days.
Subsequently, the patient was transferred to the pediatric inpatient ward with antibiotic treatment.
A few days later, he presented cardiorespiratory arrest with new suctioning of milk by endotracheal tube; consequently, he suffered from hypoxic ischemic encephalopathy that led him to death on 10/30/99.
The death diagnoses were: cardiorespiratory arrest with brain death and septic shock.
Interviews were conducted with the mother and then with the father.
Mother referred to her past, marked by abandonment of the nuclear family; institutionalized by years.
As he could not bear this way of life he decided to withdraw himself by his own means and began to live in a house of open doors; he studied and worked until he became pregnant with his first child.
He presented himself as a plaintiff, keen and not very collaborative; he attributed to the professionals who assisted his daughter the mistreatment he enjoyed when criticizing his maternal role.
He remained oriented in time and space, without awareness of the disease and with awareness of the situation.
No qualitative changes were detected in the sense-perception at the time of the interviews.
She was constantly discharged, unable to accept the severity of the episodes she suffered.
Projective and psychometric techniques were provided (Bender, Perceived and MMPI) that yielded the following results: • Attachment to experience great internal tension due to a large number of acting-related problems rigid self-impulsivity; • Attachment to other sexual behavior problems. • Attachment to self-immobility. • Attachment to other characteristics: • Attachment to other sexual drive.
The father presented himself to the interviews with a collaborating attitude; he expressed his desire to separate himself from the woman and said that he would take care of both the child's maintenance and care if the mother did not take care of her.
Regarding the personality characteristics of the couple, it was defined as a person who blames them for everything that happens, who threatened to kill them and also cleptoman.
She mentioned several episodes in which the patient's mother stole different objects from other people's houses and even money to herself.
In this case, it was also prioritized to assess the risk of the affected child and validate the diagnostic suspicion based on the characteristics of the patient and the subject that causes the symptoms.
As a result of the high risk assessed, it was decided in that opportunity and in accordance with the legislation in force at that time, that the request for person protection should be granted to the advocate of minors.
Finally, due to situational diagnosis, it was suggested: • to review the mother and the child in an extra-hospital resource that would guarantee her integral protection, with visits from her mother supervised by a father in order to reflect on the therapeutic outcome.
FINAL CONSIDERATIONS
It is important to reinforce the idea of considering the suspicion of Munchausen syndrome by power in the presence of children with suspected symptoms that do not allow consolidating a clear clinical diagnosis, the lack of response to treatment implemented and repeated health institutions.
It was observed that the intervention modality against the suspicion of Munchausen's syndrome by power had an eminently interdisciplinary character.
This team assesses the risk to which the patient is and only with the child on guard is continued with the diagnosis.
In the cases presented, the guard was based on avoiding the repetition of maneuvers that could trigger the supposed event of apparent life-threatening during hospitalization.
This situation was achieved with the permanent presence of personnel who assumed the control and care of the child.
The diagnosis is called situational since it contemplates the medical, psychological, psychiatric, social and legal aspects.
In the reference cases, the characteristics of the mothers involved in the episodes of suspected ALTE and the clinic of the affected children allowed validating the diagnostic presumption.
It is essential to repair and avoid repeat episodes.
Monitoring and monitoring of this disease is essential to prevent the fatal outcome that some patients record.
