Psychosocial Pathogenesis Should Be Considered

Letters to the Editor regarding the article Clinical Practice Guideline: The Outpatient Management of Fever in Children and Adolescents by Tim Niehues, Hanno Krafft, Juliane Schemmer, Silke Schwarz, Ricarda Möhler, and David Martin on behalf of the Guideline Group on Fever Management in Children and Adolescents in issue 8/2026

The tension between fever as a physiological defense mechanism and the necessary antipyretic measures needs to be supplemented with an assessment of the psychosocial pathogenesis and its effects, including a risk to the child’s welfare. Otherwise a threat exists of substantial effects on the child’s or adolescent’s quality of life, including dropping out of school (Abraham-Bizot et al. reported a school drop-out rate of up to 96%) (1). The prevalence of Munchausen syndrome and Munchausen syndrome by proxy has been described as low in the literature, but the unreported number of cases is high, and fever is one of the most common symptoms—artificially produced and/or reported by the parents. According to Abraham-Bizot et al. (1), children with suspected or confirmed Munchausen syndrome by proxy underwent on average 33 examinations in 6 hospitals. The mean time period taken to reach the suspected diagnosis was 5.8 years.

Why 50% of those affected by Munchausen syndrome by proxy later developed Munchausen syndrome is to date subject to speculation. According to Wang et al. 2026 (3) the victims as well as the perpetrators often have physical and mental (pre-existing) conditions, which means it may be a trauma-related subsequent condition as a result of experienced abuse, a raised genetic risk, or a combination of both factors. Munchausen by proxy syndrome co-occurring with Munchausen syndrome cannot always be ruled out with certainty.

According to empirical studies carried out to date, Munchausen syndrome can occur from an age of 4 years, whereas Munchausen syndrome by proxy syndrome may occur from very early infancy. Synonyms are “Fabricated or Induced Illness by Carers,” “Perplexing Presentations,” “Factitious disorder imposed on self,” “Factitious disorder imposed on another,” and “Medical Child Abuse.” The ICD-11 distinguishes “6D50 factitious disorder imposed on self” from “6D51 factitious disorder imposed on another.”

DOI: 10.3238/arztebl.m2026.0112

Dr. med. Ingo Spitczok von Brisinski
LVR-Klinik Viersen, Kinder- und Jugendpsychiatrie

References

1. Abraham-Bizot A, Greco C, Quartier P, et al.: Medical child abuse: Medical history and red flags in French adolescents. Child Abuse Negl 2023; 146: 106523

2. Spitczok von Brisinski I, Zick J, Nakazi J, Rast K: Münchhausen-Syndrom und andere artifizielle Störungen bei Kindern und Jugendlichen. Forum der Kinderund Jugendpsychiatrie, Psychosomatik und Psychotherapie 2016; 26: 2–58.

3. Wang D, Zhao M, Yin J, La Y: Characteristics, interventions, and outcomes of factitious disorder imposed on another (FDIA): A systematic review of 455 perpetrators and 469 victims. Front Public Health 2026; 20; 13: 1723415.

4. . Niehues T, Krafft H, Schemmer J, Schwarz S, Möhler R, Martin D, on behalf of the Guideline Group on Fever Management in Children and Adolescents: Clinical practice guideline: The outpatient management of fever in children and adolescent. Dtsch Arztebl Int 2026; 123: 226–30