Well-established policies and procedures govern the identification, management, and treatment of most variations of child abuse. For many therapists, such cases have become “routine”. Munchausen syndrome by proxy is an under-recognized form of child abuse in which a parent feigns or creates illness in a child specifically to have the child subjected to unnecessary diagnostic tests and treatments by medical practitioners. Variations range from false reports of fevers or allergies, to life-threatening abuse, such as surreptitious poisonings or injections with toxic substances. This article reports a case example of Munchausen syndrome by proxy, provides a review of historical, diagnostic and management issues, and discusses legal issues relevant to detection of the perpetrator and protection of the child victim.