OBJECTIVE Munchausen syndrome by proxy (MSP) is recognized in the differential diagnosis of apparent life-threatening events, but the early signs and the full spectrum of this presentation are not well recognized. We aim to describe MSP presenting with apnea to illustrate this spectrum and the evolution in our management over a period of 10 years. PATIENTS AND RESULTS Eleven children in five families seen in one institution and assessed by one team are described in detail. The children had apnea and/or pallor, but with a wider age range than usually seen with apparent life-threatening events, sometimes associated with other injuries, and a large percentage of parents were health care providers. In no case was apnea witnessed by health care professionals other than the parents. There were frequent disagreements in management between professionals and, consequently, delays in considering the diagnosis at first. There were two deaths. A team developed, allowing the diagnosis of MSP to be considered sooner and the cases to be assessed and managed consistently. CONCLUSION MSP is part of child abuse, and it needs to be recognized by all physicians. Family assessment is required and the development of a team interested in MSP facilitates assessment and management.