New guidance on perplexing presentations and fabricated or induced illness in children

The RCPCH has today launched new guidance for paediatricians on Perplexing Presentations (PP), Fabricated or Induced Illness (FII) in Children. This updates the College’s 2009 guidance and aims to support paediatricians when involved with these sometimes very difficult cases.

The new guidance provides procedures for safeguarding children who present with PP or FII and best practice advice in the medical management of these cases to minimise harm to children.

The guidance updates definitions of FII and PP. The new and wider interpretation of FII includes any clinical situation where the parent or carer’s actions are aimed at convincing doctors and other professionals that a child is more seriously ill than is the case. In these circumstances, the parent or carer may be acting on erroneous beliefs about the child’s state of health or, in some cases, deceiving professionals.  There is a risk that the child will be directly harmed by the parent or carer’s behaviour but in some cases, and inadvertently, also by the medical team’s response. 

Dr Alison Steele, Officer for Safeguarding at the RCPCH, said 

It is very rare for parents or carers to deliberately induce illness in a child by, for example, poisoning them or withholding treatment. Most cases are based on incorrect beliefs or misplaced anxiety which, unchecked, can cause children to undergo harms ranging from missing school and seeing friends, to undergoing unnecessary and painful or even harmful tests and treatments. Paediatricians, and other professionals, have a duty of care to the child but, in almost every case, their work will form part of a collaborative approach which involves the parent or carer as well as the child.

This guidance is extremely important for paediatricians but we hope it will also be useful for those who work in the wider areas of child health, including GPs and others concerned with safeguarding of children, including social workers, police and education staff.

The guidance describes alerting signs that are not evidence of FII but are indications of possible FII. It makes clear that the focus must always be on the health and safety of the child and that, where these signs are associated with possible harm, they may amount to a safeguarding concern. Paediatricians must ascertain the actual, current state of the health of the child. This will involve listening, examining and investigating, and gathering information from all other professionals involved in the care of the child. It will be discussed with parents or caregivers, unless there is immediate risk to the child’s health or life. In these circumstances a referral to children’s social care or police is mandated as set out in existing national guidelines.

The process of investigation may find a full medical explanation which eliminates concerns about FII. However, when concerns remain, there may need to be referral to children’s social care. The aim is for the child to resume their normal life, with reduced medical intervention and a return to school and other activities. It is hoped that  parents or carers are supportive of this process to improve their child’s health and wellbeing. However, if it is thought that the child is at risk of significant harm a, referral will need to be made to CSC on the grounds of medical or other neglect, emotional or physical abuse.

The RCPCH convened an expert working group to develop this guidance, led by the RCPCH Officer for Child Protection and involving representative Consultants currently practising within the NHS and safeguarding. We also considered the limited published evidence on prevalence and management of FII. In the absence of published evidence, we relied on extensive consultation and expert consensus from those with extensive clinical experience of managing these conditions. 

The guidance has been subject to a thorough consultation period and views have been incorporated from a range of organisations and a number of commissioning groups and provider Trusts across the UK. The following agreed to be listed as having been consulted: 

  • RCPCH Child Protection Standing Committee 
  • The Child Safeguarding Practice Review Panel, Department for Education 
  • NHS England and Improvement 
  • British Medical Association 
  • General Medical Council 
  • Medical Defence Union 
  • Royal College of General Practitioners 
  • Royal College of Nursing 
  • Royal College of Psychiatrists 
  • British Society of Paediatric Endocrinology 
  • Young People’s Health Special Interest Group. 

The RCPCH also sought the views of senior social work practitioners.