Fabricated or induced illness in a child

Fabricated or induced illness by carers is a relatively rare form of child abuse in which a parent or carer seeks medical intervention by fabricating or inducing symptoms in a child.

There is a range of terminology used to categorise this form of abuse, although it is often known as Munchausen's syndrome by proxy (Asher, 1951; Gawn and Kauffman, 1955; Meadow, 1977). However, in today's literature, particularly in the UK, the term fabricated or induced illness in a child by a carer (FII) is preferred.

FII is a descriptive term and not a discrete medical syndrome, ensuring it covers a wide range of situations, while also shifting the focus to the child. According to safeguarding guidance from HM Government (2008), there are three ways a carer may fabricate or induce illness (Box 1). All health professionals need to be aware of this issue; many perpetrators do have increased and fabricated

Epidemiology, incidence and prevalence

The first population-wide estimates described an annual combined incidence of Munchausen's syndrome by proxy, non-accidental poisoning, and non-accidental suffocation as 0.5 per 100 000 children under 16 years, with males and females affected equally. This analysis highlighted that cases mostly included children less than 5 years old, with children under 1 years of age having the highest incidence of 2.8 per 100 000 children (McClure et al, 1996). 

Nonetheless, studies have identified that there is significant under-reporting of FII (McClure et al, 1996; Davis, 2009). This could be a result of the plethora of professionals involved in treating the individual, which can complicate and delay diagnosis, or it could be because of the broad spectrum of FFI where milder cases are never reported (McClure et al, 1996; Davis, 2009). 

Although FII is relatively uncommon, it is associated with high morbidity and mortality, and is often not

In cases of FII the child's symptoms are often non-specific, intermittent, and rely heavily on the history acquired from the carer (Box 2). Anomalies in test results and/or examinations may not be repeated in further presentations (Davis, 2009; Royal College of Paediatrics and Child Health (RCPCH), 2009). Feeding problems and bowel-related symptoms are frequently reported (RCPCH, 2009). Other presentations include unexplained collapse/an apparent life-threatening event or seizures. FII may present to any specialty, anywhere. 

Box 2. Potential indicators of fabricated or induced illness

• Multiple and/or repeated symptoms
• Symptoms that are unexplained and do not match the clinical observation or results
• Symptoms that are witnessed exclusively by or in the presence of the caregiver 
• An inexplicably poor response to prescribed medication or treatment
• On resolution of symptoms, new symptoms arise or become apparent in other siblings 
• Activities of daily life limited beyond what is expected of a known disorder or development

Documentation is crucial to all aspects of nursing practice (Nursing and Midwifery Council, 2018) and is especially improtant in cases where FII is suspected. Thorough documentation and chronologies can provide enough evidence to confirm a diagnosis of FII (Sanders and Bursch, 2002; Davis, 2009; Dye et al, 2013).

A heightened awareness of FII may increase a professional's curiosity and desire to examine case notes when exposed to perplexing presentations in practice. Analysing medical records for patterns of abnormal behaviour and inconsistencies is the most common means of identifying FII (Sanders and Bursch, 2002). Once suspicions have been raised, it is important that these concerns are escalated quickly to specialist professionals so swift appropriate action can be taken.

The primary goal is to protect the child from further harm by working efficiently across all disciplines. It is important to note that, should the perpetrator become suspicious, there is an increased risk