Possible Fabricated or Induced Illness in Children and Young Persons under the age 18 - Procedure for management of

Publication: 19/05/2015  --
Last review: 12/02/2018  
Next review: 12/02/2021  
Standard Operating Procedure
CURRENT 
ID: 4206 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Procedure for management of possible Fabricated or Induced Illness in Children & Young Persons under the age 18

Background and indications for standard operating procedure/protocol

FII can cause significant harm to children. FII involves a well child being presented by a carer as ill or disabled, or an ill or disabled child being presented with a more significant problem than he or she has in reality, and suffering harm as a consequence. There are particular challenges for paediatricians and other professionals in terms of managing an FII case.

Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians RCPCH 2009 1.1

In “Perplexing presentations” of FII, the child’s clinical presentation is not explained by any confirmed genuine illness, and the situation is impacting upon the child’s health or social wellbeing. There is a spectrum of presentations, with the rarer “True FII” involving deliberate deception of medical services by the carer; which may involve

  • actions to falsify specimens or investigations
  • induction of illness in the child
  • the commoner wider range of “perplexing presentations” or “Medically Unexplained Symptoms” that should be considered in the same way but do not necessarily involve deliberate deception these presentations are primarily verbal accounts and descriptions by the carer.
    Child Protection Companion RCPCH 2013 13.1.1

If there is evidence of illness induction (i.e. the parent is physically doing things to the child to make them ill), that is an ominous and potentially fatal situation that must be addressed urgently through safeguarding procedures. These cases are rare but memorable and have a huge impact upon the treating team. Examples of induced illness, with the results of which the child is repeatedly presented to doctors, may include:

  1. Smothering to induce apnoea or anoxic seizures;
  2. Poisoning (e.g. with anticonvulsants, psychiatric drugs, narcotics, laxatives or salt) most commonly presents with drowsiness, vomiting or disorientation which may initially be investigated as an encephalopathy.
  3. Deliberately withholding food to cause failure to thrive.
  4. Deliberately withholding medication that is necessary for some genuine medical condition.
  5. Physically harming the child to cause rashes or other physical signs, or applying caustic or noxious substances to the child’s body.
  6. Injecting faeces.
  7. Removing blood from the child to cause anaemia.
  8. Induced feeding difficulties mimicking a dysmotility syndrome.

Child Protection Companion RCPCH 2013 13.1.12

The presence of a proven chronic medical condition does not exclude a diagnosis of FII; the two commonly co-exist (in about half the cases of FII) This may be because children with other health needs are more vulnerable or other illness could have been a consequence of FII.
Child Protection Companion RCPCH 2013 13.1.15

The paediatrician always has to keep an open mind in case there is a genuine medical explanation for the child’s presentation. Where there is residual doubt, or if the child continues to be ill even when the carer is not present, a careful case note review should be conducted and the situation discussed with colleagues; ideally in a multidisciplinary meeting.
Child Protection Companion RCPCH 2013 13.1.19

In some cases there is a need for immediate action, e.g. where acute suffocation or poisoning are suspected, if the child has been physically harmed in the context of FII or if there is an urgent need to secure forensic samples.
Child Protection Companion RCPCH 2013 13.4.2

If at any stage there is an acute ‘event’ that could represent an act of physical abuse, do not delay but make an immediate referral to children’s social care and the police.
Child Protection Companion RCPCH 2013 13.4.3

Do not accuse the parent/carer or confront them, but explain that you are very concerned about the child and need to institute very close observation in hospital to find out what is wrong with them.
Child Protection Companion RCPCH 2013 13.4.6

Other cases present in a more chronic or evolving way and can initially at least be managed conservatively with time to ‘pause and plan’.
Child Protection Companion RCPCH 2013 13.4.7

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Procedure method (step by step)

The majority of such cases do not occur with such speed as to mandate an immediate response. These cases should be discussed with the lead Consultant for the case, who should consider discussing the case with a Named or Designated Doctor in Child Protection (the name, and contact details of these individuals can be found either from the safeguarding nurse advisors 0113 39 23937/ 07786 915 387; or from the on call Paediatric Medicine/ General Paediatric Consultant- via switchboard).

However, in situations where there is an immediate threat to a child; that is:-

evidence, or suspicion of an action which is life threatening (which may include, see also above)

  • tampering with medical equipment;
  • administering non-food, non-prescribed substances to a child
  • withholding (including “switching”) treatments for a child

In these situations, the following management should be followed:-

  • Nurse to escalate immediately to the most senior doctor resident at this time.
  • This doctor (Registrar or Consultant) to attend & without confrontation, to recognise that the child's condition is serious & to review treatments.
  • Stop current treatment.
  • Secure current treatment, and other treatments which have caused concern - these should be placed in the CD cabinet, by the nurse responsible for the child & the nurse in charge of the clinical area (to best preserve chain of evidence).
  • Reinstitute treatment as dictated by clinical condition,
  • Instate close observation because of child's failure to improve with standardised therapy.
  • Doctor (Registrar) to inform on call consultant immediately
  • Doctor (registrar) will be advised (by Consultant) to inform social care immediately of concerns regarding the possibility of Fabricated & Induced Illness (FII), and the clinical scenario. Social care will determine, and arrange the (almost certain) need for police/forensic involvement.
  • Documentation is vital- name, contact numbers & GMC/ PIN number of staff involved should be written down in the notes (attending Registrar/ Consultant, attending nurse, nursing staff responsible for securing treatment in CD cupboard).
  • When the consultant attends, & in most cases this will be within a short period (30-60 minutes); consultant will appraise situation from staff involved, and from social care.
  • Advice should be taken at the earliest opportunity with the named or designated doctor for children’s safeguarding; the children’s safeguarding nurses should be alerted to the situation.
  • Children’s Social Care have a statutory responsibility to ‘decide and record, within one working day what response is necessary.’ Section 4.17 Safeguarding Children in whom illness is fabricated or induced HM Government 2008
  • It follows that the consultant should anticipate an urgent strategy meeting, during which social care, health and police will attend, and consider:
    1. What is the level of risk to the child ?
    2. Are there any immediate actions necessary to reduce the risk of harm (for example cancelling unnecessary medical procedures or instituting closer observation of the child)
    3. Communication with carers and confidentiality (including communication of child protection concerns)
      • How
      • When
      • By whom
    4. How the child can be given an opportunity to tell their story
    5. Any outstanding investigations, further information gathering, and other helpful opinions
    6. Responsibility for Core Assessment
    7. Security of medical records (consider use of Data Protection Act 1998; “Disclosure would be likely to cause serious harm to the physical or mental health or condition of the data subject”- that is the child)
    8. level of professional observation required, further medical assessments
    9. The needs of siblings and other children in the family
    10. The needs of carers, particularly after disclosure
    11. The development of integrated health chronology & RPC
    12. What is known of the carer’s past behaviour, medical history, current health state & treatment, equipment, aids or benefits being received either for themselves or the child.
    13. Decision regarding further meetings and their composition

In conditions where there is no immediate threat, the case should be discussed with a Named or Designated Doctor in Child Protection.

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Provenance

Record: 4206
Objective:

To standardise and optimise the management of concerns raised regarding the possibility of Fabricated or Induced Illness (FII) in Children & Young Persons under the age of 18

Clinical condition:

Concerns regarding possible Fabricated or Induced Illness

Target patient group: Children and Young people under 18years of age
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

1. HM Government (2008) Safeguarding children in whom Illness is fabricated or induced.
2. Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians RCPCH 2009
3. Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians (2009) Update statement RCPCH 2013

Evidence Level of Above Level B

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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