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Guideline review: RCPCH perplexing presentations, fabricated or induced illness in children guidance 2021
  1. Katherine Ruth Wear1,
  2. Simon Li2
  1. 1 Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
  2. 2 Paediatrics, Derby Hospitals Foundation Trust, Derby, UK
  1. Correspondence to Dr Katherine Ruth Wear, Paediatrics, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK; rwear{at}

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In the 40 years since Professor Roy Meadow first described ‘Munchausen Syndrome by Proxy’, there have been a number of significant developments, including terminology, definition, prevalence and management.

The Royal College of Paediatrics and Child Health (RCPCH) guidance on Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children outlines procedures in order to safeguard children who present with perplexing presentations and fabricated or induced illness. It offers practical advice on how to recognise it, how to manage risk and how to manage these presentations.

Information about the current guideline

This guideline was commissioned and developed by the RCPCH. There was input from a wide range of paediatric generalists and subspecialists, as well as social work practitioners and several organisations and commissioning groups.

Although written primarily for paediatricians, it is of direct relevance to general practitioners (GPs), other specialists, social care and education. See box 1 for a link to the full guideline and other related resources.

Box 1


  • Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in Children: RCPCH Guidance. Published February 2021, -and-fii/

  • The Royal College of Psychiatrists. Assessment and management of adults and children in cases of fabricated or induced illness (FII) CR223. Published November 2019 (updated March 2020),

  • RCPCH Child Protection Companion. Chapter 13: Perplexing Presentation (including FII). Published 2013,

  • e-Learning for Healthcare Safeguarding Children and Young People – Level 3 available at

Previous guidelines

While this guidance supersedes the 2009 RCPCH guideline entitled Fabricated or induced illness by carers: a practical guide for paediatricians, it does not fully replace it or render it obsolete. For the ‘high risk’ or physically injurious FII cases, the detailed management guidance in the 2009 document is still applicable. The RCPCH Child Protection Companion 2013 extended the definition of FII by introducing the term Perplexing Presentations with new suggestions for their management.

Key issues this guideline addresses

This guideline supports a cultural …

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  • Contributors RW was the main author for this piece. SL contributed and reviewed the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.