Introduction

Perplexing medical presentations encompass many situations encountered by paediatricians, where a child is reported to have symptoms or disabilities that impact significantly on their everyday functioning, and yet thorough medical evaluation has not revealed an adequate and realistic medical explanation. Unlike in other medically unexplained symptoms (MUS), the parent(s) are reluctant to support a rehabilitative approach to the child and insist on continued investigations. The clinicians dealing with the child are, in addition, alert to the possibility that there may be an unusual and potentially harmful parent-child interaction that is causing or perpetuating the presentation.1 If any of the professionals involved with the child becomes concerned that the child may be suffering (or at risk of) significant harm, and if that concern cannot be quickly and easily resolved, then under current safeguarding procedures a referral should be made to Children’s Social Care. These will be managed under existing fabricated or induced illness (FII) guidelines and procedures. However, paediatricians recognise that there are many cases just below that threshold, where safeguarding does not provide a suitable framework for managing the child, and where there is room for a rehabilitative approach to be attempted before considering a safeguarding approach. These are cases where harm to the child is predominantly iatrogenic and avoidable. There may be a potential for some of these cases to progress to ‘True’ FII over time but they are not at that stage. We propose that the essence of the management of perplexing presentations (PP)/FII is to recognise these PP at an early stage. We suggest that early intervention may reduce the potential for iatrogenic harm, help to restore normal functioning and may reduce the need for safeguarding interventions. We also propose that current procedures may need to be revised to take account of the wider spectrum of …