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SUMMARY Information is presented about 19 children, under age 7 years, from 17 families, whose mothers consistently gave fraudulent clinical histories and fabricated signs so causing them needless harmful medical investigations, hospital admissions, and treatment over periods of time ranging from a few months to 4 years. Episodes of bleeding, neurological abnormality, rashes, fevers, and abnormal urine were commonly simulated. Often the mothers had had previous nursing training and some had a history of fabricating symptoms or signs relating to themselves. Two children died. Of the 17 survivors, 8 were taken into care and the other 9 remained at home after arrangements had been made for their supervision. Study of these children and their families has enabled a list of warning signs to be compiled together with recommendations for dealing with suspected acts. The causes and the relationship of this form of behaviour to other forms of non-accidental injury, iatrogenic injury, and parental-induced illness are discussed. The enquiry considered the following aspects: the child, the 'illness' and its perpetration, the consequences and outcome, and the parents. In most cases full details were available for each aspect; in a few information was not sufficient for a particular aspect and so was omitted. Thus the results refer to all 19 children and all 17 families except in instances in which the group total is specified as being smaller than the full number.

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Aim-To identify features to help paediatricians diVerentiate between natural and unnatural infant deaths.Method-Clinical features of 81 children judged by criminal and family courts to have been killed by their parents were studied. Health and social service records, court documents, and records from meetings with parents, relatives, and social workers were studied. Results-Initially, 42 children had been certified as dying from sudden infant death syndrome (SIDS), and 29 were given another cause of natural death. In 24 families, more than one child died; 58 died before the age of 6 months and most died in the afternoon or evening. Seventy per cent had experienced unexplained illnesses; over half were admitted to hospital within the previous month, and 15 had been discharged within 24 hours of death. The mother, father, or both were responsible for death in 43, five, and two families, respectively. Most homes were disadvantaged-no regular income, receiving income support-and mothers smoked. Half the perpetrators had a history of somatising or factitious disorder. Death was usually by smothering and 43% of children had bruises, petechiae, or blood on the face. Conclusions-Although certain features are indicative of unnatural infant death, some are also associated with SIDS. Despite the recent reduction in numbers of infants dying suddenly, inadequacies in the assessment of their deaths exist. Until a thorough postmortem examination is combined with evaluation of the history and circumstances of death by an experienced paediatrician, most cases of covert fatal abuse will go undetected. The term SIDS requires revision or abandonment. (Arch Dis Child 1999;80:7-14)

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Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal. Conclusions-This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur. (Arch Dis Child 1998;78:217-221)

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