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Development delay in children < 6 years

PAEDIATRIC

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.


It is proposed that the following conditions should be sent directly to emergency. This is not a list of all conditions that should be sent to the emergency department, it is intended as guidance for presentations that may otherwise have been directed to general paediatric outpatients:

Brain & Nervous System

  • Headaches
    • that wake at night or headaches immediately on wakening
    • new and severe headaches
    • associated with significant persisting change of personality or cognitive ability or deterioration in school performance
    • recent head injury or head trauma
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • sudden onset headache reaching maximum intensity within 5 minutes  ( = explosive onset)
    • presence of an intracranial csf shunt
    • hypertension above 95th centile by age for systolic or diastolic

  • Seizures
    • all children with new onset of clinically obvious epileptic seizures should be referred to emergency for initial assessment, observation and consideration of emergency investigation or management.
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • significant change in seizures for established epilepsy:
      • new onset of focal seizures or
      • a dramatic change in seizure frequency or duration
  • Faints syncope and funny turns
    • loss of consciousness in association with palpitations
    • sudden loss of consciousness during exercise
    • possible infantile spasms. this may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old

 

Respiratory

  • Asthma, stridor and wheeze
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
    • recent onset or escalating stridor and respiratory distress
    • acute respiratory distress not responding to home management
    • acute respiratory symptoms causing inability to feed or sleep in an infant
  • Persistent and chronic cough
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
    • prominent dyspnoea, especially at rest or at night
    • cough causing inability to feed or sleep in an infant

Gastroenterology

  • Jaundice
    • Jaundice in infants with elevated liver transaminases or conjugated (direct) bilirubin > 20 microMol per litre or >15% of total bilirubin.
    • Jaundice in ≥38 week infant ≥ 330 UMol/L
    • Jaundice in 35-37 week infant ≥ 280 UMol/L
    • Jaundice in <35 week infant ≥ 230 UMol/L
  • Chronic & Recurrent Abdominal Pain
    • severe pain not able to be managed at home with simple analgesia
    • significant change in location or intensity of chronic abdominal pain suggestive of a new pathology
    • pain associated with vomiting where this has not occurred before
    • bile stained vomiting
  • Chronic Diarrhoea and/or Vomiting
    • vomiting or diarrhoea with weight loss in an infant <1 year
    • suspected pyloric stenosis
    • bile stained vomiting
    • acute onset abdominal distention
    • weight loss with cardiovascular instability, e.g. postural heart rate changes
    • new onset of blood in diarrhoea or vomitus
  • Constipation with or without soiling
    • severe abdominal pain or vomiting with pain

Urinary

  • Urinary Incontinence and enuresis.
    • recent onset of polyuria/polydipsia that might suggest diabetes (mellitus or insipidus)
  • Recurrent Urinary Tract Infections (UTI)
    • acute infant  urinary tract infection presenting septicaemia or acutely unwell

Musculoskeletal

  • Acute joint pain with fever
  • Acute joint pain unable to weight bear.   

Cardiac

  • Chest pain with haemodynamic compromise or history of cardiac disease
  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

Allergies

  • Anaphylaxis
  • Allergic reaction where there are any respiratory or cardiovascular symptoms or signs
  • Reaction to peanut or other nut should be referred to Emergency as these reactions can progress rapidly and should be observed and assessed in Emergency
  • Exposure to a known allergen with a previously identified potential for anaphylaxis in this patient even if the reaction appears currently mild
  • Severe angioedema of face

Growth concerns

  • Faltering growth (failure to thrive in children < 6 years)
    • severe malnutrition
    • temperature instability
    • cardiovascular instability – postural heart rate change
  • Short stature
    • possible CNS signs (visual disturbance, morning headaches)

Developmental concerns

  • Non verbal child with acute distress and unable to examine adequately for medical conditions causing pain  eg tooth abscess, bone infections or osteopaenic fractures

 

Behavioural concerns

  • Suicidal or immediate danger of self-harm
  • Aggressive behaviour with immediate threatening risk to vulnerable family members

Irritable Infant

  • Fluctuating or altered conscious level – weak cry, not waking appropriately for feeds, lethargy, maternal concern of failure of normal interaction
  • Suspicion of harm or any unexplained bruising, especially in infant <3 months
  • Significant escalation in frequency or volume of vomiting
  • New onset of blood mixed in stool
  • Fever
  • Increased respiratory effort
  • Weak or absent femoral pulses in infant <3 months
  • Presence of newly noted heart murmur in infant <3 months

 

Physical findings of concern in an infant <1 year

  • Inguinal hernia that cannot be reduced.
  • Painless firm neck swelling that is increasing in size.
  • White pupil or white instead of red reflex on eye examination.
  • Previously unrecognised intersex genitals (ambiguous as either virilised female or incomplete formation male eg bilateral absent testes).
  • Possible Infantile Spasms. This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old. 
  • Absent femoral pulses.
  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

Diabetes

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following:
    • systemic symptoms (fever, lethargy)
    • vomiting
    • inability to eat (even if not vomiting)
    • abdominal pain
    • headache
  • Refer to local care pathway
  • Developmental optometry and auditory processing assessments are not supported by evidence
  • Delay across multiple developmental domains is more likely to be associated with significant impairment and require general paediatric review
  • The chronological age versus the “developmental age” (which should be available through screening) can be used as a gauge of functional severity. Considering a 4 year old child:
    • MILD – 6 months delayed
    • MODERATE – 12 months delayed (i.e. a 4 year old who acts more like a three year old re abilities)
    • SEVERE – 18-24 months delayed (i.e. a 4 year old who has the abilities of a 2-21/2 year old child)
  • Refer to allied health professional for an assessment and/or intervention and review within a pre-determined period of time (e.g. 3-6 months)
  • Concerning features referral guide: Red Flags Early Identification Guide
  • Mild or unspecified developmental concerns, including isolated speech delay, should be initially referred to community child health nurse or to a community allied health provider rather than to general paediatric outpatients
  • Refer for hearing/vision testing as part of differential diagnosis and co- morbidities.
  • Parents’ evaluation of developmental status (PEDS) screening tool - is an evidence based screening tool that elicits and addresses parental concerns about children’s development, health and wellbeing. PEDS is a simple, 10-item questionnaire that is completed by the parent.
    PEDS is available in the “red book” (hand held child health record) and can be used informally to ascertain concern across single domain or multiple domains. Child Health Nurses are able to formally administer this. 
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
  • Ages and stages questionnaires are available online and can be completed by practice nurse in conversation with parent or formally by Child Health Nurse. Ages and stages questionnaires are not free but may be purchased on line.
  • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services


Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Definite history of developmental regression
    • Significant developmental delay in an infant less than 1 year
  • Category 2
    (appointment within 90 calendar days)
    • Severe developmental delays
    • Developmental delay with related medical co morbidities
    • Child not walking at 18 months
    • Marked low tone or high tone
    • Differences between right and left sides of body in strength, movement or tone
    • Child expected to be in out of home care supervised by the department of child safety for more than 6 months (only those with developmental delay)
  • Category 3
    (appointment within 365 calendar days)
    • Moderate developmental delay/ multiple domain concerns

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • General referral information
  • Provide sufficient information of screening of the developmental concern. This may be any of the following:
    • a developmental screening tool or
    • a community child health nurse or health worker developmental Assessment or
    • an allied health Assessment or
    • sufficiently detailed developmental milestone history

NB: See information in “other useful information”

  • Report presence or abscence of concerning features
    • Is there definite history of developmental regression, and if so what specific loss of skills has been noted?
    • Is the child expected to be in out of home care supervised by the department of child safety for more than 6 months?

3. Additional referral information Useful for processing the referral

Highly desirable Information – may change triage category

  • Birth history
  • Other past medical history
  • School or Child Care Centre observations.
  • Family history (parental consanguinity, history of neurological disorders, learning or developmental problems)
  • Visual acuity and audiometry (developmental optometry and auditory processing assessments are not recommended – see other useful information).
  • Copies of previous of speech, occupational therapy, physiotherapy or cognitive assessments if available.
  • If the child is in foster care please provide the name and regional office for the Child Safety Officer who is the responsible case manager.
  • Significant psychosocial risk factors (esp parents mental health, family violence, housing and financial stress, department of child safety involvement)

Desirable information- will assist at consultation

  • Immunisation history
  • Developmental history
  • Medication history
  • Height/weight/head circumference and growth charts with prior measurements if available.
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology
  • Any relevant laboratory tests or medical imaging results

4. Request

Patient's Demographic Details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

Relevant clinical information about the condition

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
  • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.

  • A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.

  • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.