Behavioural problem in a child ≥ 6 years old

+ Emergency

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 infan

Gastroenterology

• Chronic & Recurrent Abdominal Pain
  
  • severe pain not able to 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

• 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 tachypnea)

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 tachypnea)

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

+ Useful management information

• Refer to local care pathway
• The following children should be directed to Child and Youth Mental Health Services
  
  • children who may be at risk of self-harm
  • aggressive behaviour with high risk of significant injury to vulnerable family members
  • primary school child with significant school refusal due to anxiety
• Raising children network www.raisingchildren.net.au
• 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: https://www.communities.qld.gov.au/
• In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment

+ Additional resources

On-Line Resources for children with developmental or behavioural problems

• Royal Melbourne Children’s Hospital 
• Sydney Children’s Hospital 
• American Academy of Paediatrics 
• Royal College of Paediatrics and Child Health(UK)
• Diagnostic Criteria for the Neurodevelopmental Disorders Journal article
• Attachment Disorders

Click here for further resources and useful tools developed by Dr Ian Shellshear, available from the Ipswich Hospital Foundation.

+ Minimum referral criteria - Does your patient meet the minimum referral criteria?

+ Standard referral information To be included in all referrals

+ Additional referral information

Highly desirable information – may change triage category

• Brief comment on current school educational attainments (good, average, poor, very poor (>2 years behind))
• Guidance officer assessment or other information from the school.
• Information about school attendance, expulsion or suspension.
  
  • estimate number of days suspended in the previous 3 months.
  • estimate number of days missed because of school refusal.
• Previous medications or therapies used.
• Significant psychosocial risk factors (especially parents mental health, family violence, housing and financial stress, department of child safety involvement)
• Previous services accessed (other paediatricians, mental health services, allied health services, etc.)
• Family history, including family members affected with ASD, ADHD, learning difficulty or mental illness.
• Copies of previous of speech, occupational therapy, physiotherapy or cognitive assessments if available.
• Audiometry
• 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.

Desirable information- Will assist at consultation

• Pregnancy and birth history
• Other past medical history
• 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