• This list 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.
    aundice 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
• An 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 e.g. 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 e.g. 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