Neonatal Jaundice (<8weeks of age)

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 or delay in development
  • recent head injury or head trauma
  • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia, visual disturbance
  • sudden onset headache reaching maximum intensity within 5 minutes  ( = explosive onset)
  • presence of an intracranial Cerebral Spinal Fluid (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
  • Possible infantile spasms (west syndrome). This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12-month-old.  
• 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
  • Inguinal hernia/testicular torsion
• 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
  Lower limb joint pain persistently unable to weight bear
• Joint pain in a child from a population at high risk of acute rheumatic fever*    *refer also to ARF CPC

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)
    
    

Child aged 3- 16 years in High risk group for acute rheumatic fever with murmur and signs of cardiac failure – increased respiratory rate, increased heart rate, enlarged heart and liver on examination, fatigue/ exercise intolerance on history.   [see also ARF CPC]

Rheumatic Heart Disease

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

Rheumatic Heart Disease

• Suspected Acute Rheumatic Fever.

For a child in a high-risk population there is a lower threshold for referral. 

• At high-risk
  • Living in an ARF-endemic setting
  • Aboriginal and/or Torres Strait Islander peoples living in rural or remote settings
  • Aboriginal and/or Torres Strait islander peoples, and Maori and/or Pacific Islander peoples living in metropolitan households affected by crowding and/or lower socioeconomic status
  • Personal history of ARF/RHD and aged <40 years

• Acute arthritis (swollen hot joint with inability to use/ weight bear). Differential diagnosis includes septic arthritis and juvenile chronic arthritis.
• Migratory poly arthralgia
• New murmur in child aged 3- 16 years with signs of cardiac failure – increased respiratory rate, increased heart rate, enlarged heart and liver on examination, fatigue/ exercise intolerance on history.
• Child with chorea 

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

 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
• Inguinal hernia

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