Faltering growth (failure to thrive) 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 follow local emergency care protocols 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 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
    • Refer to local Healthpathways or local guidelines
    • If breast-fed baby, offer advice about technique – lactation consultant or child health nurse (weekly until seen)
    • Prematurity needs to be corrected on growth charts
    • Severe acute malnutrition is defined by more than 10% recent acute weight loss or crossing two major centiles or visible severe wasting or nutritional odema
    • Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC.

    Clinician resoucres

    • Royal Children's Melbourne Growth charts and calculators: RCH Growth Charts
    • 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: Department of Children, Youth Justice and Multicultural Affairs
    • Statement of intent – the prioritisation of health services for children and young people in the child protection system
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Infants < 1 year with faltering growth
  • Significant weight loss /failure to gain in a child up to 6 years
  • A child currently in out of home care (OOHC) or at risk of entering or leaving OOHC, where they have previously been on a waiting list for this problem and were removed without receiving a service
Category 2
(appointment within 90 calendar days)
  • Most other referrals with faltering growth in children < 6 years
Category 3
(appointment within 365 calendar days)
  • No category 3 criteria

Please insert the below information and minimum referral criteria into referral

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

  • For infants less than 12 months must provide gestational age at birth (or weeks of prematurity)
  • Details of concern about growth
    • current height and weight* (at least two weights (one of which may be birth weight)), and include date of measurement
    • if under 2 years include head circumference, development
  • Confirmation of OOHC (where appropriate)

*It is important to note the trend, 1 week apart

3. Additional referral information Useful for processing the referral

Highly Desirable Information – may change triage category.

  • Height/weight/head circumference/percentile charts (measured serially and plotted to note trend, if available). It is recommended that WHO growth standards be used for children under 2 years of age and CDC growth charts for children over 2 years of age
  • Feeding history:
    • infants – breast or formula, volumes or effectiveness of feeding, parental vegan
    • older children – feeding refusal, restrictive food choices
  • Gestational age at birth and birth weight.
  • Bowel habit and any history of vomiting
  • GP impression of current developmental status (may be parental assessment) (= age appropriate, some delays, significant delays).
  • Family history (family history with short stature)
  • Social history
    • parental mental health problems
    • lack of financial resources for food requirement
    • lack of suitable housing
    • lack of family/community supports
    • refugee or recent immigrant background
    • failure to attend/engage hospital or community services appointments
    • previous history of child protection involvement

Desirable Information- Will assist at consultation

  • Other past medical history
  • Immunisation history
  • Medication history
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology

Investigations that may be considered with referral

  • Urinalysis
  • Consider B12 & Iron studies
  • Stool PCR or M/C/S for infections, calprotectin, elastase
  • FBC with differential, LFTs U&Es TFT
  • If gluten in diet: coeliac serology, total IgA

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.)

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

    • 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.

Last updated: 21 December 2021

© State of Queensland (Queensland Health) 2023

Except as permitted under the Copyright Act 1968, no part of this work may be reproduced, communicated or adapted without permission from Queensland Health. To request permission email ip_officer@health.qld.gov.au1.