Murmur (General Paediatrics)

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  Emergency

  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
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  Other useful information for referring practitioners Not and exhaustive list

  • Refer to local Healthpathways or local guidelines
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
  • 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

  • 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