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Common Paediatric illnesses in Primary Care – when to refer?. Southend University Hospital NHS Foundation Trust. Paediatric referrals . Increased by 38% over the previous year Total Outpatient referrals per year: 15,480 Choose and Book 750 New referrals 3,850

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common paediatric illnesses in primary care when to refer

Common Paediatric illnesses in Primary Care – when to refer?

Southend University Hospital NHS Foundation Trust

paediatric referrals
Paediatric referrals
  • Increased by 38% over the previous year
  • Total Outpatient referrals per year: 15,480
    • Choose and Book 750
    • New referrals 3,850
    • Rapid access 2400
    • follow ups 8440
  • Inpatient admissions: 1300
    • Length of stay 1.1 days
urgent referrals
Urgent Referrals
  • The acutely unwell infant
  • Uncertain diagnosis and you are worried!
  • Extreme parental anxiety
  • Worries about child safety or non-accidental injury; also contact social services
  • Low threshold for admission in:
    • Children with co-morbidity eg diabetes, cystic fibrosis, on immuno-suppressives/steroids
    • Past history of intensive care treatment eg diabetic ketoacidosis, life-threatening asthma
    • Young infants below 3 months
recognition of the sick infant important considerations
Recognition of the sick infantImportant considerations
  • Completely undress the infant (remember it is easy to miss petechiae or bruising or a hernia)
  • Infants are difficult to assess objectively
  • Illness can result in rapid deterioration over a few hours. It is therefore helpful to re-assess the child after a suitable interval
  • Younger the baby lower the threshold of admission
  • With exception of dehydration, an infant that is feeding well is unlikely to have a serious illness
recognition of the sick infant significant symptoms
Recognition of the Sick Infant significant symptoms
  • Reduced feeding (<50% of normal in previous 24 hours)
  • Persistent vomiting (>50% of the previous 3 feeds)
  • Any bile-stained vomiting
  • Frank blood in stools
  • Less than 4 wet nappies in 24 hours
  • Rapid breathing – particularly if noisy and of sudden onset
  • Inappropriate drowsiness or irritability
  • Convulsions
  • Persistently unusual cry
  • History suggestive of apnoeic episodes
recognition of the sick infant significant signs
Recognition of the Sick Infant significant signs
  • Activity:
    • Floppy
    • Reduced response to verbal or painful stimuli
  • Dehydration:
    • tachycardia >120/min
    • reduced skin turgor of ≥2secs
    • Reduced capillary refill ≥3secs
    • dry mouth, sunken fontanelle
  • Respiration:
    • Tachypnoea: ≤5years: >50/min; >5years: >30/min
    • Grunting and rib recession
  • Others:
    • Marked pallor / Non-blanching rash
    • Bulging fontanelle, neck stiffness
    • Limping / joint swelling
    • Febrile: <3months ≥380C

≥3months ≥390C

common outpatient referrals

Food allergies

Chronic asthma

Chronic cough

Heart murmur



Chronic abdominal pain

Urinary Tract Infection


Constipation and soiling

Obesity and excessive weight gain


Musculoskeletal problems

Behavioural disorders

Common surgical conditions

Development concerns

Non-accidental injury

Crying baby

Common Outpatient Referrals
Diagnosis: Itchy skin + 3 or more of following:

Onset <2years

History of asthma/rhinitis

Dry skin in past 12 months

Flexural dermatitis


Emollients and moisturisers

Hydrocortisone1% TDS on inflamed skin even on face.

Stronger steroids (eumovate, dermovate, betnovate) used only for short term (1-2 weeks), avoid in children<2 years and avoid face.


Leaflet from eczema society

When to Refer: (dermatologist/paediatrician)

Uncertain diagnosis

Treatment ineffective

Non-responsive eczema on the face

If child is experiencing sleep disturbance, poor school attendance or significant social or psychological problems

If eczema associated with severe and recurrent infections

food allergies
Most children with milk allergy grow out of it by 3 years

Most children with egg allergy grow out of it by 5 years

Most children with peanut allergy remain allergic (1 in 5 may resolve)

Common food allergens: milk, egg, soya, wheat, seeds, nuts (peanuts and treenuts), fish, shellfish, exotic fruits eg kiwis, avocadoes

Symptoms of tingling tongue, urticarial rash, angioedema (lip or facial swelling), vomiting, diarrhoea (mild allergic reaction)

Respiratory symptoms or cardiovascular collapse (shock) means Anaphylaxis (severe allergic reaction)

When to refer:

Severe allergic reaction-anaphylaxis

History of poorly controlled asthma

Multiple food allergies

Unidentified triggers

High parental anxiety

Frequent reactions


History is often clear and no diagnostic tests are needed

Skin prick tests and RAST can be misleading, particularly in young children or those with eczema

Generally a negative result is highly reliable, but there are often false positives

Tests cannot reliably identify the severity of the allergy

Oral challenges are the only way to be sure a child has outgrown an allergy, but must be conducted in hospital if there is any risk of a severe reactioin

Food allergies
chronic asthma when to refer
Chronic Asthma-When to Refer:
  • Poor response to 800µg/day beclomethasone (or equivalent) – step 4 of BTS/SIGN guidelines and should be on other asthma treatments; concordance and drug delivery need careful assessment
  • Poor response to 400 µg/day beclomethasone (or equivalent) and needs add-on treatments that GP is unfamiliar with
  • Young child (<5years); uncertainty about drug delivery. Needs careful assessment of inhaler techniques and expertise of specialist asthma nurse
  • Young child (<1year); often doubt about diagnosis
  • Features that point to another diagnosis eg finger clubbing, focal signs in chest, failure to thrive, symptoms present from birth
  • Recurrent admission to hospital; suggests dangerous pattern of asthma
  • Frequent (>1/month) use of courses of oral prednisolone
  • Particularly severe acute asthma, such as needing intravenous treatments or intensive care. These are high risk patients
chronic cough
Defined as daily cough lasting ≥4weeks

Associated Wheeze, exacerbation with viral illness, exercise or during sleep, personal or family history of atopy – possible asthma

Barking or brassy cough – croup, tracheomalacia, habit cough

Paroxysmal (with/without wheeze) – pertussis and parapertussis

Check immunisation status, exposure to tobacco smoke and evidence of personal or family history of allergies

When to Refer:

Neonatal onset of cough

Chronic moist/purulent cough

Cough started and persists after choking episode

Cough occurs during or after feeding

failure to thrive

Finger clubbing

Contact with TB

Associated abnormalities (cardiac, neurodisability, immune deficiency)

Chronic cough
heart murmur
Central cyanosis (blue extremities and mucus membranes ie tongue) is a feature of cyanotic congenital heart disease. Cyanosis restricted to extremities (peripheral cyanosis) is normal in infancy in the absence of other symptoms or signs.

Feel for apex of heart (dextrocardia)

Feel femoral and brachial pulses (coarctation of aorta)

Innocent heart murmur is never associated with symptoms.

Innocent heart murmurs are soft, varies with posture / respiration, ejection systolic, high-pitched, grade1-2/6 and localised to praecordium; no praecordial thrill

When to refer:

Associated with symptoms of central cyanosis, pale, prolonged feeding (>30 mins), short of breath or failure to thrive.

Infants below 1 year

Doubts about the murmur-whether pathological

Parental anxiety

History of congenital heart disease in siblings or parents

Heart murmur
vomiting infant
Differential Diagnosis:

Viral infections (URTI / gastroenteritis)

Gastroesophageal reflux (GOR) (worse with feeds and when lying flat; often good response to feed thickeners eg infant Gaviscon)

Pyloric stenosis (1-4 months age, weight loss)

Cow’s milk protein intolerance (often history of associated diarrhoea, atopic tendency and failure to thrive)

Surgical causes eg intussusception, malrotation (bilious vomiting)

Raised intracranial pressure (lethargy, bulging fontanelle, separated sutures)

When to refer:

Bilious vomiting

Weight loss or Failure to thrive

Unable to maintain hydration

Complicated GOR associated with symptoms ie failure to thrive or crying/irritability or aspiration/apnoeic episode

Raised intracranial pressure (lethargy, bulging fontanelle, separated sutures)

Vomiting infant
Differential diagnosis:

Viral / bacterial gastroenteritris

Non-enteral infections such as UTI, meningitis or pneumonia

Cow’s milk protein intolerance or secondary lactose intolerance

Toddler’s diarrhoea / IBS

Malabsorption: cystic fibrosis, coeliac disease

Inflammatory bowel disease

Surgical causes: appendicitis, intussusception

Constipation with overflow

When to refer:

Blood in the stools

≥5 stools/day in a well child

Persists beyond 7 days in a well child

Unwell child

Lethargy / persistent crying or irritability / poor feeding

Acute episode of diarrhoea lasting for >2 weeks

Failure to thrive

Failed oral rehydration because of persistent vomiting or increasing dehydration

Parental anxiety / social concerns

chronic abdominal pain

Intermittent abdominal pain on at least 3 occasions over a 3 month period

Pain interferes with normal activities

Common causes:

Functional abdominal pain


Abdominal migraine


Mesenteric adenitis

First line investigations suggested:

Urine C&S, Stool C&S, FBC, U&Es, LFT, CRP, ESR, Coeliac screen

When to refer:

Significant illness behaviour, especially time off school

Weight loss / failure to thrive

Bilious vomiting

Bleeding PR

Frequent nocturnal pains

Abnormal examination

Abnormal first line investigations

Chronic abdominal pain
the crying baby
The crying baby

A normal baby’s cry increases from birth to a maximum at 2 months averaging 2-2.5 hours a day, with a peak between 6-12pm. Tense anxious parents have tense, anxious babies! Commonest are hunger, dirty nappy, need for company or tiredness

Refer if:

  • Baby appears systemically unwell
  • Baby is febrile without a clinical focus
  • Baby has bilious vomiting
  • Baby cries, with episodes of pallor
  • Baby has hernia or swollen testes
  • Baby is of socially isolated carers
  • Baby appears to have limb pain or there are concerns about child abuse
urinary tract infection

Upper UTI(acute pyelonephritis):

fever/loin pain or tenderness + bacteriuria

Lower UTI (cystitis):

dysuria +bacteriuria


For <3yrs: Clean-catch/bag urine for C&S

For ≥3yrs: Urine dipstick leucocytes / Nitrites:

+ /+ = UTI - treat

- / + = treat as UTI

+ / - =treat if symptoms

- / - =No UTI

Treatment of Lower UTI: Trimethoprim or amoxycillin or cephalosporin for 3 days

Always ask for Renal tract ultrasound scan (USS) before referral

When to refer:


Upper UTI

Atypical UTI which includes:

Failure to respond to treatment with suitable antibiotics within 48 hours

Seriously ill

Poor urine flow

Abdominal or bladder mass

Infection with non-E coli organisms

Recurrent UTI

Abnormal renal tract USS in <6months age (pre-existing renal tract abnormalities)

Urinary Tract Infection

Bedwetting over 6 years of age without neurological or urological cause

Make sure there is no UTI


Not indicated under 6 years other than star chart to encourage / reward progress

Refer to Incontinence Nurse Specialist

Desmomelt (use for short-term ie holidays or initial 3-month trial)

When to refer:

Children with daytime urinary problems

Treatment failures

Concerns over family dynamics (parents need to understand this is a developmental problem, not bad behaviour)

constipation and soiling
Diagnosis: Either / or

infrequent (≤1/week) stools

firm/hard consistency stools

difficult/painful defaecation


Diet (high roughage)

Develop habit of sitting on toilet with good foot rest 20 mins after meals

Laxatives (senna liquid+/-lactulose; Movicol paediatric sachets). Sometimes higher than recommended dose is necessary. Laxatives are safe

If perianal area inflamed – consider antibiotics

When to refer:

Passage of toothpaste-like stools (?anal stenosis)

Neonatal onset of symptoms

Cerebral palsy, spinal abnormalities, developmental delay

Constipation and Soiling
obesity and excessive weight gain

BMI >98th centile = Obesity

BMI >91st centile = overweight

Weight crosses centiles upwards, and exceeds height centile by at least 2 centiles


Weight maintenance is an acceptable goal

Family centred approach

Healthier diet

Increase in habitual activity to a minimum of 30 mins/day

Reduction in sedentary behaviour (eg TV/computers) to <2hrs/day or <14hrs/week

When to refer:

<2years, >99.6th centile for BMI

Exhibiting obesity-related morbidity ie sleep apnoea, hypertension/hyperlipidaemia, diabetes, orthopaedic disorders or psychological problems

Associated physical or learning difficulties

Obesity and Excessive weight gain

Migraine/migrainous features: paroxysmal, well in between, 1-48 hours, unilateral/bilateral, frontal/temporal, banging/pulsating, worse with routine exertion, extended family history


Lifestyle advice – avoid cheese, dark chocolate, caffeinated drinks, orange juice

Ibuprofen/paracetamol (rescue) up to 3 days/week

Prophylaxis with pizotifen/propranolol if migraine≥4/month

When to refer:

Age <5years

Acute severe headache with signs of meningeal irritation

New persistent daily headache or accelerating course – every few months, then weeks, then days

Worse lying down, bending over or coughing

Nocturnal awakening

Associated with complex symptoms/impairments eg general fatigue, social or school withdrawal, depression or behavioural disturbances

Treatment / reassurance failed

faints and funny turns
Faints and Funny turns

Normal paroxysmal events:

    • Vasovagal syncope:
      • Older children (-14yeras);
      • occurs when upright; may be triggered by pain, emotional stimuli or prolonged standing.
      • Associated light-headedness, nausea, blurred vision or pallor
      • Secondary anoxic seizures can cause stiffening or fine twitching
      • Recovery often rapid after lying down
    • Reflex anoxic seizures:
      • Young children (6months to 3 years)
      • triggered by unpleasant events eg emotional trauma or pain.
      • Onset is rapid and there is no preceding history of light-headedness or visual loss.
      • The child looks pale, loses consciousness and may have brief tonic or tonic-clonic seizure. Can be associated with incontinence and tongue biting
    • Blue breath-holding spells: precipitated by physical or emotional trauma. Child starts crying and holds the breath in prolonged expiration, resulting in cyanosis, limpness and loss of consciousness for a short period of time (few minutes)
  • Refer if:
    • History of collapse during exercise or swimming
    • Family history of sudden death
    • Abnormal cardiac examination or abnormal ECG (abnormal QTc)
    • Epileptic seizure to be likely
    • Associated neurological or learning difficulties
musculoskeletal problems
Musculoskeletal problems
  • Common presenting symptoms are pain, limping, limb or joint swelling, limitation/paucity of movements, muscle stiffness / spasm
  • Refer to Orthopaedic surgeon:
    • History of Trauma
    • Febrile child with above symptoms
    • Night pains and always in the same place
  • Refer to paediatric rheumatology / physiotherapist:
    • for all persistent (≥2weeks) symptoms with no history of trauma
    • Joint swelling (≥1week)
behavioural problems
A significant problem in behaviour is more likely:

When the behaviour is frequent and chronic

When >1 problem behaviour occurs

If behaviour interferes with social and cognitive functioning

Consider referral to health visitors / child and family consultation services (CFCS) prior to hospital referral

When to refer:

Less than 5 years age

Learning difficulties / developmental delay

Suspected autism

Suspected seizures

Motor coordination difficulties

Speech delay

Suspected ADHD in ≥6 years age

Behavioural problems
development warning signs
Development Warning Signs
  • At any age
    • Maternal concern
    • Regression in previously acquired skills
  • At 10 weeks
    • Not smiling
  • At 6 months
    • Persistent primitive reflexes
    • Persistent squint
    • Hand preference
    • Little interest in people, toys, noises
  • At 10 - 12 months
    • No sitting
    • No double-syllable babble
    • No pincer grasp
developmental warning signs cont
Developmental Warning Signs cont…
  • At 18 months
    • Not walking independently
    • Fewer than six words
    • Persistent mouthing and drooling
  • At 2 ½ years
    • No 2-3 word sentences
  • At 4 years
    • Unintelligible speech

Refer to the Health visitor to do a developmental assessment and then refer to paediatrician (with interest in neurodisability) if necessary

some common surgical conditions
Some common surgical conditions
  • Pre-auricular skin tag:Ask for renal tract ultrasound scan (refer if abnormal). Refer to plastic surgeon for its removal. Make sure neonatal hearing screen has been done.
  • Tongue tie: tight frenulum prevents tongue getting over lower lip and gum ridge. Refer to surgeons if difficulty with breast/bottle feeding leading to pain for the mother and poor infant weight gain
  • Umbilical granuloma: Cauterise with silver nitrate stick (or refer). Make sure it is not a umbilical polyp (refer if unsure).
  • Umbilical hernia: ‘Strapping’ is ineffective. Normally disappears spontaneously by 1 yr of age. Refer if: hernia persists to the age of 3-5 yrs, becomes progressively larger after 1-2yrs of age or causes symptoms
  • Inguinal hernia: Refer
  • Hydrocoele: disappears by 1 yr of age. Refer if persists
  • Undescended testis: Refer if testis not descended by first birthday.
  • Phimosis: Remember normally prepuce becomes retractable by 3 yrs of age. Refer if: prepuce not retractable by 3 yrs; history of balanoposthitis
  • Polydactyly and syndactyly: Refer to orthopaedics or plastic surgery
  • True talipes (the foot cannot be passively everted and dorsiflexed to the normal position): Refer to physiotherapist / orthopaedic surgery
  • Developmental dysplasia of Hip (formerly known as congenital dislocation of hip or CDH): More common in infants born breech, family history of CDH or associated other limb or joint anomalies. Ask for:
    • Before 8 months – ask for ultrasound scan of hip (if normal – discharge)
    • ≥8 months – ask for plain Xray of Hip (if normal – discharge)

Delayed presentation

History not consistent with injury

History not consistent with development

History changes

Different history from carers

Recurrent injuries or burns

Poor interaction with carers

Carers overreacting to misbehaviour

Sexualised behaviour at young age


Any bruising to young babies

Fracture in <1 yr age

Spiral fractures

Bruising on unusual places (ie the cheeks)

Small circular burns

Scalds to either feet or buttocks

Red lines to wrists or ankles (from ligatures)

Isolated tear of upper lip fraenulum

General neglect

Failure to thrive without organic causes

Multiple injuries of different ages

Injuries to genitalia

Recognition of Non-accidental injurySafeguarding Children and Young people: a toolkit for general practice:
consultant paediatricians with special interests
Consultant Paediatricians with Special Interests
  • Dr Awadalla, F - diabetes, metabolic disorders
  • Dr Emcy, N - gastroenterology, neurodisability, ADHD
  • Dr Khan, A - children <1year, neonatology
  • Dr Margarson, I - neurodisability, autism
  • Dr Nerminathan, V - growth/endocrinology, enuresis/encopresis
  • Dr Rahman, M - cardiology, neurodisability
  • Dr Ranasinghe, T - haematology/oncology, infectious diseases
  • Dr Shrivastava, A - nephrology, rheumatology, neonatology
  • Dr Sriskandan, S - Epilepsy, haematology/oncology

Others (Associate specialists):

Dr Perera, J - ADHD

Dr Sen, G - Hearing impairment

Dr Sutherland, V - Neurodisability