This list is intended as guidance for presentations:

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 eg 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 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