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Primary care management and referral guideline Primary care management and referral guideline

Developmental Concerns in Young Children – Management and referral guideline

Red flags

  • Significant impairment or delay across 2 or more developmental domains
  • Developmental regression
  • Complex psychosocial situation e.g., out-of-home care, child protection involvement

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Child development is a dynamic process that is best assessed by regular longitudinal observation.
  • Development should be considered across a number of domains:
    • Motor (fine and gross)
    • Speech and language
    • Social and emotional (including behaviour)
    • Daily living skills (play and cognition)
  • If systematically elicited, parent and teacher concerns are known to be appropriate indicators for making referral decisions.
  • Developmental delay, sensory impairment (vision or hearing), or social emotional factors may initially present as a behavioural problem, so careful assessment of the ‘difficult child’ is required.
  • Early recognition of a developmental problem allows for early intervention, which may improve long-term functional outcomes for children and families.

Assessment

Explain importance of thorough assessment

A good child developmental assessment takes time. Explain the importance of a thorough assessment and arrange an extended follow-up appointment. The time between consultations can be used to gather further information e.g., parental questionnaires, hearing or vision testing.

Explain the importance of a thorough assessment, and assess development:

  • at all childhood vaccination encounters.

    Childhood vaccination encounters
    For each planned visit, check the Personal Health Record (Red Book) for a brief description of what parents should expect from their child (Milestones on page 5) and topics for discussion.

    Encourage parents to complete the Parents Evaluation of Developmental Status (PEDS) questionnaire.

  • yearly from age 2 years.
  • opportunistically, i.e. track skills during unplanned visits and address any parental concerns.

The time between consultations can be used to gather further information.

Review medical and social history for risk factors for developmental delay.

Risk factors
Psychosocial

  • Parental mental illness or substance abuse
  • Parental learning difficulty
  • Social isolation
  • Poverty
  • Poor housing
  • Lack of access to services
  • Aboriginal and Torres Strait Islander children:
    • Cultural factors do not increase risk, however social determinants (e.g., poverty, poor housing) might.
    • An understating of culture is essential to assess and manage development in the Aboriginal and Torres Strait Islander population.
  • Child in out‑of‑home care or has Child Protection involvement
  • Exposure to trauma or stressful life events, including family violence

Medical

  • Prenatal:
    • Genetic disorders e.g., trisomy 21, fragile X syndrome, 22q deletion
    • Maternal infections e.g., rubella, CMV, toxoplasmosis, herpes virus (TORCH)
    • Maternal drugs or toxins e.g., anticonvulsants, alcohol
  • Perinatal:
    • Premature birth (< 28 weeks) and low birth weight (< 1500 g)
    • Birth injury
    • Severe neonatal illness e.g., congenital heart disease
  • Postnatal:
    • Serious infections e.g., meningoencephalitis
    • Traumatic head injury
    • Hypoxia e.g., near drowning
    • Toxins e.g., lead
    • Malnutrition e.g., iron deficiency
    • Chronic medical illness
  • Vision or hearing impairment

Assess the child’s current abilities against those expected for age across all developmental domains:

Examine the child. Perform:

  • general examination.

    General examination
    In particular:

    • Growth – track height, weight, and head circumference on growth charts. assess trajectory over time
    • Ent – evidence of glue ear, submucous cleft plate, tonsillar hypertrophy
    • Skin – neurofibromas, café au lait spots, hypopigmentation
    • Abdomen – evidence of consiptation, hepatosplenomegaly
    • Parental interaction with the child
    • Signs of non‑accidental injury
  • neurological examination.

    Neurological examination
    In particular:

    • Rapid increase in head size
    • Increased or decreased tone
    • Localising neurological signs
    • Evidence of a seizure disorder
    • Eye movements
    • Limb strength and tone
  • developmental assessment.

    Developmental assessment
    In particular:

    • Dysmorphic features
    • Lack of response to sound or visual stimuli
    • Verbal and non verbal communication skills
    • Gross and fine motor function
    • How the child explores and plays

If a problem is suspected, arrange:

  • formal developmental screen. If there is no expertise in the practice, arrange this via your local Child Health Service.

    Developmental screen

  • Audiology assessment for any child with speech or language delay.
  • optometry assessment for any child with vision concerns.
  • investigations only for suspected underlying medical conditions (e.g., FBC, E/LFT, Coeliac screen, iron studies, thyroid function testing, lead, creatine kinase).
    • Genetic studies (e.g., karyotype, microarray, Fragile X testing) should only be requested in consultation with a specialist service.
    • Imaging is only required if specific neurological indications, and is best considered in conjunction with a specialist service.

Based on findings, consider if:

  • there is developmental delay across a single domain or multiple domains.
  • a medical diagnosis needs to be considered e.g., cerebal palsy, seizure disorder.
  • there are complex developmental issues resulting in a functional disturbance for the child or family.

Management

If suspected child neglect or abuse, ensure the child’s safety.

Ensure the child’s safety

  • Contact child safety services immediately and manage according to their advice.
  • If signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • Clearly document the event.

If an underlying medical condition is suspected, follow the appropriate guideline and discuss with your local paediatric team.

If developmental regression, request discuss with your local paediatric team on call and arrange acute assessment.

If single domain developmental delay:

  • request early assessment from the appropriate allied health professional. Consider private referral under General Practice Management Plan (GPMP) and Team Care Arrangements (TCA) as public services may not be available in your region or may have lengthy waiting times.

    Allied health professionals

    • Speech pathology – communication e.g., speech generation and comprehension
    • Physiotherapy – gross motor skills e.g., gait, postural control, limb dystonia or weakness, hopping, jumping, running
    • Occupational therapy:
      1. Fine motor skills e.g., drawing, writing, cutting, fastening buttons
      2. Concentration and organisation e.g., purposeful play, dressing, daily life skills
      3. Coordination
    • Psychology:
      1. Behaviour and socialisation
      2. Assessment of school readiness
      3. Issues with learning
  • arrange access to the Early Childhood Early Intervention (ECEI) program, if eligible.
  • with any developmental red flags (see Red Flags Early Identification Guide), refer to your local General Paediatrics service to exclude an underlying medical cause for presentation.
  • if suspected autism spectrum disorder, follow the Autism Spectrum Disorder guideline.

If multiple domain developmental delay (e.g., across 2 developmental domains) or suspected autistic spectrum disorder:

  • request multidisciplinary assessment through the Child Development Program if available in your area. Otherwise, refer to your local General Paediatrics service.

    Child Development Program

    • Eligibility for Child Development Services may vary between regions – clarify with your local HHS network via the Child Development Program Access Service.
    • For more information, see Children’s Health Queensland – Child Development Program.
  • while awaiting specialist review, request early assessment and intervention from the appropriate allied health professionals.

    Allied health professionals

    • Speech pathology – communication e.g., speech generation and comprehension
    • Physiotherapy– gross motor skills e.g., gait, postural control, limb dystonia or weakness, hopping, jumping, running
    • Occupational therapy:
      1. Fine motor skills e.g., drawing, writing, cutting, fastening buttons
      2. Concentration and organisation e.g., purposeful play, dressing, daily life skills
      3. Coordination
    • Psychology:
      1. Behaviour and socialisation
      2. Assessment of school readiness
      3. Issues with learning

Inform parents their child may be eligible for additional support:

  • School aged children with a disability may be eligible for Education Queensland funding to provide additional support in the school environment. Only certain conditions are eligible for this, and require verification by a paediatrician.

    Conditions eligible for Education Queensland funding

    • Autistic spectrum disorder
    • Hearing impairment
    • Vision impairment
    • Physical impairment
    • Intellectual impairment
    • Severe speech and language impairment
  • Preschool children may be eligible for entry to an early childhood development program.

If behavioural or psychological problems without developmental delay, follow the Behavioural Concerns in Children Under 6 Years guideline.

Strengthen parental resources, even if development is progressing normally.

Parental resources

When to refer

  • If suspected child neglect or abuse:
    • contact child safety services immediately.
    • and signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • If significant medical illness or developmental regression, discuss with your local paediatric team on call and arrange acute assessment.
  • If child with an impairment, request early assessment from the appropriate allied health professional:
    • Speech pathology
    • Occupational therapy
    • Physiotherapy
    • Psychology
  • For formal developmental screening, ongoing surveillance and support, request assessment from the local child health nurse.
  • If single domain developmental delay with any developmental red flags (see Red Flags Early Identification Guide), refer to your local General Paediatrics service
  • If multiple domain developmental delay or suspected autistic spectrum disorder:
    • request multidisciplinary assessment through the Child Development Program if available in your area and eligible. Otherwise, refer to your local General Paediatrics service
    • while awaiting specialist review, request early assessment and intervention from the appropriate allied health professionals.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging

    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 27/06/2019 Review date 01/06/2022

Disclaimer

Referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.
Our referral guidelines aim to help GPs decide which tests and treatments are appropriate for their patients based on their presenting symptoms and previous medical history. Consulting the relevant referral guideline before a patient is referred on to a specialist service may mean that an appointment can be booked sooner and the outcome of their consultation is more conclusive. It can also eliminate the need to refer a patient where preliminary tests rule out the need for specialist intervention.
The information contained within our referral guidelines has been developed in collaboration with specialist medical professionals. They are intended to support referring GPs and are in no way intended to replace their professional medical judgement.

Resources

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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