An Approach to the Child

Last updated 1 Jun 2026 · Paediatrics

📋 Key Information Summary

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A structured approach to the child in general practice integrates the parent–child interaction, developmental assessment, growth monitoring, and age-appropriate physical examination into a single, efficient consultation.
Begin every paediatric consultation by observing the undirected parent–child interaction before introducing yourself — this yields invaluable clinical information about attachment, behaviour, and developmental capacity.
Establish rapport with the parent first; acknowledge their expertise as the primary historian and partner in care, then gently include the child in the conversation at an age-appropriate level.
Use the RACGP red book and the Australian National Immunisation Program Schedule to guide anticipatory guidance and preventive health screening at each age-specific visit.
Developmental milestones should be screened routinely using validated tools such as the ASQ-3 (Ages and Stages Questionnaire) or PEDS (Parents' Evaluation of Developmental Status) at 0, 6, 12, 18, and 24 months and at 4 years of age.
Growth must be plotted on WHO growth charts (0–2 years) and CDC/BMI-for-age charts (2–18 years) at every visit; centile crossing of ≥2 major lines warrants further investigation.
Key developmental red flags include: no social smile by 8 weeks, no babbling by 10 months, no single words by 18 months, no two-word phrases by 30 months, and any regression of attained skills at any age.
Achieving cooperation in small children (under 5 years) requires distraction, play-based examination, the "examination sandwich" technique, and performing the least distressing manoeuvres first.
The physical examination should be adapted to the child's age and temperament: start with observation, then auscultation (heart, lungs, abdomen) while the child is calm, and leave invasive or distressing components (ears, throat, genitalia) until last.
Always consider and ask about psychosocial determinants of health — family structure, housing, food security, parental mental health, and exposure to domestic violence — as these profoundly influence child health outcomes.
Aboriginal and Torres Strait Islander children experience disproportionate rates of otitis media, rheumatic fever, skin infections, and growth faltering; culturally safe, trauma-informed practice and engagement with Aboriginal health workers is essential.
Red flags in any consultation — including parental concern, abnormal vital signs, failure to thrive, bruising in non-ambulatory infants, or unexplained injuries — should prompt urgent escalation and consideration of child protection referral.

Introduction & Australian Epidemiology

Children represent a significant proportion of general practice consultations in Australia. According to the Royal Australian College of General Practitioners (RACGP) and the Australian Institute of Health and Welfare (AIHW), approximately 25–30% of all GP encounters involve patients under the age of 18 years. The paediatric consultation is fundamentally different from the adult encounter: the clinician must simultaneously assess the child, engage the caregiver, observe family dynamics, and deliver age-appropriate preventive health care — all within time-pressured primary care settings.

A structured approach to the child ensures that no critical domain is overlooked. The consultation extends beyond the presenting complaint to encompass growth monitoring, developmental surveillance, anticipatory guidance, immunisation, and psychosocial screening. In Australia, the Medicare Benefits Schedule (MBS) supports comprehensive health assessments for children aged 0–4 years (MBS item 701) and 45–49 years (for parents, MBS item 702, 703, 705, 707), but child-specific health assessments should be embedded in routine care at key developmental milestones.

Australian children face a dual burden of disease: persistent communicable diseases (particularly in remote and Indigenous communities, including otitis media, skin infections, and rheumatic fever) alongside rising rates of chronic non-communicable conditions such as childhood obesity (affecting approximately 25% of Australian children), asthma (prevalence ~10%), allergies and anaphylaxis (Australia has one of the highest rates globally), and mental health conditions including anxiety and ADHD. General practitioners are uniquely positioned to provide longitudinal, family-centred care that addresses these intersecting health challenges.

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Australian context: The Australian Early Development Census (AEDC) data consistently shows that approximately 21.7% of children entering school are developmentally vulnerable on one or more domains. Early identification in primary care is critical to closing this gap.

Parent–Child Interaction & Approach to the Parent

The parent–child interaction is the single most informative element of the paediatric consultation and should be assessed from the moment the family enters the consulting room. This observation occurs during the pre-consultation period, ideally before the clinician introduces themselves, and continues throughout the encounter.

Observing the Undirected Interaction

Before greeting the family, observe:

Attachment behaviours: Does the child seek proximity to the caregiver when distressed? Is the caregiver responsive to the child's cues? Secure attachment is characterised by the child using the caregiver as a "safe base" from which to explore.
Parenting style: Authoritative (warm but firm), authoritarian (strict, low warmth), permissive (high warmth, low boundaries), or neglectful. Both extremes of control and permissiveness may contribute to behavioural difficulties.
Communication patterns: Does the parent speak to the child? At what level? Is there eye contact? Are questions answered or ignored?
Affect and emotional tone: Is the child's mood congruent with the situation? Does the parent appear anxious, flat, irritable, or disengaged?
Physical interaction: Appropriate physical contact, handling, and comfort-seeking behaviours versus avoidance, excessive restriction, or roughness.
Red flags for concern: Child flinching from the caregiver, absence of eye contact, hypervigilance, flat affect in the child, caregiver speaking about the child in the third person while the child is present, or a markedly discordant presentation (e.g., cheerful parent with withdrawn child).

Approaching the Parent

The parent (or primary caregiver) is the gatekeeper of the consultation and the historian. A positive parent–clinician relationship directly influences adherence, satisfaction, and health outcomes.

Welcome and Acknowledge

Greet the parent by name. Acknowledge the child by name and at eye level. Validate the effort of attending ("Thank you for bringing [child's name] in today").

Open-Ended History

Use open-ended questions directed at the parent: "Tell me what's been happening." Allow the parent to speak without interruption for at least 60 seconds — this improves diagnostic accuracy and parent satisfaction.

Validate Concerns

Explicitly acknowledge parental concerns: "I can see you're worried about this — that's completely understandable." Avoid minimising or dismissing, even if the concern appears minor clinically.

Partner in Care

Position the parent as the expert on their child: "You know [child's name] best — does this seem like their usual self?" Use shared decision-making for investigations and management.

Include the Child

By age 3–4, children can contribute meaningfully. Address the child directly: "Can you show me where it hurts?" By school age, balance parent and child contributions. Adolescents require time alone with the clinician (RACGP guideline).

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Parental mental health: Perinatal depression and anxiety affect 1 in 5 mothers and 1 in 10 fathers in Australia (PANDA data). A parent with untreated mental illness may have difficulty engaging with the child's care. Screen with the Edinburgh Postnatal Depression Scale (EPDS) where indicated and refer to appropriate support services (PANDA Helpline: 1300 726 306).

Psychosocial Screening

Every well-child visit should include brief psychosocial enquiry. Use the HEADSS framework for school-age children and adolescents (Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/depression). For younger children, enquire about:

Family structure, household composition, and support networks
Housing stability and food security (1 in 6 Australian children experience food insecurity — Foodbank Australia)
Parental smoking, alcohol, and substance use
Exposure to domestic and family violence (DFV)
Screen time and physical activity
Childcare and school attendance
Social media use and cyberbullying (school-age children)

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Mandatory reporting: In all Australian states and territories, registered medical practitioners are mandatory reporters of suspected child abuse and neglect. Thresholds vary by jurisdiction, but any reasonable suspicion of physical abuse, sexual abuse, emotional abuse, or neglect must be reported to the relevant state or territory child protection authority. Familiarise yourself with your jurisdiction's reporting requirements. In an emergency, call 000. For the Child Protection Helpline (NSW): 132 111.

Growth & Developmental Milestones

Growth monitoring and developmental surveillance are the cornerstones of preventive paediatric care. In Australia, the RACGP Guidelines for Preventive Activities in General Practice (Red Book, 9th edition) recommends structured assessment at key ages aligned with the MBS-funded health assessments and the National Immunisation Program Schedule.

Growth Monitoring

Growth parameters must be measured accurately and plotted on standardised charts at every well-child visit.

Age	Measurements	Chart	Frequency
0–2 years	Weight, length (supine), head circumference	WHO Growth Standards	At each immunisation visit (1, 2, 4, 6, 12, 18 months) and as indicated
2–5 years	Weight, standing height, BMI	WHO Growth Standards (2–5 yrs) or CDC charts	Annually minimum; more frequently if concern
5–18 years	Weight, standing height, BMI	CDC Growth Charts / BMI-for-age	Annually; at school entry and mid-adolescence

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When to investigate growth concerns: A child crossing ≥2 major centile lines (up or down) on the growth chart over any period warrants investigation. Consider coeliac disease, thyroid dysfunction, growth hormone deficiency, chronic illness, nutritional deficiency, or psychosocial failure to thrive. Initial investigations include FBC, EUC, LFTs, TFTs, coeliac serology (anti-tTG IgA + total IgA), and urinalysis.

Failure to Thrive

Failure to thrive (FTT) is defined as weight persistently below the 3rd centile or crossing downward through ≥2 major centile lines. In Australia, FTT affects approximately 1–5% of children presenting to primary care. Aetiology is broadly divided into:

Organic (≤30% of cases): Coeliac disease, cystic fibrosis, chronic renal disease, cardiac disease, metabolic disorders, food allergy (IgE- and non-IgE-mediated cow's milk protein allergy)
Non-organic (≥70% of cases): Inadequate caloric intake (misguided dietary restriction, poverty, food insecurity), poor feeding technique, parental mental illness, neglect, or chaotic family environment
Combined: Many children have overlapping organic and psychosocial factors

Developmental Surveillance

Developmental screening is distinct from surveillance. Surveillance is the ongoing process of monitoring development at every encounter; screening uses validated tools at specific ages.

Recommended screening tools in Australian general practice:

PEDS (Parents' Evaluation of Developmental Status) — validated, parent-completed questionnaire suitable for 0–8 years; Medicare-rebatable as part of child health assessments
ASQ-3 (Ages and Stages Questionnaire, 3rd edition) — more detailed developmental screening tool, parent-completed, domain-specific (communication, gross motor, fine motor, problem-solving, personal-social)
M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-up) — autism-specific screening recommended at 18 and 24 months

Developmental Milestones — Age-Based Reference

The following table summarises key developmental milestones. Note: there is a normal range for each milestone; the ages listed represent the upper limit of typical attainment (i.e., when concern should be raised if the milestone is not yet achieved).

Age	Gross Motor	Fine Motor / Vision	Language	Social / Cognitive
6 weeks	Lifts head in prone	Fixes and follows to midline	Social smile	Quiets when picked up
3 months	Head steady in sitting; lifts head 45° in prone	Fixes and follows past midline; hands open	Coos (vowel sounds)	Recognises caregiver
6 months	Sits with support; rolls front-to-back	Reaches for objects; raking grasp	Babbles (consonant-vowel combinations)	Stranger anxiety; laughs
9 months	Sits unsupported; may crawl	Pincer grasp emerging; transfers objects	Babbling with intonation; "dada/mama" (non-specific)	Object permanence; waves bye-bye
12 months	Pulls to stand; cruising; may walk independently	Mature pincer grasp; puts objects in container	1–2 words with meaning; understands "no"	Points to indicate interest; imitates actions
18 months	Walks independently; begins to run	Scribbles; builds tower of 2–3 blocks	≥6 words; follows simple commands	Points to named body parts; pretend play emerging
2 years	Runs; kicks ball; walks up stairs (2 feet per step)	Tower of 6–7 blocks; turning pages	≥50 words; 2-word phrases	Parallel play; symbolic play (feeds doll)
3 years	Tricycle; stairs with alternating feet; jumps	Draws circle; copies vertical line	3-word sentences; understood by strangers ~75%	Cooperative play; toilet training daytime
4 years	Hops on one foot; catches ball	Draws person (3+ parts); copies cross	Complex sentences; asks "why?" constantly	Group play; understands rules; gender identity
5 years	Skips; balance on one foot 10 seconds	Writes some letters; copies triangle	Count to 10; knows colours; tells stories	Ready for school; understands time concepts

Red Flags Requiring Urgent Referral

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Regression of any previously attained skill at any age — always pathological and requires urgent investigation (consider neurodegenerative disorder, autism spectrum disorder, child maltreatment, or CNS pathology)
No social smile by 8 weeks
No babbling by 10 months
No single words by 18 months
No two-word phrases by 30 months
Not walking independently by 18 months
Persistent toe-walking with tight Achilles tendons beyond 2 years
Persistent hand preference before 12 months (may indicate hemiplegia)
Concern for autism: lack of joint attention, no pointing by 12–14 months, loss of language/social skills, or absent pretend play by 24 months — refer to paediatrician and consider M-CHAT-R/F screening

Speech and Language Development

Speech and language concerns are among the most common reasons for paediatric referral in Australia. Approximately 15–20% of Australian children at school entry have some form of language difficulty. Key considerations:

Bilingual or multilingual children may have a temporary lag in English acquisition but should demonstrate normal milestones in their dominant language
Hearing assessment is mandatory for any child with speech delay — refer for audiological assessment (MBS item 11000 series) before attributing delay to other causes
Otitis media with effusion (OME) is highly prevalent in Aboriginal and Torres Strait Islander children and is a leading cause of conductive hearing loss and consequent speech/language delay
Referral to speech-language pathology should be made for any child with expressive or receptive language delay; in Australia, community health speech pathology services are available free through state/territory health services, though wait times may be prolonged

Achieving Cooperation in Small Children

Children under 5 years do not respond to logic, reason, or direct requests for cooperation. Achieving cooperation requires an understanding of child development, effective use of play, and modification of the clinical environment and examination technique. The goal is to obtain an accurate assessment while minimising distress and preserving the child's trust in healthcare interactions.

Principles of Cooperation

Environmental Preparation

Ensure the consulting room is child-friendly: toys, stickers, colourful décor, and age-appropriate reading material. Remove or conceal frightening equipment (otoscopes, ophthalmoscopes) initially. Avoid white coats if possible — they can provoke anxiety.

The "Examination Sandwich"

Begin with non-threatening, play-based interaction (sandwich filling). Perform the clinical examination (sandwich bread). Return to play or positive reinforcement (second slice). This reduces anxiety and improves future healthcare encounters.

Distraction Techniques

Use bubbles, puppets, songs, counting games, toys, and smartphone apps. For infants, sweet-taste distraction (sucrose solution on a dummy) is evidence-based for procedural pain. Engage the parent as co-distractor.

Let Them Explore

Allow the child to handle safe equipment (stethoscope, tongue depressor, reflex hammer). "Can I listen to your teddy's heart first? Now can I listen to yours?" This demystifies the process and gives the child a sense of control.

Developmentally Appropriate Language

Use simple, concrete language. Avoid "This won't hurt" (it might, and trust is broken). Instead: "You might feel something cold/warm/pressing — squeeze mummy's hand if you want to." Never lie to a child.

Age-Specific Strategies

Infant (0–12 months)

Comfort & Timing

Examine in the parent's lap or on the parent's chest. Use warm hands and instruments. Auscultate first while the child is calm and quiet. Leave crying-inducing assessments (ears, throat) until last. Offer a feed or dummy for comfort.

Setting: In parent's arms or on examination couch with parent nearby

Toddler (1–3 years)

Play & Control

Maximal stranger anxiety peaks at 10–18 months. Allow the child to remain in the parent's lap. Use indirect examination (auscultate through clothing). Give choices when possible ("Do you want to sit on mummy's lap or on the chair?"). Use play: "Let's play Simon Says — can you say 'aaah'?"

Setting: Parent's lap preferred; play-based interaction essential

Pre-school (3–5 years)

Explanation & Cooperation

Brief explanations before each step. "I'm going to look in your ears with my special torch." Offer choices and positive reinforcement. Sticker/reward at the end. Use simple anatomy teaching ("This is the thing that helps me hear your heart beat"). Can begin to engage the child as participant.

Setting: May sit independently; explain each step; sticker reward

Managing the Uncooperative Child

Despite best efforts, some children will be inconsolable or uncooperative — particularly when unwell, in pain, or distressed. In these situations:

Parental lap examination: The child sits facing the parent, wrapped in the parent's arms, while the clinician examines from behind. This is particularly useful for ear examination, throat inspection, and peripheral IV access.
Limit the examination: If the child is too distressed, perform only essential components. Auscultation of heart and lungs can usually be achieved even during crying. Document what was deferred and plan a follow-up.
Resist restraint: Avoid physical restraint unless absolutely necessary (e.g., a life-threatening emergency requiring immediate intervention). Restraint damages trust and may be experienced as traumatic.
Consider sedation: For necessary painful procedures, intranasal midazolam (0.3–0.5 mg/kg, max 6 mg) can be used in a monitored setting, with appropriate resuscitation equipment available. Refer to local emergency department or procedural sedation guidelines.
Postpone non-urgent assessments: If the clinical situation permits, reschedule for a better time of day (early morning, after a nap) or request the family bring a comfort item or favourite toy.

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Parental coaching: Advise parents to avoid threats ("If you don't let the doctor look, you'll get an injection") or bribes that become precedents. Instead, model calm behaviour and use simple language: "The doctor needs to check you to make sure your body is healthy. It's okay to feel nervous."

Physical Examination of the Child

The paediatric physical examination should be systematic yet flexible, adapted to the child's age, temperament, and clinical presentation. The approach differs significantly from adult examination: it begins with observation, proceeds from non-invasive to invasive, and leverages the child's developmental stage to maximise cooperation and diagnostic yield.

General Principles

Observe first, touch second: A wealth of clinical information can be gathered before any physical contact. Observe the child's behaviour, activity level, respiratory effort, colour, posture, and interaction with the caregiver.
Vital signs first: Temperature, heart rate, respiratory rate, oxygen saturation (if indicated), and blood pressure (in children ≥3 years with appropriate cuff size). Use age-appropriate normal ranges.
The quiet child is your opportunity: When the child is still and calm, perform auscultation (heart, lungs, abdomen) and abdominal palpation immediately. Do not waste this window on history-taking.
Expose appropriately: Undress the child progressively — examine one area at a time and re-cover before moving to the next. Preserve warmth and dignity. Always have a parent present.
Examine the child in the parent's lap for infants and toddlers — this reduces anxiety and allows the parent to assist with gentle immobilisation.

Age-Appropriate Vital Signs

Age	Heart Rate (bpm)	Respiratory Rate (/min)	Systolic BP (mmHg)	Temperature (°C)
Newborn	100–160	30–60	60–76	36.5–37.5
Infant (1–12 months)	100–150	25–50	70–90	36.5–37.5
Toddler (1–3 years)	90–130	20–30	80–100	36.5–37.5
Pre-school (4–5 years)	80–120	20–25	85–105	36.5–37.5
School age (6–12 years)	70–110	15–25	90–110	36.5–37.5
Adolescent (12–18 years)	60–100	12–20	100–120	36.5–37.5

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Fever in children under 3 months: Any infant under 3 months of age with a temperature ≥38°C should be considered a potential serious bacterial infection (SBI) until proven otherwise. Urgent assessment, blood cultures, urine culture (suprapubic aspirate or catheter), and consideration of lumbar puncture is required. Administer empirical IV antibiotics (e.g., cefotaxime 50 mg/kg) and admit. Do not discharge from general practice.

Systematic Examination Approach

The following order maximises diagnostic yield while minimising distress:

1. General Inspection (Undirected Observation)

Activity level, alertness, colour, respiratory effort, posture, habitus
Dysmorphic features (facial dysmorphism, limb anomalies, skin markers)
Nutritional status — wasted or obese, muscle bulk, subcutaneous fat distribution
Skin colour: pallor, jaundice, cyanosis, mottling
Breathing pattern: nasal flaring, intercostal recession, grunting, head bobbing (signs of respiratory distress)

2. Cardiovascular

Palpate brachial and femoral pulses simultaneously — radio-femoral delay suggests coarctation of the aorta
Auscultate the heart in the supine position, then sitting forward (for murmurs)
Assess for peripheral oedema (uncommon in children — if present, consider nephrotic syndrome, cardiac failure)
Note: Still's murmur is the most common innocent murmur in children (vibratory, systolic, left sternal edge, age 3–7 years)
Measure blood pressure in children ≥3 years at every well-child visit; use appropriate cuff bladder width (40% of arm circumference)

3. Respiratory

Observe respiratory pattern, effort, symmetry of chest expansion
Auscultate anteriorly and posteriorly; compare sides
Percuss if effusion suspected (rare in primary care)
Examine the upper airway: nasal patency, tonsil size (graded 1+ to 4+), pharyngeal erythema, and presence of exudate

4. Abdomen

Inspect for distension, visible peristalsis, herniae (umbilical, inguinal)
Auscultate bowel sounds before palpation
Palpate gently — start distally (away from the area of concern) and work towards it. Ask the child to "blow up a balloon" or count to distract during deep palpation
Assess liver and spleen span; hepatosplenomegaly in a child requires investigation (storage disease, malignancy, chronic infection)
Check for renal masses (Wilms tumour — typically a firm, non-tender flank mass in a child aged 2–5 years)

5. Skin

Systematic inspection during undressing — note birthmarks, café-au-lait spots (≥6 café-au-lait macules >5 mm before puberty suggest neurofibromatosis), haemangiomas, Mongolian spots (common in Indigenous and Asian children — differentiate from bruising)
Assess for petechiae and purpura — if accompanied by fever, consider meningococcaemia (medical emergency)
Examine skin infections carefully — impetigo (bullous and non-bullous), scabies, tinea, and cellulitis are common in Australian children, particularly in remote communities
Check for bruising patterns: bruising over bony prominences (shins, forehead) in ambulatory children is expected. Bruising over soft tissue (buttocks, back, ears, neck), in non-ambulatory infants, or in patterns consistent with objects requires mandatory reporting consideration.

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Non-accidental injury (NAI): Bruising in a non-ambulatory infant (under ~6 months or not yet cruising) is highly suspicious for physical abuse. Bilateral bruising, bruising on the ears, neck, buttocks, or trunk, and patterned injuries (loop marks, cigarette burns) are red flags. Any clinician suspecting NAI must act on their concern — refer to child protection services, arrange safe discharge (if in ED), and document meticulously. Under-reporting is a greater risk than over-reporting.

6. Musculoskeletal

Observe gait, posture, and movement during free play before formal examination
Screen for developmental dysplasia of the hip (DDH): Barlow and Ortolani manoeuvres at every well-child visit until walking; assess for hip asymmetry, limited abduction, and leg length discrepancy. Risk factors include breech presentation, family history, and first-born female.
Examine the spine for scoliosis (Adam's forward bend test) from age 10 onwards
Assess joint range of motion, swelling, and tenderness — inflammatory arthritis in children (juvenile idiopathic arthritis) requires urgent rheumatology referral

7. Ears, Nose, and Throat

Examine ears LAST (most distressing for young children)
Otoscopy: assess tympanic membrane colour, position, light reflex, and mobility (pneumatic otoscopy is preferred for detecting middle ear effusion)
Examine the nose for mucosal swelling, discharge, and foreign bodies (unilateral foul-smelling discharge in a toddler — suspect foreign body until proven otherwise)
Oral cavity: check for dental caries (refer to dental services), oral thrush, and palate integrity

8. Neurological

Primitive reflexes in the newborn: Moro, rooting, sucking, grasp, and stepping reflexes — all should be present at birth and disappear by 3–6 months. Persistence beyond expected age suggests neurological abnormality.
Tone assessment: passive movement of limbs, scarf sign (newborn), pull-to-sit
Deep tendon reflexes — brisk or absent reflexes require further evaluation
Cranial nerves — assess as part of the routine examination, particularly for facial symmetry (Bell's palsy vs. upper motor neuron lesion)
Cerebellar function: heel-to-shin testing, finger-nose-finger, Romberg (school-age children)

9. Genitalia (When Clinically Indicated)

Newborn: check for undescended testes (palpable vs. non-palpable — refer if not palpable by 6 months), hypospadias, ambiguous genitalia
Assess for inguinal hernia (inguinal bulge, positive cough impulse) — more common in premature infants and males
In pre-pubertal girls, labial adhesion is common and usually benign — treat with topical oestrogen if symptomatic
Always have a chaperone present and explain the examination to the parent and child (where age-appropriate)
Tanner staging is used to assess pubertal development — document when indicated (precocious puberty before age 8 in girls/9 in boys, or delayed puberty)

The "Tried to Examine But Child Would Not Allow" Note

If elements of the examination could not be completed due to the child's distress or lack of cooperation, document this clearly: "Attempted ear examination — child distressed and uncooperative. Deferred to next visit. Advise parent to return in 48 hours if symptoms persist." This is not a failure — it is honest clinical practice and protects both the clinician and the patient.

Special Populations

👶 Premature and Late-Preterm Infants

Correct for gestational age when assessing growth and development until age 2 years

Higher risk of developmental delay, respiratory illness (bronchiolitis, BPD), hearing impairment, and retinopathy of prematurity (ROP)

Synagis® (palivizumab) PBS Authority Required for RSV prophylaxis in high-risk infants during RSV season

Ensure 6-week corrected age check for DDH (if breech) and cardiac assessment

Paediatrician follow-up recommended for all infants born <32 weeks

🛡️ Immunocompromised Children

Modified vaccination schedule — live vaccines (MMR, varicella, BCG, rotavirus) may be contraindicated depending on the degree and type of immunosuppression

Lower threshold for investigation and treatment of fever — treat as neutropenic sepsis if on chemotherapy

Refer to the Australian Immunisation Handbook (Department of Health) for specific guidance

Annual influenza vaccination is strongly recommended for the child and all household contacts

🫘 Children with Chronic Kidney Disease

Monitor growth closely — CKD causes growth faltering through metabolic bone disease and acidosis

Blood pressure monitoring at every visit — paediatric hypertension is under-recognised

Medication renally adjusted — consult paediatric nephrology for dosing guidance

Vitamin D and calcium supplementation often required; monitor phosphate levels

🧒 Children from CALD Backgrounds

Use professional interpreter services (TIS National: 131 450) — do not rely on family members or children to interpret

Growth charts may need adjustment for ethnicity; WHO charts are internationally validated

Be aware of cultural practices affecting healthcare (e.g., traditional medicine use, dietary restrictions)

Screen for iron deficiency (common in children from South Asian, Middle Eastern, and African backgrounds), vitamin D deficiency, and haemoglobinopathies (Hb electrophoresis if indicated)

Refugee and asylum-seeker children require comprehensive health screening including infectious disease (TB, hepatitis B, HIV, Strongyloides), nutritional deficiencies, and mental health assessment

🧠 Children with Neurodevelopmental Conditions

Children with ASD, ADHD, or intellectual disability may require modified examination approaches — allow extra time, use visual schedules, and minimise sensory overload

Regular monitoring of growth and medication side effects (e.g., stimulant-associated weight loss in ADHD)

NDIS (National Disability Insurance Scheme) support — assist families with access and planning

Annual dental assessment — higher caries risk in children with special needs

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander children in Australia experience significantly poorer health outcomes compared to non-Indigenous children, with a life expectancy gap of approximately 8 years for males and 6 years for females beginning in childhood. Key considerations for approaching the child in this context require cultural safety, historical awareness, and recognition of systemic barriers to healthcare access.

Otitis Media

Chronic suppurative otitis media (CSOM) affects up to 50% of Aboriginal and Torres Strait Islander children in some remote communities — one of the highest rates globally. Otitis media with effusion (OME) is near-universal in the first years of life. This is a leading cause of conductive hearing loss and subsequent speech, language, and educational disadvantage. Routine ear checks at every visit are essential. Refer to the Clinical Practice Guidelines for the Management of Otitis Media (RHDAustralia/MSIC). Tympanometry and audiology referral should be considered early.

Rheumatic Fever & RHD

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are almost exclusively diseases of Aboriginal and Torres Strait Islander children in Australia (incidence 60–380 per 100,000 in high-risk populations vs. <2 per 100,000 in non-Indigenous children). The sore throat must never be dismissed — Group A Streptococcal pharyngitis should be treated promptly with IM benzathine penicillin G (Jenject® 900 mg, or weight-based dosing). Secondary prophylaxis (4-weekly IM benzathine penicillin) is critical. Refer to the RHDAustralia ARF/RHD guidelines.

Skin Infections

Scabies, impetigo (including bullous impetigo), and school sores are highly prevalent in remote Aboriginal communities. Skin sores are a portal of entry for post-streptococcal glomerulonephritis and potentially ARF. Whole-of-community treatment approaches are recommended (treat the entire household for scabies simultaneously). Topical permethrin 5% (adults and children >2 months) and oral ivermectin (200 mcg/kg, PBS Authority Required <5 years) are first-line for scabies.

Growth & Nutrition

Aboriginal and Torres Strait Islander children have higher rates of undernutrition and failure to thrive, particularly in remote communities, as well as increasing rates of childhood obesity in urban settings. Growth monitoring should be performed at every encounter. Iron deficiency anaemia is prevalent — screen with FBC and ferritin. Food insecurity is a significant contributing factor; link families with community nutrition programs and Closing the Gap health services.

Cultural Safety

Provide culturally safe care by acknowledging the traditional owners of the land, using culturally appropriate communication, and engaging Aboriginal and Torres Strait Islander health workers and liaison officers wherever possible. Recognise the impact of intergenerational trauma from colonisation, the Stolen Generations, and ongoing systemic racism. Avoid deficit framing — focus on strengths, resilience, and community. Use the Communicating Positively: A Guide to Appropriate Aboriginal and Torres Strait Islander Terminology (AIHW) for respectful language.

Access & Remoteness

For families in remote and very remote areas (MM 6–7), access to paediatric specialists, speech pathologists, audiologists, and developmental services is severely limited. Telehealth (MBS items 99200–99215) is an essential tool. Coordinate care with visiting specialist services (e.g., Royal Flying Doctor Service, Outreach programs). Aboriginal Community Controlled Health Organisations (ACCHOs) are the preferred point of care for many Indigenous families — work collaboratively with these services.

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Strengths-based approach: Aboriginal and Torres Strait Islander families have deep cultural knowledge about child-rearing, kinship systems, and holistic health. Incorporate family, community, and Country into the management plan where appropriate. Recognise the role of Elders in health decision-making and support self-determination in healthcare choices.

📚 References

1. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book), 9th edition. Melbourne: RACGP; 2016 (updated 2023).
2. World Health Organization (WHO). WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass-for-Age: Methods and Development. Geneva: WHO; 2006.
3. Squires J, Twombly E, Bricker D, Potter L. ASQ-3 User's Guide. 3rd ed. Baltimore: Paul H. Brookes Publishing; 2009.
4. Glascoe FP. Collaborating with Parents: Using Parents' Evaluation of Developmental Status (PEDS) to Detect and Address Developmental and Behavioral Problems. 2nd ed. Nolensville, TN: PEDStest.com; 2013.
5. Robins DL, Fein D, Barton ML. The Modified Checklist for Autism in Toddlers, Revised, with Follow-up (M-CHAT-R/F). Pediatrics. 2009;123(1):e116–e126.
6. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023.
7. RHDAustralia (Rheumatic Heart Disease Australia), Menzies School of Health Research. 2020 Australian Guideline for Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 3rd ed. Darwin: RHDAustralia; 2020.
8. Gunasekera H, Morris PS, Daniels J, et al. Otitis media in Aboriginal and non-Aboriginal children. J Paediatr Child Health. 2019;55(10):1168–1175.
9. Department of Health and Aged Care, Australian Government. The Australian Immunisation Handbook. 11th ed (online). Canberra: Australian Government Department of Health; updated 2024.
10. National Health and Medical Research Council (NHMRC). Child Health Screening and Surveillance: A Critical Review of the Evidence. Canberra: NHMRC; 2002 (updated guidance via RACGP).
11. Royal Children's Hospital Melbourne. Paediatric Clinical Practice Guidelines. Melbourne: RCH; updated 2024. Available at: https://www.rch.org.au/clinicalguide/
12. American Academy of Pediatrics (AAP). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Itasca, IL: AAP; 2017. (Widely used in Australian practice as supplementary guidance.)
13. Centre for Community Child Health, Murdoch Children's Research Institute. Australian Early Development Census (AEDC) National Report. Melbourne: Australian Government; 2021.
14. Royal Australian College of General Practitioners (RACGP). Abuse and Violence: Working with Our Patients in General Practice (White Book), 4th ed. Melbourne: RACGP; 2020.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).