Emergencies in Children

Last updated 1 Jun 2026 · Paediatric Emergency Medicine

📋 Key Information Summary

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Serious illness can deteriorate rapidly in children — the paediatric assessment triangle (PAT: appearance, work of breathing, circulation to skin) is the first critical step in every emergency encounter.
Age-specific vital sign ranges are essential — heart rate, respiratory rate, blood pressure, and capillary refill all vary significantly from neonates to adolescents; always use age-appropriate reference charts (RCH Melbourne or APLS tables).
Red flags across all ages include: inconsolable crying or lethargy, poor feeding, mottled or cyanotic skin, grunting, nasal flaring, head bobbing, reduced urine output, bulging fontanelle, petechial/purpuric rash, and prolonged capillary refill >2 seconds.
The "Worried" child — parental concern that "something is not right" is a validated predictor of serious illness and must never be dismissed.
Airway obstruction is the leading cause of preventable cardiac arrest in children — the sequence of paediatric resuscitation is Airway–Breathing–Circulation (A-B-C), unlike the adult C-A-B approach.
Croup (laryngotracheobronchitis) is the most common paediatric airway emergency; a single dose of oral dexamethasone 0.15 mg/kg (max 10 mg) is first-line; nebulised adrenaline 4 mL of 1:1000 is reserved for severe croup.
Anaphylaxis in children is managed with intramuscular adrenaline 10 mcg/kg (0.01 mg/kg) into the mid-anterolateral thigh; 0.15 mg autoinjector for 15–30 kg, 0.3 mg autoinjector for >30 kg.
Foreign body aspiration must be considered in any sudden choking episode in children under 3 years; back blows (5) followed by chest thrusts (5) for infants; abdominal thrusts for children >1 year.
Meningococcal disease can progress from non-specific febrile illness to septic shock and death within hours — petechial or purpuric rash in a febrile child is meningococcal until proven otherwise; administer IV ceftriaxone 80 mg/kg (max 2 g) immediately and transfer.
Latent Neck Stiffness and Kernig's sign are unreliable in young children — the absence of meningism does NOT exclude meningitis; a bulging fontanelle is a more useful sign in infants.
Basic metabolic investigations in the sick child include: capillary blood gas, glucose, full blood count, C-reactive protein, blood culture, urine (catheter specimen or clean catch), and lactate — lactate >4 mmol/L indicates significant tissue hypoperfusion.
Weight-based dosing is mandatory — always weigh the child in kilograms; use the Broselow tape or an age-based weight-estimation tool (e.g., Mercy method) if immediate weighing is impractical.
Aboriginal and Torres Strait Islander children experience significantly higher rates of invasive meningococcal disease, bronchiolitis, rheumatic fever, and sepsis — lower thresholds for escalation and early retrieval from remote communities are essential.

Introduction & Australian Epidemiology

Paediatric emergencies present a unique diagnostic and management challenge. Children are not small adults — their physiology, pharmacokinetics, disease patterns, and psychological needs demand an age-specific approach. The majority of paediatric emergency presentations in Australia are managed in general practice, regional hospitals, and emergency departments (EDs), with the Royal Children's Hospital Melbourne (RCH), Children's Health Queensland (CHQ), and Sydney Children's Hospitals Network (SCHN) providing tertiary-level paediatric emergency care.

In 2022–23, Australian emergency departments recorded approximately 3.1 million presentations by children aged 0–14 years, accounting for roughly 25% of all ED visits nationally (AIHW Emergency Department Care 2023). Respiratory presentations (bronchiolitis, croup, asthma) remain the leading cause, followed by febrile illness, injury, and gastroenteritis.

Critically, paediatric cardiac arrest in Australia has an overall survival rate of approximately 5–10%, but outcomes are markedly better when early recognition and bystander CPR are initiated. The Australasian College for Emergency Medicine (ACEM) and the Australian Resuscitation Council (ARC) emphasise that prevention of cardiac arrest through early recognition and treatment of respiratory failure and shock is the cornerstone of paediatric emergency care.

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Key principle: Children compensate for long periods before decompensating suddenly and catastrophically. Tachycardia and tachypnoea are early signs of decompensation — by the time hypotension develops, the child is in decompensated shock and may be peri-arrest. Always intervene during the compensated phase.

This article covers the four pillars of paediatric emergency assessment and management in Australian primary and emergency care: (1) age-specific recognition of serious illness, (2) airway and breathing emergencies, (3) rational investigation of the sick child, and (4) meningococcal disease and the febrile child — with reference to current Australian guidelines including ARC ANZCOR, eTG, RCH Clinical Practice Guidelines, and the National Safety and Quality Health Service (NSQHS) Standards.

Signs of Serious Illness by Age Group

The early identification of the seriously unwell child relies on structured assessment. The Paediatric Assessment Triangle (PAT), endorsed by the APLS (Advanced Paediatric Life Support) and used widely in Australian emergency departments, evaluates three domains simultaneously:

Appearance — tone, interactiveness, consolability, look/gaze, speech/cry (TICLS mnemonic)
Work of breathing — nasal flaring, retractions (subcostal, intercostal, suprasternal, supraclavicular), grunting, head bobbing, stridor, wheeze
Circulation to skin — pallor, mottling, cyanosis (central and peripheral)

An abnormality in any one domain indicates a potentially critically ill child requiring immediate senior assessment and intervention.

Age-Specific Vital Sign Reference Ranges

Age Group	Heart Rate (bpm)	Respiratory Rate (breaths/min)	Systolic BP (mmHg)	Key Red Flags
Neonate (0–28 days)	100–180	30–60	60–80	Poor feeding, temperature instability, bulging fontanelle, irritability or lethargy, seizures, grunting
Infant (1–12 months)	100–160	25–50	70–90	Inconsolable crying, poor feeding, reduced wet nappies, mottled skin, grunting, nasal flaring, head bobbing
Toddler (1–4 years)	90–150	20–35	80–100	Lethargy, poor interaction, petechiae, persistent vomiting, reduced urine output, increased work of breathing
Preschool (4–6 years)	80–140	20–30	85–105	Inability to walk or stand, altered behaviour, persistent fever >5 days, signs of meningism
School-age (6–12 years)	70–120	15–25	90–115	Chest pain, syncope, prolonged tachycardia, reduced exercise tolerance, persistent fever
Adolescent (12–18 years)	60–100	12–20	100–130	Substance ingestion, deliberate self-harm, haemodynamic instability, meningism, signs of sepsis

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Compensated vs. Decompensated Shock in Children: Compensated shock presents with tachycardia, cool peripheries, prolonged capillary refill (>2 sec), weak peripheral pulses, and irritability or lethargy — blood pressure is MAINTAINED. Decompensated shock is heralded by hypotension (systolic BP <70 + [2 × age] mmHg), altered consciousness, mottled/grey skin, absent peripheral pulses, and bradycardia (pre-terminal). By the time hypotension is detected, the child has lost ≥25–30% of circulating volume equivalent. Intervene during the compensated phase.

The "Worried Parent" and Clinical Gestalt

Multiple studies have validated that parental concern — particularly the statement "I know my child, and something is wrong" — has a high sensitivity for serious illness. In Australian EDs and general practice, clinicians should document and act upon parental concern as part of the structured assessment. The APLS guidelines recommend that any child identified as "abnormal" on the PAT should be assessed as a medical emergency, with immediate vital signs, senior clinician review, and establishment of intravenous or intraosseous access.

Red Flags Demanding Immediate Escalation (All Ages)

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Central cyanosis (tongue, lips)
Severe respiratory distress: grunting, nasal flaring, head bobbing, oxygen saturation <92% on room air
Petechial or purpuric rash (especially non-blanching) in a febrile child — presume meningococcal disease
Bulging fontanelle in an infant
Seizure lasting >5 minutes or focal seizure
Glasgow Coma Scale (GCS) <15 in a child (use age-appropriate GCS: paediatric GCS)
Capillary refill time >2 seconds (press on sternum in a warm room)
Anuria or <1 mL/kg/hr urine output
Blood glucose <3 mmol/L
Temperature >40°C or hypothermia <36°C in a neonate

Airway & Breathing Emergencies

Airway and breathing emergencies are the most common paediatric life-threats. The infant and child airway differs anatomically from the adult — a proportionally larger tongue, more cephalad larynx, shorter trachea, and omega-shaped (floppy) epiglottis mean that small degrees of oedema cause proportionally greater obstruction. The cricoid cartilage is the narrowest point of the paediatric airway (not the glottis as in adults).

Croup (Acute Laryngotracheobronchitis)

Croup is the most common cause of acute stridor in children aged 6 months to 3 years, typically caused by parainfluenza virus. It presents with a barking cough, hoarse voice, and inspiratory stridor — often worse at night.

Mild

Westley Score 0–2

Intermittent barking cough, no stridor at rest, mild hoarseness. Child is alert and feeding.

Setting: Home / GP / ED discharge

Moderate

Westley Score 3–5

Frequent barking cough, stridor at rest (inspiratory), mild subcostal retractions, mild agitation.

Setting: ED observation (4 hours post-treatment)

Severe

Westley Score 6–11

Stridor at rest with significant retractions (subcostal, intercostal, suprasternal), marked agitation or lethargy, cyanosis, reduced air entry.

Setting: Paediatric HDU/ICU — senior anaesthetic review

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Dexamethasone (oral/IM)

First-line for all croup severities

Adult dose Not applicable

Paediatric dose 0.15 mg/kg PO/IM/IV (max 10 mg) as a single dose

Route PO (preferred) / IM / IV

Duration Single dose — repeat dose rarely needed

Renal adjustment None required

PBS status ✔ PBS General Benefit

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Nebulised Adrenaline (Epinephrine)

Severe / moderate croup with significant distress

Paediatric dose 4 mL of 1:1000 (4 mg) via nebuliser; L-adrenaline preferred in some centres

Onset Within 10–30 minutes; effect lasts 2 hours

Key point MUST observe for ≥4 hours post-nebulisation due to rebound oedema risk

PBS status ✔ PBS General Benefit

Acute Severe Asthma (Children)

Asthma affects approximately 10% of Australian children (AIHW 2023). Acute severe asthma remains one of the leading causes of paediatric hospital admission. The National Asthma Council Australia guidelines and the RCH Clinical Practice Guideline provide a standardised severity assessment and treatment ladder.

Mild–Moderate

Features

Speaking in sentences, mild wheeze, SpO₂ ≥92%, RR mildly increased, can lie flat.

Setting: ED / GP — salbutamol + oral prednisolone

Severe

Features

Speaking in words/phrases, marked wheeze or "silent chest", SpO₂ <92%, accessory muscle use, unable to lie flat, HR >160 (preschool) or >140 (school age).

Setting: ED — continuous salbutamol, IV magnesium, senior review

Life-Threatening

Features

Drowsiness, confusion, silent chest, cyanosis, bradycardia, SpO₂ <92% despite high-flow O₂, exhaustion.

Setting: PICU — IV salbutamol, aminophylline, consider ketamine, anaesthetic review for intubation

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Salbutamol (Albuterol)

Ventolin® · First-line bronchodilator

Paediatric dose — mild 2–4 puffs MDI + spacer (repeat every 20 min × 3 doses)

Paediatric dose — severe Continuous nebulisation 2.5–5 mg (<6 yrs) or 5–10 mg (≥6 yrs) via oxygen-driven nebuliser

Paediatric dose — life-threatening IV bolus 15 mcg/kg over 10 min → infusion 1–5 mcg/kg/min

PBS status ✔ PBS General Benefit

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Prednisolone

Solone® / Redipred® · Oral corticosteroid

Paediatric dose 1–2 mg/kg PO (max 40 mg) once daily for 3–5 days

Alternative Dexamethasone 0.15–0.3 mg/kg (max 10 mg) PO as single dose (equivalent efficacy, improved compliance)

PBS status ✔ PBS General Benefit

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IV Magnesium Sulfate

Severe acute asthma — second-line

Paediatric dose 25–50 mg/kg IV over 20 minutes (max 2 g); may repeat once at 1 hour

Monitoring Continuous ECG, blood pressure q5min during infusion; monitor for hypotension, flushing, nausea

PBS status ✔ PBS General Benefit

Bronchiolitis

Bronchiolitis (predominantly RSV) is the most common lower respiratory tract infection in infants under 12 months and the leading cause of paediatric hospital admission in Australia during winter months. There is no role for antibiotics, salbutamol, or corticosteroids in typical bronchiolitis. Management is supportive: maintain hydration, provide nasal saline and suction, and monitor oxygen saturation.

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2024 RSV update: Nirsevimab (Beyfortus®), a long-acting monoclonal antibody, was listed on the Australian National Immunisation Program (NIP) in 2024 for all infants in their first RSV season. Palivizumab (Synagis®) remains available for high-risk infants (prematurity, CLD, haemodynamically significant CHD) via authority prescription.

Anaphylaxis

Anaphylaxis in children requires immediate intramuscular adrenaline. Common triggers include food (egg, peanut, cow's milk in young children; tree nuts, shellfish in older children), insect stings, and medications. Australian ASCIA guidelines are the standard of care.

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Adrenaline (Epinephrine) IM

EpiPen® / Anapen® · First-line for anaphylaxis

Infants <15 kg 10 mcg/kg IM (0.01 mg/kg) using 1:1000 solution drawn up in a syringe; 0.15 mg autoinjector if no syringe available

Children 15–30 kg 0.15 mg IM autoinjector (EpiPen Jr® / Anapen Jr 150 mcg)

Children >30 kg 0.3 mg IM autoinjector (EpiPen® / Anapen 300 mcg)

Repeat dose Every 5 minutes if no clinical improvement; no maximum number of doses

PBS status ✔ PBS General Benefit (autoinjectors: Authority Required)

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Never delay adrenaline in anaphylaxis. Intramuscular injection into the mid-anterolateral thigh is the route of choice. IV adrenaline is reserved for refractory anaphylaxis under specialist supervision with continuous cardiac monitoring. Antihistamines and corticosteroids are second-line and do NOT replace adrenaline.

Foreign Body Aspiration & Choking

Foreign body aspiration is most common in children aged 1–3 years. Food items (grapes, nuts, hot dog pieces, popcorn) are the most frequent cause. The presentation may be sudden onset of choking, coughing, and/or wheezing in a previously well child. Partial obstruction with effective cough should be managed with observation and encouragement to cough. Complete or near-complete obstruction requires immediate intervention per ARC ANZCOR guidelines:

Infants (<1 year)

5 back blows (firm, between shoulder blades, supporting the head and neck) → 5 chest thrusts (two fingers on lower sternum, one-third depth). Alternate until obstruction clears or child becomes unconscious.

Children (>1 year)

5 abdominal thrusts (Heimlich manoeuvre — standing or sitting behind the child, fist above umbilicae, sharp upward thrusts). Alternate with back blows if obstruction persists.

Unconscious child

Call 000. Commence CPR (30 compressions : 2 breaths for lone rescuer). Before each breath, open the airway and check for visible foreign body — remove if seen. Do NOT perform blind finger sweeps.

Paediatric Basic & Advanced Life Support (ARC ANZCOR)

The ARC ANZCOR Paediatric Basic Life Support (BLS) algorithm applies to children from birth to puberty (approximately 12 years). Key differences from adult BLS:

Compression-to-ventilation ratio: 30:2 for a lone rescuer; 15:2 for two rescuers (in infants and children)
Compression depth: one-third of the anteroposterior diameter of the chest (approximately 4 cm in infants, 5 cm in children)
Compression rate: 100–120 per minute
Rescue breaths are critical in paediatric arrest — most paediatric cardiac arrests are secondary to respiratory failure (hypoxia), not primary cardiac events
The A-B-C (Airway–Breathing–Circulation) approach applies, unlike the adult C-A-B sequence

Defibrillation: use paediatric pads or a paediatric dose attenuator for children <8 years if available. First shock: 2 J/kg; subsequent shocks: 4 J/kg. Automated external defibrillators (AEDs) are safe and recommended for use in children >1 year.

Investigations in the Sick Child

Investigation of the acutely unwell child should be guided by clinical assessment — not performed as a "blanket screen." Unnecessary venepuncture or catheterisation causes distress, may delay treatment, and risks iatrogenic harm. The following framework guides rational investigation in Australian emergency and primary care settings.

Tier 1 — Core Bedside Investigations (Perform Immediately)

Essential Pulse oximetry (SpO₂) Continuous monitoring in any child with respiratory distress, cyanosis, or altered consciousness. Target SpO₂ ≥94% in most acute settings. Available in all Australian EDs, GP practices, and Retrieval Services.

Essential Point-of-care blood glucose (BGL) Capillary blood glucose in ALL sick children — hypoglycaemia (<3 mmol/L) is both a sign of severity and a treatable cause of deterioration. Available universally (glucometer).

Essential Temperature (core) Axillary in children >3 months; rectal temperature more accurate in neonates (<3 months). Fever ≥38.0°C (axillary) requires structured assessment; neonatal fever (≥38.0°C) warrants a full sepsis workup per RCH/ACSQHC guidelines.

Available Capillary blood gas (CBG) Rapid assessment of pH, pCO₂, bicarbonate, lactate, and base deficit. Lactate >4 mmol/L is a marker of significant tissue hypoperfusion and should prompt aggressive resuscitation. Available in most Australian EDs; point-of-care devices (i-STAT, ABL) increasingly in regional centres.

Tier 2 — Blood Pathology (When Clinical Suspicion Justifies)

Available Full Blood Count (FBC) White cell count (leucocytosis or leucopenia), haemoglobin (acute haemorrhage), platelets (thrombocytopenia in DIC/meningococcemia). Available in all Australian pathology laboratories. MBS Item 65060 (standard FBC).

Available C-Reactive Protein (CRP) Useful marker of inflammation and bacterial infection when interpreted with clinical context. CRP >80 mg/L in a febrile child raises concern for serious bacterial infection (SBI). MBS Item 65095.

Available Blood cultures Obtain before antibiotics in any child with suspected sepsis or meningitis. Minimum 1 mL per bottle (ideally 2–5 mL in older children). Takes 24–48 hours for preliminary results; modern continuous-monitoring systems (BacT/ALERT, BACTEC) in major labs. Available in all Australian hospitals with pathology services.

Available Urine (catheter specimen or clean-catch) UTI is one of the most common serious bacterial infections in febrile infants. Bag specimens are acceptable for culture screening but have high contamination rates; suprapubic aspirate (SPA) is gold standard in neonates. Catheter specimen of urine (CSU) preferred in infants <12 months. MBS Item 69317 (urine culture).

Available Electrolytes, urea, creatinine (EUC) Assess dehydration, renal function, hyponatraemia (SIADH in meningitis), hyperkalaemia in shock. MBS Item 66515.

Available Lactate (venous or arterial) Serum lactate >4 mmol/L = significant tissue hypoperfusion; >2 mmol/L warrants close monitoring. Part of the sepsis bundle in Australian paediatric emergency guidelines. MBS Item 66573.

Tier 3 — Advanced / Specialist Investigations

Referral Lumbar puncture (LP) Gold standard for meningitis diagnosis. CSF analysis: cell count, protein, glucose, Gram stain, culture, PCR (enterovirus, HSV, meningococcal). Contraindicated in raised ICP (signs: GCS <13, focal neurology, seizures, papilloedema, unequal pupils), coagulopathy, or local infection. Blood cultures MUST be taken before LP. Performed by senior clinician or paediatric registrar. Imaging (CT brain) before LP only if signs of raised ICP — do NOT delay antibiotics for LP or CT if meningitis is suspected.

Referral Chest X-ray (CXR) Indicated in suspected pneumonia (focal crackles, persistent fever, respiratory distress), foreign body aspiration (unilateral hyperinflation, mediastinal shift), and assessment of endotracheal tube position. Not routinely indicated in bronchiolitis or simple croup. Available in all Australian EDs and most regional hospitals (MBS Item 58503).

Specialist CT Brain Indicated before LP only when signs of raised intracranial pressure are present, or in head trauma per PECARN/Australian paediatric head injury guidelines. Sedation or general anaesthesia may be required in young children. Refer to paediatric/neurosurgical team.

Specialist Nasopharyngeal aspirate (NPA) for respiratory PCR panel Detects RSV, influenza A/B, parainfluenza, adenovirus, SARS-CoV-2, human metapneumovirus. Essential in bronchiolitis and for infection-control cohorting in paediatric wards. Available in major hospital laboratories; results usually within 1–4 hours (multiplex PCR).

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Do NOT delay antibiotics for investigations in suspected meningococcal disease or meningitis. Administer IV ceftriaxone immediately upon clinical suspicion. Blood cultures should be taken before antibiotics if this does not cause a delay of more than a few minutes. LP can follow once the child is stabilised — but should not be omitted if safely achievable.

Febrile Child — Rational Investigation Approach

For the well-appearing febrile child aged >3 months with no focus of infection, Australian evidence supports a pragmatic approach: urine culture is the single most valuable investigation. CRP and procalcitonin can help risk-stratify for serious bacterial infection but should not replace clinical assessment. The RCH Fever Guideline recommends blood tests only in children with high fever (≥39°C without clear source), prolonged fever (≥5 days), or clinical signs of serious illness.

Meningococcal Disease & the Febrile Child

Meningococcal disease, caused by Neisseria meningitidis, remains one of the most feared paediatric emergencies in Australia. Although overall incidence has declined significantly since the introduction of conjugate meningococcal C vaccine (2003) and the MenACWY vaccine on the National Immunisation Program (NIP) for 12-month-olds (2018), serogroup B disease continues to circulate, and outbreaks occur, particularly in Aboriginal and Torres Strait Islander communities and among young adults (15–24 years) in congregate settings.

In 2023, Australia reported approximately 150–200 cases of invasive meningococcal disease (IMD), with an overall case-fatality rate of 5–10%. Serogroup B accounts for the majority of cases in children under 5 years. The disease can present as meningitis, septicaemia, or a combination. Septicaemic presentation carries the highest mortality and may not show meningism.

Clinical Presentation

The classic presentation of meningococcal disease is a febrile child with a non-blanching petechial or purpuric rash, but early disease is notoriously non-specific. The child may present with:

Early (non-specific): Fever, irritability, poor feeding, lethargy, myalgia, headache — identical to a viral URTI
Meningitis: Fever, headache, neck stiffness, photophobia, bulging fontanelle (infants), vomiting, altered consciousness, seizures
Septicaemia: Fever, petechial/purpuric rash (may start as a maculopapular rash), signs of shock (tachycardia, mottling, prolonged capillary refill, hypotension), cold extremities, confusion or obtundation
Menigococcaemia (fulminant): Rapid progression to purpura fulminans, DIC, multi-organ failure, Waterhouse-Friderichsen syndrome (adrenal haemorrhage)

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Any child with fever AND a non-blanching petechial/purpuric rash MUST be treated for meningococcal disease until proven otherwise. Do not wait for a "critical number" of petechiae — even a single petechium in the context of a febrile, unwell child warrants immediate empirical treatment with IV ceftriaxone and urgent transfer to hospital. The glass test (pressing a clear glass against the rash to check for non-blanching) should be performed on every febrile child with a rash.

Emergency Management — Meningococcal Disease

Immediate Antibiotics

IV ceftriaxone 80 mg/kg (max 2 g) as a single dose. If IV access cannot be established rapidly, give IM ceftriaxone. Do NOT delay antibiotics for hospital transfer or investigation. In penicillin anaphylaxis: IV chloramphenicol 25 mg/kg (max 1 g).

Fluid Resuscitation

If signs of shock: 20 mL/kg 0.9% sodium chloride IV bolus over 5–10 minutes. Reassess after each bolus. May repeat to a total of 40–60 mL/kg in the first hour. Inotropic support (noradrenaline/dopamine) should be initiated in PICU if fluid-refractory shock.

Transfer & Notification

Urgent transfer to the nearest paediatric centre. Notify the state/territory Public Health Unit immediately — IMD is a notifiable disease in all Australian jurisdictions. Contact details: NSW Public Health Unit 1300 066 055; QLD 13 HEALTH (13 43 25 84); VIC 1300 651 160. Chemoprophylaxis for close contacts (see below).

Steroids (Meningitis Only)

Dexamethasone 0.15 mg/kg IV (max 10 mg) every 6 hours for 4 days in confirmed bacterial meningitis — ideally given before or with the first dose of antibiotics. Evidence strongest for H. influenzae meningitis; benefit in meningococcal meningitis is uncertain but recommended by RCH/eTG.

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Ceftriaxone

Rocephin® · Empirical therapy for meningococcal disease

Paediatric dose — meningitis 100 mg/kg IV/IM (max 2 g) once daily for 7 days (adjusted by culture results)

Paediatric dose — empirical pre-transfer 80 mg/kg IV/IM stat (max 2 g)

Neonatal dose 50 mg/kg IV once daily (50–75 mg/kg for meningitis in neonates)

Renal adjustment No adjustment required (biliary excretion predominant)

Key interaction Avoid concurrent IV calcium-containing solutions in neonates (risk of fatal calcium-ceftriaxone precipitation)

PBS status ✔ PBS General Benefit

Chemoprophylaxis for Close Contacts

Close contacts (household members, kissing contacts, those sharing utensils, healthcare workers performing mouth-to-mouth resuscitation) require antibiotic chemoprophylaxis. This should be administered as soon as possible (ideally within 24 hours, effective up to 14 days post-exposure). Recommended regimens per the Australian Immunisation Handbook (current edition):

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Ciprofloxacin

Preferred for adults and children ≥5 years (single dose)

Paediatric dose (≥5 years) 20 mg/kg PO (max 500 mg) as a single dose

PBS status ✔ PBS General Benefit

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Rifampicin

Preferred for infants <5 years and pregnant women

Paediatric dose (<1 month) 5 mg/kg PO every 12 hours for 2 days

Paediatric dose (≥1 month) 10 mg/kg PO every 12 hours for 2 days (max 600 mg per dose)

Key warning Orange discolouration of urine, tears, and contact lenses. Significant drug interactions (OCP, anticonvulsants, anticoagulants)

PBS status ✔ PBS General Benefit

The Febrile Child — Beyond Meningococcus

Fever is the most common presenting complaint in paediatric emergency care. The vast majority of febrile children have self-limiting viral infections. However, a small proportion have serious bacterial infection (SBI) — urinary tract infection, pneumonia, meningitis, or bacteraemia — which must not be missed. Australian practice emphasises a structured approach combining clinical assessment, age-appropriate investigation, and judicious use of empirical antibiotics.

Age Group	Key Concerns	Minimum Investigation	Management
Neonate (<28 days) with fever ≥38°C	HSV, GBS, E. coli, listeria; SBI rate up to 10–15%	Blood culture, urine (SPA/catheter), FBC, CRP, LP (strongly recommended), NPA if maternal HSV risk	IV ampicillin + gentamicin (or cefotaxime) — hospital admission mandatory
Infant (1–3 months) with fever ≥38°C	UTI, bacteraemia, meningitis; higher risk than older children	Blood culture, urine (CSU), FBC, CRP — LP if unwell or elevated inflammatory markers	Low threshold for IV antibiotics and admission; consider ceftriaxone IM if oral not tolerated and SBI suspected
Child (3–36 months) with fever ≥39°C, no focus	UTI (most common SBI), pneumonia, bacteraemia	Urinalysis/urine culture, consider CRP/PCT; blood culture if appearing unwell	If well-appearing: antipyretics, safety-net advice, review if persistent; if unwell: treat as per clinical assessment
Child (>36 months) with prolonged fever ≥5 days	Consider Kawasaki disease, systemic JIA, malignancy, MIS-C	FBC, CRP, ESR, LFTs, urinalysis, blood culture, echocardiography if Kawasaki suspected	Referral to paediatrics for prolonged fever without source

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Simple febrile convulsions (age 6 months–5 years, generalised seizure <15 minutes, occurring once in 24 hours during a febrile illness, with no prior afebrile seizures, no focal features, and normal post-ictal recovery) are benign and do not require antiepileptic treatment. However, the underlying cause of the fever must be investigated and managed. Recurrent or complex febrile convulsions warrant paediatric assessment and may warrant further investigation (EEG, neuroimaging).

Special Populations

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Neonates (<28 days)

The neonate with fever ≥38°C is a medical emergency requiring full sepsis workup and admission. The threshold for investigation and treatment should be extremely low.

IV Ampicillin + Gentamicin (or cefotaxime) is the empirical regimen for suspected neonatal sepsis per eTG and RCH guidelines.

HSV encephalitis must be considered in any neonate with seizures, vesicular rash, or unexplained deterioration — treat with IV aciclovir 20 mg/kg every 8 hours.

Drug dosing must be weight-based and adjusted for gestational age and postnatal age (neonatal pharmacokinetics differ significantly from older children).

All neonatal febrile illness should be managed in a hospital with neonatal special care nursery (SCN) or NICU capability.

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Infants (1–12 months)

Bronchiolitis is the leading cause of hospital admission in this age group; supportive care (nasal saline, suction, monitoring SpO₂) is the mainstay — bronchodilators, corticosteroids, and antibiotics are NOT recommended.

UTI is the most common serious bacterial infection in febrile infants without an identifiable source — always collect a urine specimen (CSU preferred over bag specimen).

Infants cannot reliably express symptoms; clinical assessment relies on observation of behaviour, feeding, activity, and work of breathing.

The Mercy method or parental report are practical weight-estimation tools when direct weighing is not feasible (critical for drug dosing).

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Children with Chronic Disease & Disability

Children with cerebral palsy, tracheostomies, neuromuscular disorders, or chronic lung disease are at higher risk of respiratory emergencies, aspiration pneumonia, and respiratory failure.

Baseline vital signs and "normal-for-this-child" parameters may differ significantly — obtain prior medical records and contact the child's usual specialist team early.

Many chronic conditions require modified drug dosing (e.g., reduced renal clearance in renal impairment, altered volume of distribution in neuromuscular disease).

Always involve the child's established care team (paediatrician, respiratory physician, developmental paediatrician) in emergency management decisions.

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Children with Renal Impairment

Ceftriaxone does not require renal dose adjustment (biliary excretion), making it suitable for children with renal impairment.

Gentamicin requires therapeutic drug monitoring (TDM) — aim for trough <1 mg/L; extend interval in renal impairment (consult pharmacy or eTG).

Avoid nephrotoxic agents (NSAIDs, aminoglycosides at standard intervals) where possible; use paracetamol for analgesia/antipyresia.

Fluid resuscitation must be cautious — risk of fluid overload and pulmonary oedema; consider 10 mL/kg boluses with close reassessment.

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Immunocompromised Children

Children on chemotherapy, biologics, corticosteroids (>2 mg/kg/day prednisolone >14 days), post-transplant, or with primary immunodeficiency require a lower threshold for empirical broad-spectrum antibiotics.

Neutropenic fever (ANC <0.5 × 10⁹/L) is an emergency — administer IV broad-spectrum antibiotics (piperacillin-tazobactam 100 mg/kg [max 4.5 g] every 8 hours or cefepime 50 mg/kg [max 2 g] every 8 hours) within 60 minutes of presentation.

Consider opportunistic organisms (PJP, invasive fungal infection, CMV) in the immunosuppressed child with respiratory deterioration — consult paediatric infectious disease or oncology team.

Live vaccines are contraindicated during immunosuppression — check immunisation status and discuss with the treating specialist.

⚠️

Adolescents

Adolescents may present with adult-pattern disease — ectopic pregnancy and pelvic inflammatory disease must be considered in sexually active adolescent females with abdominal pain.

Substance ingestion (alcohol, synthetic cannabinoids, MDMA, prescription opioids) is an increasingly common cause of altered consciousness in Australian adolescents.

Deliberate self-harm and suicidal ideation require sensitive assessment using validated tools (e.g., ASQ — Ask Suicide-Screening Questions) and appropriate mental health referral.

Adolescents have unique confidentiality needs — balance patient autonomy with safety, and involve parents/carers where appropriate.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander children experience significantly higher rates of paediatric emergency presentations, hospitalisation, and mortality compared to non-Indigenous Australian children. The gap is widest for respiratory infections, rheumatic fever, invasive bacterial infections (including meningococcal disease), and injuries. These disparities reflect the broader social determinants of health — overcrowded housing, reduced access to primary and specialist healthcare in remote communities, food insecurity, and intergenerational trauma.

Key statistics (AIHW 2023; Menzies School of Health Research):

Aboriginal and Torres Strait Islander children are hospitalised for respiratory infections at 2–3 times the rate of non-Indigenous children.
Rates of invasive meningococcal disease are 3–5 times higher in Indigenous children, particularly in remote Northern Territory and Western Australian communities.
Acute rheumatic fever (ARF) — essentially absent in non-Indigenous Australian children — continues to disproportionately affect Aboriginal and Torres Strait Islander children, particularly in NT, QLD, and WA. ARF can present as an acute emergency with carditis and heart failure.
Otitis media rates in Aboriginal and Torres Strait Islander children are among the highest globally, contributing to conductive hearing loss and educational disadvantage.

Remote access to care

Many Aboriginal and Torres Strait Islander children live in communities without a resident doctor. Remote Area Health Corps (RAHC), Royal Flying Doctor Service (RFDS), and Retrieval Services (e.g., CAREFlight NT, QGAPS QLD) provide emergency medical support. Lower thresholds for retrieval and transfer are essential — if in doubt, evacuate early.

Cultural safety

Engage Aboriginal and Torres Strait Islander Health Practitioners and Health Workers early in the clinical encounter. Respect cultural obligations around gender-specific care (same-gender clinician preferred where possible), sorry business (bereavement), and family-centred decision-making. Use plain language and check understanding without being patronising.

Skin infections

Scabies, impetigo (bullous and non-bullous), and skin sores are extremely common in remote Aboriginal and Torres Strait Islander communities and can serve as a portal of entry for invasive Group A streptococcal (GAS) infection, which is linked to post-streptococcal glomerulonephritis (PSGN) and ARF. Treat skin infections aggressively with topical mupirocin and oral flucloxacillin (or intramuscular benzathine penicillin for GAS eradication in high-risk settings).

Immunisation gaps

Despite improvements, immunisation coverage for Aboriginal and Torres Strait Islander children at age 5 remains lower than the national average in some jurisdictions. Additional vaccines recommended on the NIP for Indigenous children include pneumococcal conjugate (13vPCV at 2, 4, and 12 months — additional to schedule), hepatitis A, and meningococcal B (MenB) vaccine funded for Aboriginal and Torres Strait Islander infants in some states. Clinicians should check and update immunisation status during any emergency encounter.

Rheumatic fever recognition

Any Aboriginal and Torres Strait Islander child presenting with joint pain, fever, a new or changed cardiac murmur, or chorea must be assessed for ARF per the 2020 Australian Guideline for ARF Diagnosis (RHDAustralia). ARF is a notifiable disease in NT, QLD, and WA. Secondary prophylaxis with 4-weekly IM benzathine penicillin is critical for preventing recurrence and rheumatic heart disease (RHD).

Health literacy and discharge

Discharge instructions must be provided in plain language (avoid medical jargon), ideally with pictorial aids. Use the "teach-back" method to confirm understanding. Ensure follow-up arrangements are made with the local Aboriginal Community Controlled Health Organisation (ACCHO) or remote health clinic, and document these clearly. Include an Aboriginal and Torres Strait Islander Health Worker in the discharge process where available.

⚠️

Sepsis and meningococcal disease in remote communities: In remote Aboriginal and Torres Strait Islander communities, the nearest hospital may be hours away by road or accessible only by air retrieval. Healthcare workers in remote clinics should be trained and authorised to administer IM ceftriaxone for suspected meningococcal disease and initiate fluid resuscitation for septic shock while awaiting retrieval. Standing orders and emergency drug kits (including ceftriaxone, adrenaline, and fluid resuscitation equipment) should be maintained and regularly audited in all remote clinics per RHDAustralia and CARPA Standard Treatment Manual recommendations.

📚 References

1. Australian Resuscitation Council (ARC) and New Zealand Resuscitation Council (ANZCOR). ANZCOR Guidelines — Paediatric Advanced Life Support. Melbourne: ANZCOR; 2021 (updated 2023). Available from: resus.org.au.
2. Advanced Paediatric Life Support (APLS) Australia & New Zealand. APLS: The Practical Approach to Paediatric Emergency Care. 6th ed. Melbourne: APLS Australasia; 2023.
3. Royal Children's Hospital Melbourne. Clinical Practice Guidelines — Croup, Bronchiolitis, Asthma, Fever, Meningococcal Disease, Sepsis. Melbourne: RCH; 2024. Available from: rch.org.au/clinicalguide.
4. Australian Institute of Health and Welfare (AIHW). Emergency Department Care 2022–23. Canberra: AIHW; 2023. Cat. no. HSE 252.
5. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Canberra: Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
6. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA Guidelines — Acute Management of Anaphylaxis. Sydney: ASCIA; 2023.
7. National Asthma Council Australia. Australian Asthma Handbook — Acute Asthma in Children. Melbourne: NAC; 2024. Available from: asthmahandbook.org.au.
8. RHDAustralia (Rheumatic Heart Disease Australia — Menzies School of Health Research). Australian Guideline for Prevention, Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 3rd ed. Darwin: Menzies School of Health Research; 2020 (updated 2022).
9. National Health and Medical Research Council (NHMRC). Statement on the Management of Acute Bacterial Meningitis. Canberra: NHMRC; 2023.
10. Kuppermann N, Dayan PS, Levine DA, et al. A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA Pediatr. 2019;173(4):342–351.
11. Commonwealth of Australia (CARPA). Central Australian Rural Practitioners Association Standard Treatment Manual. 8th ed. Alice Springs: CARPA; 2022.
12. National Safety and Quality Health Service (NSQHS) Standards. Standard 8: Recognising and Responding to Acute Deterioration. Sydney: Australian Commission on Safety and Quality in Health Care (ACSQHC); 2021.
13. Paediatric Research in Emergency Departments International Collaborative (PREDICT). Management of the febrile child: evidence-based review and position statement. J Paediatr Child Health. 2023;59(6):851–860.
14. Australian Bureau of Statistics (ABS). Estimates of Aboriginal and Torres Strait Islander Australians, 2021 Census. Canberra: ABS; 2023.

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).