📋 Key Information Summary
- Infantile colic peaks at 6 weeks of age and resolves by 3–4 months; defined by Wessel's "rule of threes" (≥ 3 hours/day, ≥ 3 days/week, ≥ 3 weeks). Reassurance and parent support are first-line; dicycloverine (dicyclomine) is contraindicated in infants < 6 months.
- Red-flag causes of excessive crying include intussusception, strangulated hernia, corneal abrasion, hair tourniquet, and meningitis — always exclude surgical and serious infective causes before labelling colic.
- Failure to thrive (FTT) is weight consistently below the 3rd percentile or crossing two major percentile lines; organic causes account for ~10–20 % of cases, with non-organic (inadequate intake, psychosocial) being most common.
- Short stature is height > 2 SD below the population mean for age and sex; constitutional delay of growth and puberty is the most common cause, but familial short stature, chronic disease, and growth hormone deficiency must be excluded.
- Growing pains are bilateral, non-inflammatory, intermittent limb pains occurring in children aged 3–12 years, typically in the evening or at night, with a completely normal examination. No investigations are required if the presentation is typical.
- Innocent (functional) cardiac murmurs are the most common murmurs in childhood, heard in up to 80 % of children; they are systolic, vary with position, and have no associated symptoms or signs of cardiac disease.
- Pathological murmurs are diastolic, continuous, or associated with symptoms (cyanosis, failure to thrive, exercise intolerance, abnormal S2) — these require urgent paediatric cardiology referral and echocardiography.
- Blocked nasolacrimal duct (dacryostenosis) affects up to 20 % of newborns; 90 % resolve spontaneously by 12 months. Crigler massage is first-line; probing is considered if symptoms persist beyond 12–18 months.
- Early childhood caries (ECC) is the most common chronic disease in Australian children; the Child Dental Benefits Schedule (CDBS) provides up to ,095 over two calendar years for eligible children aged 2–17 years.
- Aboriginal and Torres Strait Islander children experience FTT, dental disease, rheumatic fever, and otitis media at significantly higher rates — early identification, culturally safe care, and access to allied health are critical.
- Growth monitoring using WHO growth charts (0–2 years) and CDC/WHO charts (2–20 years) is recommended at every scheduled child health visit; plot length/height, weight, and head circumference.
- When to refer: FTT not responding to nutritional intervention at 4 weeks; short stature with suspected endocrine or genetic aetiology; persistent nasolacrimal obstruction after 12 months; any pathological murmur — all warrant timely paediatric referral.
Introduction & Australian Epidemiology
Children present to general practice and paediatric services with a wide range of specific problems that, while common, can generate considerable parental anxiety and diagnostic uncertainty. In Australian primary care, paediatric consultations account for approximately 15–20 % of all encounters, with infant crying, growth concerns, musculoskeletal pains, cardiac murmurs, nasolacrimal duct obstruction, and dental caries among the most frequently encountered issues.
Infantile colic affects an estimated 10–40 % of infants worldwide, with similar rates documented in Australian cohorts. Failure to thrive has a prevalence of approximately 5–10 % among infants referred to paediatric outpatient services. Short stature accounts for roughly 3 % of paediatric endocrine referrals. Growing pains are reported in 10–35 % of children aged 3–12 years, making them one of the most common paediatric musculoskeletal complaints. Innocent murmurs are auscultated in up to 80 % of children at some point during childhood. Congenital nasolacrimal duct obstruction affects 5–20 % of newborns, and dental caries remains the most prevalent chronic disease in Australian children, with the 2017–2018 National Child Oral Health Survey reporting that approximately 34 % of children aged 5–6 years had experienced caries in their deciduous teeth.
This article addresses the assessment and management of four groups of common paediatric presentations: crying and colic in infants; failure to thrive and short stature; growing pains and childhood cardiac murmurs; and blocked nasolacrimal duct and dental problems. Each section provides evidence-based guidance, Australian-specific resources, and key referral pathways.
Crying & Colic in Infants
Definition & Epidemiology
Infantile colic is defined by Wessel's criteria (the "rule of threes"): an infant who cries for more than three hours per day, for more than three days per week, for more than three weeks, in an otherwise healthy, well-nourished infant aged < 5 months. More recently, the Rome IV criteria define colic as recurrent and prolonged periods of crying, fussing, or irritability reported by caregivers that occur without obvious cause and cannot be prevented or resolved by caregivers, in infants < 5 months of age with no failure to thrive.
Crying is the normal means by which an infant communicates hunger, discomfort, fatigue, and the need for comfort. Normal crying increases from birth, peaks at approximately 6 weeks of age (averaging 2–3 hours per day), and declines to less than one hour per day by 12 weeks. Colic affects 10–40 % of infants and is one of the leading reasons for early paediatric consultation in Australia.
Aetiology
The exact cause of colic remains poorly understood. Proposed mechanisms include:
- Gastrointestinal: immature gut motility, visceral hypersensitivity, gas trapping, gut microbiome dysbiosis (reduced Lactobacillus and Bifidobacterium species)
- Neurodevelopmental: immature self-regulation, normal developmental crying pattern at the peak of the crying curve
- Dietary: cow's milk protein allergy (CMPA) in a small subset, lactose overload (foremilk–hindmilk imbalance in breastfed infants), overfeeding
- Parental: postnatal depression, anxiety, low social support, smoking exposure (particularly maternal smoking during pregnancy — a documented risk factor)
Red-flag causes of excessive crying — exclude before diagnosing colic:
- Intussusception (episodic pallor, drawing up of legs, redcurrant jelly stool)
- Incarcerated inguinal hernia
- Hair tourniquet (digits, genitalia)
- Corneal abrasion or foreign body
- Otitis media
- Meningitis (fever, bulging fontanelle, irritability)
- Fracture (non-accidental injury — consider in all infants with unexplained crying)
- Urinary tract infection
Clinical Assessment
A thorough history should include onset, duration, and pattern of crying; feeding method (breast, bottle, mixed); feeding volumes and frequency; stool pattern and consistency; associated symptoms (fever, vomiting, lethargy, poor feeding); maternal mental health; and family/social supports. Physical examination should be comprehensive, with particular attention to:
- General appearance and weight gain trajectory
- Anterior fontanelle tension
- Ears (pneumatic otoscopy)
- Oral cavity
- Abdomen (distension, masses, tenderness)
- Inguinal regions and genitalia (hernia, hair tourniquet)
- All digits (hair tourniquet)
- Skin (bruising — non-accidental injury screen)
- Hip examination (developmental dysplasia of the hip)
If the infant is well, growing normally, and the examination is normal, a diagnosis of colic can be made confidently. Routine investigations are not required. If red flags are present, targeted investigations (full blood count, C-reactive protein, urine microscopy and culture, abdominal ultrasound) should be performed urgently.
Management
First-line management — reassurance and parent support: Colic is self-limiting and resolves by 3–4 months. Provide clear, empathetic education that the infant is healthy and the condition is time-limited. Address parental mental health and provide support resources (e.g., Tresillian, Karitane, PANDA).
Non-pharmacological strategies
- Responsive settling techniques — gentle rocking, swaddling, white noise, warm bath
- Avoid overfeeding and ensure correct bottle-feeding technique (pace feeding)
- If breastfeeding, consider maternal dietary modification (trial elimination of cow's milk protein for 1–2 weeks if CMPA suspected)
- Parental respite — encourage "safe" breaks; never shake an infant
- Infant probiotics: Lactobacillus reuteri DSM 17938 (BioGaia® drops, 5 drops/100 million CFU once daily) — some evidence of benefit in predominantly breastfed infants; available OTC in Australia
Pharmacological options
Simethicone (Dimethicone)
Infacol® · Anti-foaming agent
Dose
0.5–1 mL (20 mg/mL) PO before feeds; may give up to QID
Duration
As needed; review at 2 weeks
Renal / Hepatic
No adjustment required (not systemically absorbed)
PBS status
✘ Not PBS — OTC
Contraindicated in infants < 6 months: Dicycloverine (dicyclomine) — associated with serious adverse effects including apnoea, seizures, and respiratory depression. It is not recommended for infantile colic regardless of age. Avoid all anticholinergic agents in this age group.
When to consider CMPA trial
If there are additional features suggestive of cow's milk protein allergy (eczema, atopic family history, rectal bleeding, vomiting, persistent diarrhoea), a 2–4 week trial of extensively hydrolysed formula (e.g., Aptamil AllerPro®) for formula-fed infants, or maternal exclusion of dairy for breastfeeding mothers, is appropriate. If CMPA is confirmed, refer to paediatrics and consider dietitian input.
Failure to Thrive (FTT) & Short Stature
Failure to Thrive
Definition
Failure to thrive (FTT) is a descriptive term indicating inadequate physical growth during childhood. While no single definition is universally accepted, the following criteria are commonly used:
- Weight below the 3rd percentile (or < 2nd percentile on WHO charts) for age and sex
- Weight crossing two major percentile lines downward on a growth chart over time
- Weight-for-length < 80 % of expected (weight-for-height z-score < −2)
- Decline in weight velocity (rate of weight gain below expected for age)
Aetiology — Organic vs Non-Organic
| Category | Proportion | Common Causes |
|---|---|---|
| Inadequate caloric intake (most common — ~50 %) | ~50 % | Poor feeding technique, incorrect formula preparation, restrictive diets, poverty, food insecurity, parental mental illness, neglect |
| Inadequate caloric absorption | ~25 % | Coeliac disease, cystic fibrosis, chronic diarrhoea, short bowel syndrome, cows' milk protein allergy |
| Increased caloric expenditure | ~10 % | Congenital heart disease, chronic lung disease (BPD), hyperthyroidism, chronic infection |
| Combination / genetic / syndromic | ~15 % | Chromosomal abnormalities (Down, Turner syndrome), intrauterine growth restriction (SGA), skeletal dysplasias, inborn errors of metabolism |
Non-accidental injury and neglect: FTT may be the presenting feature of child neglect or abuse. A psychosocial assessment is essential in every child with FTT. If there are concerns, mandatory reporting obligations apply under relevant state and territory legislation.
Clinical Assessment
- Growth chart review: Plot weight, height/length, and head circumference on WHO growth charts (0–2 years) or CDC charts (2–20 years); assess growth velocity
- Detailed feeding history: Breast/bottle/combination; weaning timeline; dietary variety; feeding environment; mealtime dynamics
- Developmental assessment: Global developmental delay suggests organic aetiology or significant psychosocial deprivation
- Physical examination: Dysmorphic features, signs of malnutrition (temporal wasting, loss of subcutaneous fat, dry skin, oedema), organomegaly, heart murmur, skin rashes
- Psychosocial assessment: Family structure, parental mental health, financial stress, housing, domestic violence, substance use
Investigations
Essential
Full blood count, ESR/CRP
Anaemia (iron deficiency, chronic disease), infection
Essential
Urea, electrolytes, creatinine, LFTs, albumin
Renal and hepatic function; nutritional status
Essential
Iron studies, zinc, vitamin D (25-OH)
Common deficiencies in FTT; MBS item 66828 (vitamin D)
Available
Coeliac serology (anti-tTG IgA, total IgA)
Screening for coeliac disease — must be on gluten-containing diet
Available
Thyroid function tests (TSH, fT4)
Hypothyroidism or hyperthyroidism
Available
Urine microscopy, culture, and sensitivity
UTI can be asymptomatic and contribute to poor growth
Specialist
Sweat test (chloride)
Cystic fibrosis — if respiratory or GI symptoms present
Management
- Nutritional rehabilitation: Dietitian referral is essential; aim for calorie-dense diet (age-appropriate with energy supplementation); consider high-energy formula supplements (e.g., S26 Gold®, Karicare+®) if indicated
- Address feeding difficulties: Correct formula preparation; responsive feeding; manage oral aversion
- Treat underlying organic cause once identified
- Psychosocial support: Social work referral if food insecurity, parental mental health concerns, or neglect suspected
- Follow-up: Weekly to fortnightly weight checks initially; paediatric referral if no improvement after 4 weeks of nutritional intervention
Short Stature
Definition
Short stature is defined as height more than 2 standard deviations (SD) below the mean for age and sex (i.e., below the 2.3rd percentile on population-based growth charts). Growth velocity below the 25th percentile for bone age over 6–12 months is also significant.
Common Causes
| Cause | Key Features | Prevalence Among Short Stature Referrals |
|---|---|---|
| Familial (genetic) short stature | Normal growth velocity; parents short; bone age = chronological age; normal puberty | Most common |
| Constitutional delay of growth and puberty (CDGP) | Delayed bone age (≥ 2 years); delayed puberty; family history of "late bloomers"; often presents with short stature in mid-childhood and delayed puberty | Common — especially in boys |
| Growth hormone deficiency (GHD) | Subnormal growth velocity; increased body fat; truncal adiposity; young-appearing face; may have micropenis in males | ~5 % of referrals |
| Turner syndrome (45,X) | Female; webbed neck; broad chest; lymphoedema at birth; coarctation of aorta; streak ovaries | 1 in 2,500 live female births |
| Chronic disease | Inflammatory bowel disease, coeliac disease, chronic kidney disease, severe asthma (steroid effect), cyanotic heart disease | Variable |
| Hypothyroidism | Weight gain, lethargy, constipation, cold intolerance, delayed puberty | Uncommon but important |
Investigations
Investigations should be guided by clinical suspicion. For a child with short stature and normal growth velocity, no dysmorphic features, and a family history of short stature, observation with serial growth measurements may be sufficient.
Essential
Bone age (left wrist X-ray — Greulich and Pyle atlas)
Assesses skeletal maturity; MBS item 57716
Essential
FBC, ESR, UEC, LFTs, coeliac serology, TFTs
Screen for chronic disease, coeliac, thyroid disorders
Available
IGF-1 and IGFBP-3
Screening for growth hormone deficiency (low IGF-1)
Specialist
GH provocation tests (insulin tolerance test, arginine-GHRH)
Confirm GHD — performed in paediatric endocrinology
Specialist
Karyotype (females with suspected Turner syndrome)
45,X or mosaic variants
Referral Indications
- Height > 3 SD below the mean
- Growth velocity declining across percentiles over 6–12 months
- Suspected GHD, Turner syndrome, or chronic disease
- Significant psychosocial impact
- Bone age significantly delayed (or advanced)
Growth Hormone Therapy
Somatropin (Recombinant GH)
Norditropin® · Genotropin® · Humatrope®
Paediatric dose
0.025–0.05 mg/kg/day SC injection (evening)
Indications (PBS-authorised)
GHD, Turner syndrome, Prader-Willi syndrome, chronic renal insufficiency, SGA with failure to catch up, SHOX deficiency
Duration
Until near-adult height or epiphyseal fusion
Monitoring
Height velocity every 3–6 months; IGF-1; glucose; thyroid function; scoliosis screen
PBS status
Restricted Benefit — Authority Required — must be initiated by a paediatric endocrinologist
Growing Pains & Childhood Cardiac Murmurs
Growing Pains
Definition & Epidemiology
Growing pains are the most common cause of recurrent musculoskeletal pain in children, affecting 10–35 % of children aged 3–12 years. The term is a misnomer — there is no evidence that growth itself causes pain. The condition is benign and self-limiting.
Diagnostic Criteria (Evans Criteria)
- Pain typically occurs in the late afternoon or evening, often waking the child from sleep
- Pain is bilateral, most commonly affecting the thighs, calves, and behind the knees
- Pain is intermittent (not present every day) with pain-free intervals of days to weeks
- Next morning the child is completely well and fully mobile
- Normal physical examination — no joint swelling, erythema, tenderness, or restricted movement
- Normal growth and development
Red flags — investigate or refer urgently:
- Unilateral pain
- Morning stiffness or gelling phenomenon
- Joint swelling, warmth, or erythema
- Limp or refusal to weight-bear
- Pain at rest (not just evening/night)
- Systemic symptoms (fever, weight loss, fatigue, night sweats)
- Bone pain (point tenderness over bone rather than muscle)
- Bleeding tendency (haemarthrosis — consider haemophilia)
These features raise concern for malignancy (leukaemia, bone tumour), juvenile idiopathic arthritis (JIA), osteomyelitis, septic arthritis, slipped capital femoral epiphysis (SCFE), or Legg-Calvé-Perthes disease.
Management
- Reassurance: Explain the benign, self-limiting nature of growing pains; emphasise that they do not cause long-term harm
- Simple analgesia: Paracetamol (15 mg/kg/dose PO, max 4 doses/day) or ibuprofen (5–10 mg/kg/dose PO TDS PRN) for symptom relief
- Local measures: Gentle massage, warm compresses, stretching exercises before bed
- Footwear: Assess and advise on supportive footwear; consider podiatry referral for biomechanical issues
- Investigations are NOT required if the presentation is classic; FBC and inflammatory markers may be performed if there is any clinical uncertainty
Paracetamol
Panadol® · Dymadon® · Panamax®
Paediatric dose
15 mg/kg/dose PO (max 60 mg/kg/day in divided doses, max 4 doses/day)
Renal adjustment
eGFR 10–50: extend interval to Q6–8H; eGFR < 10: Q8H
PBS status
✔ PBS General Benefit
Ibuprofen
Nurofen for Children® · Brufen®
Paediatric dose
5–10 mg/kg/dose PO TDS PRN with food
Renal adjustment
Avoid if eGFR < 30 mL/min; use with caution
PBS status
✔ PBS General Benefit
Childhood Cardiac Murmurs
Epidemiology
Cardiac murmurs are auscultated in up to 80 % of children at some point during childhood. The vast majority (approximately 50–70 % of all murmurs heard) are innocent (functional or physiological) murmurs, which are benign and require no further investigation. Differentiating innocent from pathological murmurs is a core competency in paediatric primary care.
Innocent vs Pathological Murmurs
| Feature | Innocent Murmur | Pathological Murmur |
|---|---|---|
| Timing | Systolic (ejection) | Diastolic, continuous, or pansystolic |
| Intensity | Grade 1–3/6 | Grade ≥ 3/6, or any diastolic murmur |
| Location | Left sternal border, pulmonary area, apex | Any — may radiate |
| Variation with position | Changes with posture and activity | Persistent, unchanged |
| S2 | Normal splitting | Single, widely split, or fixed split |
| Thrill | Absent | May be present (grade ≥ 4) |
| Symptoms | None; well-grown, active child | Cyanosis, failure to thrive, exercise intolerance, dyspnoea, feeding difficulty, recurrent chest infections |
| Common types | Still's murmur, pulmonary flow murmur, venous hum, supraclavicular arterial bruit | VSD, ASD, PDA, aortic stenosis, pulmonary stenosis, coarctation, Tetralogy of Fallot |
Specific Innocent Murmurs
- Still's murmur: Musical or vibratory, loudest at the left lower sternal border, grade 1–3/6, best heard supine; peaks age 3–6 years. Most common innocent murmur in children.
- Pulmonary flow murmur: Soft, ejection systolic, heard in the pulmonary area (left upper sternal border); common in thin children and during fever/illness.
- Venous hum: Continuous, heard in the supraclavicular fossa and neck; abolished by compression of the jugular vein or turning the head. Most common continuous innocent murmur.
- Supraclavicular arterial bruit: Brief systolic bruit above the clavicles; caused by turbulent flow in the great vessels.
Approach to the Child with a Murmur
1
Full history and examination
Feeding, growth, exercise tolerance, cyanosis, family history of CHD, associated anomalies. Examine femoral pulses, S2, signs of heart failure.
2
Classify the murmur
If classic innocent features (systolic, soft, varies with position, normal S2, no symptoms, well child) — reassure and observe.
3
Refer if uncertain or pathological features
Echocardiography via paediatric cardiology is the gold standard. Refer urgently if diastolic murmur, cyanosis, heart failure, absent femoral pulses, or associated syndrome (Down, Turner).
Down syndrome and cardiac screening: Approximately 40–50 % of children with Down syndrome have congenital heart disease (most commonly AVSD, VSD, ASD, PDA). All neonates with Down syndrome should have an echocardiography within the first 2 weeks of life, regardless of whether a murmur is present.
Blocked Nasolacrimal Duct & Dental Problems
Blocked Nasolacrimal Duct (Dacryostenosis)
Epidemiology & Anatomy
Congenital nasolacrimal duct obstruction (CNLDO) affects approximately 5–20 % of newborns. It results from failure of canalisation of the nasolacrimal duct at the valve of Hasner at the distal end (the most common site of obstruction). In most cases, the membrane perforates spontaneously.
Natural History
- 60 % resolve by 6 months of age
- Up to 90 % resolve spontaneously by 12 months of age
- Approximately 96 % resolve by 13–14 months without intervention
Clinical Presentation
- Unilateral (bilateral in ~20–30 %) watery eye (epiphora) from birth or early infancy
- Mucoid or mucopurulent discharge
- Mattering/crusting of the eyelashes, especially on waking
- Medial canthal swelling (mucocele or dacryocystocele — if present at birth, may need earlier intervention)
- Eye is otherwise white and non-inflamed; the child is well
Differential diagnosis — exclude:
- Congenital glaucoma (buphthalmos — enlarged cornea, photophobia, tearing; ophthalmology emergency)
- Acute dacryocystitis (erythema, swelling, tenderness over the lacrimal sac — requires antibiotics)
- Dermatochalasis / epicanthal folds (pseudoepiphora)
Management
Stage 1 — Conservative (birth to 12 months)
- Crigler lacrimal sac massage: Apply firm, sustained pressure over the lacrimal sac (medial canthus, inferior to the medial canthal tendon) with a downward stroke. Perform 2–3 times daily, 5–10 strokes each session. This increases hydrostatic pressure within the sac and promotes distal membrane perforation.
- Lid hygiene: Clean discharge with warm water or sterile saline on cotton wool
- Topical antibiotics: If discharge is copious or mucopurulent, chloramphenicol 0.5 % eye drops, 1 drop QID for 5–7 days to reduce bacterial load. Not needed as maintenance.
Stage 2 — Referral for persistent obstruction (12–18 months)
- Refer to ophthalmology if symptoms persist beyond 12 months of age
- Nasolacrimal duct probing: Day procedure under brief general anaesthesia; success rate ~70–90 % for primary probing
- If probing fails, options include repeat probing, balloon dacryoplasty, or nasolacrimal intubation (silicone stent)
- Dacryocystorhinostomy (DCR) is rarely required in childhood
Congenital dacryocystocele (mucocele): Presents at or shortly after birth as a blue-tinged swelling below the medial canthal tendon. Requires urgent ophthalmology referral — risk of secondary infection (dacryocystitis) and nasal extension (intranasal cyst). May require probing within the first few weeks of life.
Dental Problems in Children
Early Childhood Caries (ECC)
Early childhood caries (ECC) is defined as the presence of one or more decayed (cavitated or non-cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under 6 years of age. Severe ECC (S-ECC) is defined differently based on age: in children < 3 years, any sign of smooth-surface caries; in children aged 3–5, one or more cavitated, missing, or filled smooth surfaces in the primary maxillary anterior teeth, or a DMFS ≥ 4 (age 3), ≥ 5 (age 4), or ≥ 6 (age 5).
Australian Epidemiology
- The 2017–2018 National Child Oral Health Survey reported that 34.3 % of children aged 5–6 years had experienced caries in their deciduous teeth
- Mean dmft (decayed, missing, filled teeth) score was 1.5 in 5–6-year-olds
- Aboriginal and Torres Strait Islander children have significantly higher rates of dental disease — approximately 1.7 times the dmft of non-Indigenous children
- Dental disease is the leading cause of preventable hospital admissions for children in many Australian states
Risk Factors
- Prolonged bottle use (especially with milk or sweetened drinks at bedtime — "bottle caries")
- Early colonisation with Streptococcus mutans (vertical transmission from caregiver)
- Low socioeconomic status and food insecurity
- Limited access to fluoridated water (some rural and remote communities)
- Sugary snack and drink consumption
- Parental dental health and oral health literacy
Prevention — Key Messages for Parents and Caregivers
- First dental visit: Within 6 months of eruption of the first tooth, or by 12 months of age (Australian Dental Association recommendation)
- Brushing: From first tooth — smear of low-fluoride children's toothpaste (400–550 ppm) up to age 18 months; pea-sized amount of standard fluoride toothpaste (1,000 ppm) from 18 months. Parents should brush children's teeth until age 8.
- Fluoride: Use fluoridated water for reconstitution of formula; discuss fluoride varnish application at dental visits (6-monthly from tooth eruption)
- Diet: Limit sugary foods and drinks; avoid bottles in bed; transition from bottle to cup by 12 months; water and milk are the only recommended drinks for infants
- Weaning: Introduce a free-flow cup from 6 months; discourage bottle use after 12 months
Common Dental Presentations in General Practice
| Condition | Features | GP Role |
|---|---|---|
| Teething (eruption gingivitis) | Drooling, gum irritation, mild fussiness (6–30 months); NOT associated with high fever | Reassurance; chilled teething ring; paracetamol or ibuprofen PRN. Avoid benzocaine gels (risk of methaemoglobinaemia) |
| Dental trauma — avulsion | Permanent tooth knocked out completely | Place tooth in milk or saline; do NOT scrub root; reimplant if possible within 60 min. Emergency dental referral |
| Dental abscess | Localised swelling, pain, fluctuant mass adjacent to tooth | Amoxicillin 30 mg/kg PO TDS (max 500 mg TDS) for 5 days if systemically unwell; urgent dental referral |
| Eruption cyst | Fluid-filled cyst overlying erupting tooth; usually painless | Reassurance; self-resolving; refer if infected |
Child Dental Benefits Schedule (CDBS)
Child Dental Benefits Schedule (CDBS): Provides up to ,095 (indexed over two consecutive calendar years) in benefits for basic dental services for children aged 2–17 years whose family receives Family Tax Benefit Part A or other eligible Australian Government payments. Services include examinations, X-rays, cleaning, fissure sealants, fillings, root canals, and extractions. Bulk-billing dental providers are available through the scheme. GPs should check eligibility and encourage families to access this service.
Antibiotics for Dental Infection
Amoxicillin
Amoxil® · Alphamox® · Penicillin antibiotic
Paediatric dose
30 mg/kg/dose PO TDS (max 500 mg TDS)
Duration
5 days (for dental abscess with systemic features)
Penicillin allergy
Azithromycin 10 mg/kg day 1, then 5 mg/kg days 2–5 (max 500 mg/250 mg)
PBS status
✔ PBS General Benefit
Special Populations
Premature and SGA Infants
Adjusted age must be used for growth assessment and developmental milestones until 2 years of corrected age.
FTT is more common — regular dietitian involvement and early intervention are essential.
Infants born SGA (birth weight < 10th percentile) who remain below −2 SD at 2 years should be referred for consideration of growth hormone therapy.
Colic is equally prevalent in preterm infants; exclusion of NEC-related stricture should be considered if history of NEC.
Children with Chronic Kidney Disease
CKD causes growth failure through multiple mechanisms: metabolic acidosis, renal osteodystrophy, anaemia, poor nutrition, and chronic inflammation.
Growth hormone (somatropin) is PBS-subsidised for children with CKD-related growth failure — refer to paediatric nephrology.
NSAIDs (ibuprofen) should be avoided or used with extreme caution in children with CKD; paracetamol is preferred for growing pains.
Dental care requires special attention — increased risk of enamel hypoplasia and periodontal disease.
Immunocompromised Children
Dental infections in immunocompromised children (oncology, transplant) may rapidly progress to systemic sepsis — lower threshold for antibiotics and dental referral.
FTT in immunocompromised children may reflect underlying disease activity (e.g., graft-versus-host disease affecting the gut), opportunistic infection, or drug side effects.
Immunosuppressed children with cardiac murmurs should be assessed promptly — endocarditis is a differential in the febrile immunocompromised child.
Children with Chronic Liver Disease
Cholestasis impairs fat-soluble vitamin absorption (A, D, E, K) — supplementation is routinely required.
Growth failure is common and multifactorial; requires multidisciplinary management with paediatric hepatology and dietetics.
Paracetamol dose reduction may be required in severe hepatic impairment (consult paediatric hepatology).
Monitoring & Follow-Up
Every scheduled Child Health visit (birth–5 years)
Plot weight, length/height, and head circumference on WHO growth charts. Assess developmental milestones. Screen for dental eruption and advise first dental visit.
FTT — initial management phase
Weekly to fortnightly weight checks. Dietitian review within 1–2 weeks. Social work assessment if psychosocial concerns. Paediatric referral if no improvement by 4 weeks.
Short stature — surveillance
Growth velocity assessment every 6 months. Bone age X-ray annually (or more frequently if monitoring response to treatment). Endocrine review as indicated.
Colic — review at 2–4 weeks
Reassess feeding, growth, and parental wellbeing. If not improving by 3–4 months or new symptoms develop, consider CMPA investigation or further workup.
Nasolacrimal duct — 6-monthly review
Reassess symptoms. If persisting beyond 12 months, refer to ophthalmology for consideration of probing.
Innocent murmur — follow-up
Reassess at 6-month intervals. If murmur persists or new features develop, refer for echocardiography. Most innocent murmurs resolve by early adolescence.
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander children experience significantly higher rates of many of the conditions discussed in this article. Culturally safe, trauma-informed care and genuine partnership with communities are essential to improving outcomes.
📚 References
- 1. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework. Canberra: AIHW; 2023. Available from: aihw.gov.au.
- 2. Australian Dental Association (ADA). Guidelines for the Use of Fluorides in Australia: Update 2019. Sydney: ADA; 2019.
- 3. Benninga MA, Nurko S, Faure C, Hyman PE, St James Roberts I, Schechter NL. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology. 2016;150(6):1443–1455.e2. (Rome IV criteria)
- 4. Department of Health and Aged Care. Child Dental Benefits Schedule — Overview. Australian Government; 2024. Available from: health.gov.au.
- 5. Evans AM. Growing pains: a non-diagnosis? Journal of Paediatrics and Child Health. 2012;48(12):1042–1045.
- 6. Hauser GJ. The child with a murmur. Pediatrics in Review. 2014;35(12):517–527.
- 7. National Health and Medical Research Council (NHMRC). Australian Dietary Guidelines. Canberra: NHMRC; 2013.
- 8. Oral Health CRC. The Child Dental Health Survey: Australia 2017–2018. Adelaide: Australian Research Centre for Population Oral Health; 2020.
- 9. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. Melbourne: RACGP; 2018 (updated 2023).
- 10. 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: RHDAustralia; 2020.
- 11. Saavedra Pérez MA, Ament LJ, Vrijkotte TGM, et al. Growth patterns in the first year of life and risk of becoming overweight in childhood. European Journal of Clinical Nutrition. 2016;70(4):482–487.
- 12. Sung V, D'Amico F, Cabana MD, et al. Lactobacillus reuteri to treat infant colic: a meta-analysis. Pediatrics. 2018;141(1):e20171811.
- 13. World Health Organization (WHO). WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva: WHO; 2006.