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Immigrant health - acute presentations

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  • See also

    Illness in returned traveller guideline 
    Immigrant health service resources 
    Immigrant health - initial assessment

    Key Points

    1. In the emergency setting, the main issue is a recently-arrived child with fever. Other health screening should be completed in the outpatient setting
    2. An interpreter is usually needed. It is not appropriate to use a family member for interpreting
    3. Asylum seekers receive free hospital care in NSW, Queensland and Victoria

    Background

    • Refugee and asylum seeker children/adolescents will have typical paediatric health problems and may also have health issues specific to their background or forced migration experience
    • Pre-migration health checks are limited in children. Small numbers of refugee children may arrive in Australia with a health alert
    • Post-arrival refugee health screening is recommended within 1 month but is not mandated, many children may not have had this screening

    Considerations in the Emergency Department

    Screening

    • Recent arrivals (<3 months in Australia) from malaria-endemic areas who are febrile need malaria screening
      • Screening (thick/thin films and rapid diagnostic test - RDT) can be completed on finger prick bloods. See Malaria
    • All other refugee screening should be completed in the outpatient setting - most of the relevant issues are not acute problems
    • If bloods are being taken in ED and the child has not had post-arrival screening:
      • consider storing extra blood for screening with consent; large gel serum tube (7.5 mL) & EDTA tube (2.7 mL)
      • notify your immigrant health (or equivalent) team and they can order the appropriate tests (Initial Assessment)

    Immunisation

    • A verbal history of immunisation is not reliable. If there is no written record presume the child is unimmunised
    • Consider directing the family to an immunisation service after their visit

    Common Acute Presentations

    Presentation

    Common causes

    Additional considerations in
    refugee children

    Links

    Fever

    Viral infections 
    Bacterial infections

    • Malaria (endemic areas)
    • Typhoid 
    • Dysentery
    • Dengue and arboviral infections 
    • Hepatitis

    Febrile Child
    Illness in returned traveller 
    Malaria

    Respiratory symptoms

    Viral RTI
    Pneumonia,
    Asthma
    Bronchiolitis
    Croup

    • Pertussis: vaccination may not have been available in country of origin
    • Tuberculosis (TB) consider in children with chronic cough or contact history
    • Parasite infection may (very rarely) cause wheeze/respiratory symptoms
    • Sickle cell disease may present with acute chest syndrome

    Pneumonia 
    Asthma 
    Bronchiolitis 
    Croup 
    Cough 
    Immigrant health -TB screening 
    Sickle cell disease

    Abdominal
    pain

    Acute infection 

    Constipation

    Surgical 
    or gynaecological causes.

    • Parasite infection  
    • Helicobacter pylori gastritis - epigastric pain, early satiety, nausea/vomiting, family history
    • Hepatitis

    Abdominal pain
    Immigrant health – Intestinal Parasites
    Immigrant health - H pylori
    Immigrant health - Hepatitis B

    Diarrhoea

    Viral gastroenteritis
    Bacterial gastroenteritis
    Malabsorption

    • Parasite infection
    • Lactose intolerance is more common in some racial groups
    • Bacillary and amoebic dysentery

    Diarrhoea and vomiting 
    Immigrant health – Intestinal Parasites

    Hypocalcaemia
    Tetany, muscle cramps, stridor, seizures

    Vitamin D deficiency (low calcium more likely in children <12 months)

    • Examine for rickets (bossing, swelling wrists/ankles, bony deformity)
    • Children with rickets or symptomatic hypocalcaemia need screening in ED (Vitamin D, Ca, Mg, PO4, ALP and PTH, UEC and urine Cr, Ca PO4) and specialist management

    Immigrant health - Vitamin D

    Rashes

    Infective
    Eczema 
    Dermatophyte (tinea) infection 

    • Strongyloides infection may cause an intermittent urticarial rash lasting a few days (larva currens), typically on the buttocks/perianal region
    • Patients with untreated Strongyloides infections can develop hyperinfection syndrome if given immunosuppressant therapy, including steroids

    Eczema 
    Skin infections 
    Immigrant health – Intestinal Parasites
    Immigrant health -Strongyloidiasis

    Continence/UTI

    UTI
    Irritable bladder
    Enuresis

    • Chronic UTI may not have been detected/treated
    • Consider mental health issues as a cause of secondary enuresis
    • Consider female circumcision (female genital mutilation - FGM) as an additional possibility in girls (seek advice on how to raise this)

     

    Musculoskeletal pain

    Injury
    Growing pains
    Joint pathology/ inflammation

    • Low vitamin D is an extremely common cause in refugee children and adolescents with risk factors

    Immigrant health - Vitamin D

    Nutrition concerns, fussy eating

    Poor intake
    Increased losses (gut, urine)
    Increased requirements
    Behavioural issues
    Excess milk intake
    Enlarged tonsils

    • Malnutrition - may need admission
    • Food insecurity (not being able to afford/access adequate food)
    • Iron deficiency is common in refugee children
    • Consider B12 deficiency
    • Helicobacter pylori gastritis
    • Other gastrointestinal infections
    • Dental disease – pain with chewing may restrict food intake
    • Rickets may restrict linear growth

    Immigrant health - Growth and nutrition
    Immigrant health - Iron deficiency
    Immigrant health - B12

    Disability
    (and developmental or learning concerns)

    Genetic
    Environmental
    Trauma - injury

    • May be a multifactorial combination of antenatal, peri- and post-natal contributors
    • Children with complex disability may not have had any access to treatment, check nutrition and clarify seizures, link urgently with care
    • Be wary of attributing to English as an additional language - seek specialist review
    • Check age in older children and consider interrupted schooling
    • Consider mental health contributors

     

    Mental health

    Behaviour concerns
    Sleep issues
    Anxiety/separation issues
    Mental health diagnosis

    • PTSD
    • Experience of violence/conflict, including sexual violence
    • Clarify family background, separations and migration history, parent mental health, and detention experience for people arriving as asylum seekers

    Mental State Examination

    Consider consultation with local paediatric team when

    • Escalating needs of care
    • Requiring inpatient admission or outpatient follow-up
    • Age assessment/clarification of birthdate
    • All unaccompanied minors or orphan relative visa holders
    • Developmental delay or disability
    • Malnutrition - weight/BMI <5th centile for age and disproportionate for family
    • Complex medical issues
    • Offshore detention or prolonged immigration detention

    Consider transfer when

    Care required is beyond the comfort level of the local hospital

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when
    Child is stable and clear advice has been provided about when to return and how/when to access emergency services if needed

    Discharge information and follow-up

    • Ensure contact details are up to date as families often move in the early settlement period
    • Consider contacting the family’s settlement case worker or refugee health nurse about the presentation
    • Ensure children are referred to a paediatrician with any issues listed above

    Parent information

    Additional notes

    Outpatient refugee health specialist paediatric services

    New South Wales
    Australian Refugee Health Practice Guide: NSW

    Queensland
    Queensland Health Refugee and Asylum Seeker Health Services

    Victoria                  
    Royal Children’s Hospital Immigrant Health Service

     

    Last Updated September 2020

  • Reference List

    1. Victorian Foundation for Survivors of Torture Inc (Foundation House), 2020, Australian Refugee Health Practice Guide – Primary care for people from refugee backgrounds, Victoria, viewed August 2020, <https://refugeehealthguide.org.au/>