Immigrant health - acute presentations

PIC Endorsed

Key points

In the emergency setting, the main issue is a recently-arrived child with fever. Other health screening should be completed in the outpatient setting
An interpreter is usually needed. It is not appropriate to use a family member for interpreting
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	Gastroenteritis 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

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/>

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines