Section 2 - Child health checks

Health check recommendations

• All children from birth to < 15 years at each scheduled health check

1. Procedure

• Ask the parent or child about any skin concerns as per Table 1.
• Perform a head to toe visual inspection
• Gain permission to remove clothing to better visualise skin. Older children may decide to lift shirts or partly remove pants
• Provide brief intervention if required
• Determine if the child requires a referral and place on a follow-up and recall register

1. All children ^1–7
   • Inspect skin for:
     • sores, scabs, scars, scratches, rashes or cuts
     • jaundice
     • bruises; red/dark blue = new bruise, purple/yellow = older bruise
     • mosquito or sandfly bites
     • itches or irritations
     • loss of sensation or pigmentation
     • nodules or lumps
     • sunburn
     • infections; red, swollen, warm, painful, +/- pus or exudate
     • fluid filled blisters
     • See Resource 1.
   • For jaundice see Birth information
2. Infants aged 1–6 weeks ^1–7
   • Observe the umbilicus:
     • the umbilical stump area should be dry, clean, odourless and usually dark
     • inspect skin folds (neck, behind legs, groin, armpits etc) for any infected tissue i.e. discharge, redness, warm skin
     • note any visible and palpable bulges through the umbilicus or abdominal muscles (hernia) when the infant strains, coughs or cries; common in infants
     • the umbilicus is usually inverted
   • Milk pimples (milia); small white spots resembling pimples over nose, checks and eyelids
   • Protective waxy white/grey substance coating the skin (vernix)
   • Birthmarks are mostly harmless and fade, shrink or disappear over time. They can be:
     • flat, raised, have regular or irregular borders and vary in colour from brown, tan, black, pale blue, pink, red or purple
     • red and vascular e.g. strawberry haemangiomas, port-wine stains and stork bites
     • pigmented e.g. moles, café-au-lait spots and Mongolian spots
   • Mongolian spots are:
     • irregular areas of deep bluish-black to grey pigment
     • usually found on the back, buttocks, shoulders and legs of babies
     • often mistaken for bruises
     • often present in dark skinned babies which disappear in preschool years
3. Children > 6 weeks to 15 years
   • Inspect areas where bacteria and scabies mites are commonly found:
     • behind knees, soles of feet and between toes
     • in creases of arms and under armpits
     • between fingers, palms of hands and wrists
     • around neck, scalp and behind ears
     • lower back and between buttocks

2. Results

• Skin should be clean, intact and free of abnormalities

3. Brief intervention ^1–7

• Discuss hand hygiene as the single most important strategy to prevent skin infections. See Resource 2.
• Reassure parents of normal or common childhood skin conditions that settles with time or of no concern medically:
  • most birth marks e.g. Mongolian spots
  • clean umbilicus stump daily
  • vernix and milia are both normal and resolve in time
• Haemangiomas may bleed easily but stop quickly when continuous pressure is applied
• Clean any non-infected sores with soap and water and apply a cover:
  • Staphylococcus aureus is the most common cause of skin infections (e.g. boils,
    cellulitis, impetigo, school sores) and usually managed with topical therapy
  • Streptococcal skin infections can lead to acute rheumatic fever (ARF), Rheumatic heart disease, acute post-streptococcal glomerulonephritis (APSGN) and Heart failure
• Regularly wash and change clothes and bedding:
  • parasites that invade the skin (e.g. pubic and head lice, scabies) can cause infections that leads to Chronic kidney disease
• Use mosquito coils and skin repellent during evenings. Rid homes and yards of containers of stagnant water. Spray insecticide under and around household items:
  • mosquitoes, ticks, fleas and other insects can transmit viruses and parasites e.g. dengue fever, malaria, Ross River fever, Japanese encephalitis (JE)
• Keep skin dry, aired and moisture free. Change sweaty or damp clothes:
  • ringworm, tinea, jock rash, double skin, thrush and athlete’s foot are common fungal infections
• Infectious viral skin infections include:
  • herpes: adults with mouth herpes to not kiss or touch children when herpes sore is active
  • warts: avoid touching or bathing with others to avoid spreading
  • molluscum contagiosum (multiple watery blisters): spread prolifically from bathing. Shower only. Cover and avoid contact with other children
  • common viral infections are harmless and resolve with time however ensure all children are vaccinated e.g. chicken pox, measles, mumps and rubella, etc.
• Rashes and contact dermatitis are common and can be due to:
  • detergents, creams, and skin products. Avoid in infants
  • environmental irritants or allergens. See Asthma (children 1–12 years)
  • prolonged exposure to urine or faeces (nappy rash)
• Sunburn:
  • < 6 months protect skin with clothing
  • slip on sun protective clothing
  • slop on SPF 30 (or higher) sunscreen > 6 months
  • slap on a broad-brimmed hat
  • seek shade
  • slide on wrap-around sunglasses
• For further information of common childhood skin conditions see Resource 1.

4. Referral ^1–7

• For multiple children presenting with similar skin conditions, be alerted to a broader community public health outbreak e.g. APSGN or ARF. Contact your local Population Health Unit to determine a course of action
• Refer to the Primary Clinical Care Manual for:
  • any unvaccinated child
  • boils, cellulitis and impetigo
  • suspectedstreptococcal skin infections
  • head lice and scabies
  • suspected mosquito, tick, flea or other parasite borne viruses e.g. dengue fever, Ross River fever, Japanese encephalitis (JE) and Lyme disease
  • ringworm, tinea, jock rash, double skin, thrush and athlete’s foot
  • herpes, warts, molluscum contagiosum and vaccine preventable infections such as chicken pox
  • always suspect ARF or APSGN in rural and remote locations. See Rheumatic heart disease
• Refer to the MO/NP for:
  • haemangiomas:
    • of any size on any part of the head or over joints
    • of large size to any part of the body
  • any unresolving skin condition e.g. rashes
  • any concerns

5. Follow-up

• Place the child on a recall register if required
• Ensure all referrals are actioned
• Provide the parent with details of the next scheduled follow-up appointment

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Recognising and treating skin infections: a visual clinical handbook and Skin infections in children and Neonatal and skin care
2. Handwashing resources available at Hand Hygiene Australia