Author: Rebecca Rhodes / Editor: Liz Herrievan / Codes: SaP2, SLO5 / Published: 10/06/2025
Every emergency department (ED) has a vast turnover of patients amongst which some are extremely unwell and others less so. As colleagues we work tirelessly to triage, assess and appropriately treat, refer or reassure. At the same time, we aspire to make every contact count for tackling childhood poverty, obesity or indoor/outdoor air pollution. It could be argued that making every contact count for developmental impairment is also key. Families trust the advice of professionals in the ED so having a few quick references up your sleeve can make this topic feel less daunting.
The causes for developmental impairment are very varied including genetic, metabolic, endocrine and infective conditions impacting antenatally, perinatally or postnatally. It can also be linked to adverse childhood events and lack of opportunity. Developmental impairment can occur in one or more domains. Children with early developmental impairment particularly in the domains of speech and language and social interactions may later fulfil criteria for a diagnosis of autism spectrum condition. Children with developmental impairment can have a higher likelihood of intellectual disability (although not always) and it is important to understand the challenges faced by each child and their family so that we can support as best as we can (further information in the RCEM Learning Disability Toolkit).
First, a quick reference guide for developmental milestone red flags is key to helping you know if there are concerns. Often, parents will pick up on these concerns themselves. If highlighted that there is impairment*, clarifying the extent, any evidence of regression of skills and therefore urgency of referral is key to instigating early intervention which can help the child.
*Use the term developmental impairment rather than delay because delay can be a misleading term and gives families the not-always-true hope that every child will ‘catch up’.
Reference red flag guide:
If the family have any concerns, find out who else is involved with the child, when their next review by the health visitor is due and signpost how to contact the health visitor and GP who can direct the family to support or refer for formal assessment.
Many colleagues worry about their role in investigating and over recent years there has been recognition that there is not a prescribed list of investigations which would ‘catch all’. Instead, if time allows a discussion with a paediatric colleague might be appropriate to guide ongoing management. Local practices vary but generally paediatric review (via admission or very soon rapid access) should be sought for first identification or worsening of:
- Developmental skill loss (think brain tumour, previously Head Smart, criteria)
- Floppiness/persistently low tone/excessive sleepiness (consider encephalopathy)
- New onset seizures
- Head circumference >99.6th/crossing 2 centiles (look for signs of raised ICP – if present speak to neurosurgical team)
- Asymmetry of tone or movement disorders
- Vision – difficulty fixing/following or impairment
What about bloods? In most cases, these don’t need to be done in the ED. Nevertheless, if a child presents with sleepiness and developmental red flags, especially regression, and you decide to do a septic screen it is worth considering also collecting blood for the following, which might highlight an underlying metabolic condition whose long-term impacts might be reduced by early identification:
Fig.1 Adapted from A Handbook of Neurological Investigations in Children
Obviously, if you have concerns regarding regression or seizures the child will need admitting under the paediatric team, so a quick conversation regarding who will do the bloods might be helpful to prevent miscommunication. A urine test for inborn errors of metabolism is a handy test. It does not need to be clean catch but ideally don’t keep it hanging around the department too long as it may give falsely elevated readings.
Some of the above tests you may receive back before the child leaves the department but those in the final box may take a number of weeks. Clear communication with families to ensure that they receive feedback on these results is key to nothing being missing. Departments will all have their own processes for following up on results. Borderline results are the most frustrating of all and often cause multiple repeat visits to health services. This is why it’s important to be aware of the indication for the test and level of suspicion. The above guide gives a general summary but does not replace the expert advice of your paediatric, biochemistry or metabolic colleagues.
Finally, once you’ve identified an abnormality in a child’s development and considered whether urgent paediatric review and investigations are needed, it’s important to signpost to local pathways. These are particularly important if the child has ongoing difficulties related to their developmental impairment such as failure to thrive, limited diet, sleep difficulties, difficulties accessing education, or they require targeted interventions for behaviour or speech difficulties. Every local area has a different pathway. Some will require referral from GPs, others receive referrals from other professional teams. Usually, these pathways are tailored to the needs of the community and provide support and training and assessment of the concerns which ensures a clearer picture is gathered from which assessment and targeted investigations can be used to guide management.
Health visitors and schools have access to a number of options for support for families.
National organisations such as the National Autistic Society have a wealth of information which might be relevant to some families, even if a diagnosis of autism has not yet been formalised. Websites such as Healthier Together have lots of helpful good quality information. Some EDs have compiled a list of QR codes to local services and resources for commonly occurring issues.
Case study 1:
Bertie is a 7-month-old little boy presenting to ED with increased work of breathing over the past 24 hours. He’s had a slight snuffle but no fevers. His feeds have decreased a little, but he’s been vomiting more than usual. There are no concerns in his birth history or past medical history although he’s always been a bit unsettled. He doesn’t take any medications. Mum reports that he has never been able to roll, and he took a long time to develop the small amount of head control that he has. She has been reassured that he will grow stronger with time. On examination:
A: Patent
B: Bertie’s breathing is laboured, respiratory rate of 60 breaths per minute, sats 96% on air.
C: Mild tachycardia, capillary refill time of 2 seconds, BP 83/55, peripheries warm.
D: Very sleepy, hard to rouse. Low tone. Pupils equal and reactive to light. BM 6.2.
E: Abdomen soft, no rashes, nappy a little bit wet. External male genitalia appear normal. Temperature 37.9C.
Blood gas: pH 7.32, PaCO2 6.2, BE -1.4, bicarb 24, Hb 132, Na 149, K 3.6, glucose 6.2, lactate 3.9
Something just doesn’t sit right with you so you discuss with the paediatric registrar and decide to perform a partial septic screen, collect a urine sample and whilst doing so you send an ammonia level and admit to the paediatric ward for observation. The blood cultures came back with no growth and Bertie appeared much better after a couple of days, but his development was still severely impaired.
Over subsequent weeks the paediatric team discover that his lactic acidosis persists. He undergoes an MRI scan of his head with spectroscopy and genetic testing and with time a mitochondrial disorder was discovered. He is commenced on a ketogenic diet by the specialist team and started to make progress with his development. You can learn more about his prognosis here: What is mitochondrial disease? – The Lily Foundation
Case study 2:
Imran presents with a first febrile convulsion aged 3 years 5 months.
He was born at term, with no antenatal or postnatal concerns. He is usually well with no regular medications or allergies and is up to date with his immunisations. He’s been a bit coryzal and today at nursery was apparently quieter and more sleepy than usual, before having a 3-minute tonic clonic seizure during which felt very hot to touch. That was around 4 hours ago now and his parents feel he is now back to his normal self. You notice that he has poor eye contact, no speech aside from high pitched noises and is doing some rocking movements. He seems quite upset so you ask if there is a quieter space free for you to speak with him and his parents – this seems to help calm him.
You explain to his parents regarding febrile convulsions and provide safety net advice (Febrile Convulsion: Healthier Together). You take a couple of extra minutes just to check his developmental history and whether parents/nursery have any further worries about Imran. His parents tell you that they’re really worried – he could say words when he was about 2 years old but now has no words. You ensure that there are no red flags as per brain tumour criteria. His parents ask you whether you think Imran has autism. You explain that there are certainly worries about Imran’s communication but it’s very hard to assess from one interaction. They explain to you how hard it is to constantly watch him and how frustrated he gets when he can’t express himself clearly. His sleep is also really tricky and they look exhausted.
You recognise that whilst Imran has not yet had a formal diagnosis, they may find some of the information on the Help and support area of the National Autism Society website and SEND Local Offer website for your region helpful. This will also help explain the local assessment process and you encourage them to speak to their GP for referral and also to speak to Nursery about their concerns. By seeking advice this way, Nursery are able to put in place extra support to help Imran, they receive help regarding his communication from Speech and Language and information is gathered to build up a fuller picture of Imran’s needs and the support that will help him and his family moving forwards (giving time for the correct diagnosis to be made).
Take away points:
- Through professional curiosity you can be confident to identify developmental impairment in children presenting to the ED
- There is no ‘catch all’ blood test but considering first line tests and referral particularly in children who will be bled anyway might be helpful
- Discuss and signpost to appropriate follow up with appropriate teams.
- Recognise that caregivers are experts in their child’s care. Listening to them is of utmost importance as is making every contact count to support caregivers.