Refugee and unaccompanied asylum seeking children and young people: paediatric health assessment

 These pages were developed in partnership with the Child Protection Standing Committee and the Advocacy Committee to support paediatricians in the assessment and management of children and young people of refugee background, with links to key external information and resources.

Paediatric health assessment

The health assessment of refugee children and young people, whether undertaken as part of a statutory Initial Health Assessment for looked-after children or as part of an initial general health assessment, should be a thorough and rounded one, and commence with a detailed history, as for any child seen by a well-trained paediatrician.

Please note that an initial health assessment may be conducted by other health professionals – see Looked after children: knowledge, skills and competence of health care staff for further information.

  • It is important to allow sufficient time to gather a comprehensive set of information at the initial meeting. This prevents the possibility that a child, young person or family may have to relive trauma and loss repeatedly.
     
  •  Paediatricians should aim to understand the political circumstances of the child, young person or family’s country of origin and countries of transit. A brief discussion will provide useful information as well as information about the processing of their asylum claims and any age determination issues. The British Association for Adoption and Fostering (BAAF), now CoramBAAF, have produced the following:

Information regarding children arriving from different countries.  This provides specific information to give foster carers an understanding of the kind of country, society and family a child or young person has come from.

An essential guide titled Promoting the health of children in public care: the essential guide for health and social work professionals and commissioners, in which a detailed chapter about the health assessment of unaccompanied asylum-seeking and other separated children is available.
 

  • Any assessment should include consideration of what has happened to the child, young person and/or family before entering the UK, en route and at their final destination. 
     
  • Paediatricians should use a structured proforma to avoid missing any health needs.  This can help guide the conversation, firstly by discussing with the young person straightforward issues such as demographics and then dealing with subjects that may cause more distress.

During a health assessment, paediatricians should check for and ask about the following:


Note – there should be minimal use of jargon and paediatricians should also be aware of cultural differences in the significance of a health concern.

 

Past health

Ask about surgery, illnesses requiring treatment, jaundice and fevers. Include specific questions regarding injuries.

Preschool children:

  • Document perinatal history and any perinatal screening in the home country.
     
  • If there is no history of neonatal screening such as the Guthrie, or hearing screening, be aware that treatable conditions such as hypothyroidism could be missed.
     
  • It should not be assumed that developmental problems are solely due to the displaced and traumatic refugee experience.

Family health

  • Ask routine history on consanguinity, siblings and family illnesses.
     
  • Siblings and parents may be in detention centres or placed with other families and it is helpful for the young person to know their location and contact details.
     
  • You can raise the question of family members in the context of possibility of family tracing.

Physical health

Undertake a complete systems examination including overall appearance, vision, hearing, chest, gut, skin, neurology, co-ordination, gait, cardiac, dental care, assessment of puberty (if indicated) and nutrition.

Growth and nutrition:

  • Document height weight and head circumference using current RCPCH centiles.
     
  • If malnutrition is suspected, document Mid-Upper Arm Circumference (MUAC).
     
  • Look for signs of anaemia and vitamin deficiency including scurvy/thiamine and Vitamin D.
     
  • Ask about diet and constipation.
     
  • For younger children food and weaning practices may vary due to unfamiliarity with local shopping and food insecurity. Some families may be dependent on food banks which can have unsuitable food for children.
     
  • Some young people may have experienced extremely poor diets in transfer to the UK, and often do not know how to cook for themselves.
     
  • Nutrition should be documented, health visitor informed (where appropriate), and follow-up should be arranged with the local GP.

For further information see Food with TLC: supporting children in care to eat well and develop a healthy relationship with food, published February 2016 by Children’s Food trust and Fostering Network.

Development:

  • Document developmental milestones, play and learning, including schooling, learning difficulties, outstanding achievements and talents.
     
  • Preschool children should be referred for developmental assessment and further follow up if there are any concerns. It may also be appropriate to refer school-aged children for further follow –up if there are any concerns. 
     
  • Signs of conditions such as scabies, lice, eczema, infected acne should be sought and documented. Presence of tattoos and risk of blood –borne disease such as hepatitis B and HIV also noted.
     
  • Injuries should be documented carefully using a body map (sample body maps are provided in the Child Protection Companion). Also see safeguarding.
     
  • If a sea journey was involved, ask about any near drowning/resuscitation episodes.
     
  • Consider evidence of regression.

Communicable diseases

The prevalence and nature of bacterial and viral infections will vary across countries. See the Migrant Health Guide for prevalence rates in country of origin. The information below on TB and latent TB has been agreed by the London TB clinical leadership group (including adult physicians and public health specialists), the national paediatric TB network and the national TB nursing network.
 

  • A significant number of refugees and asylum seekers arrive from countries where blood-borne infections are highly prevalent, and/or they may have been at exposed to diseases on route to the UK. Paediatricians should consider the possibility of TB (document the presence of a BCG scar), hepatitis, scarlet fever, malaria, measles, typhus and enterovirus and refer appropriately.
     
  • TB should be considered in any child presenting with suggestive symptoms (e.g. but not exclusively- fever, persistent, non-remitting cough, weight loss, failure to thrive, lethargy) and an urgent referral to TB services made if symptomatic.
     
  • Any child presenting from a country with a TB incidence of 40/100,000 or greater (which includes Afghanistan, Eritrea and Somalia), should be automatically referred to paediatric TB services for assessment (as per NICE guidance)
     
  • The journeys to the UK (often involving overcrowding and contact with unwell persons) of children from countries with lower rates of TB incidence) may have brought them into close contact with cases of active pulmonary TB and thus these children should be referred for TB screening.
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  • Unaccompanied asylum seeking children are an especially vulnerable group. They should be assessed at Looked After Children (LAC) review for evidence of symptoms compatible with TB disease and screened proactively for latent TB Infection (LTBI) either by the LAC team or through pre-existing referral pathways to TB services. They should not wait for IGRA screening through the current GP programme (available in some GP surgeries for those >16 years from countries with TB incidence of 150/100,000).
     
  • Children with blood borne viruses such as hepatitis B, C and HIV may be entirely asymptomatic.  Children fleeing regions of conflict may not have benefitted from ante-natal screening and they or their mothers may have been victims of sexual violence. Screening for Hepatitis B, C and HIV should be strongly considered.
     
  • Paediatricians should be aware of the risk of soil transmitted helminthes such as Ascaris and hookworm and should send stool for ova, cysts and parasites or consider empiric treatment with albendazole.
     
  • Paediatricians should be aware of the risk of schistosomiasis and leishmania in children coming from endemic regions and consider testing.
     
  • Paediatricians should consider testing for malaria parasitaemia in children from endemic areas (NB Afghanistan the risk of P. vivax is higher than falciparum)Be aware of the risk of vaccine preventable diseases, cholera and typhoid in child refugees and unaccompanied asylum seekers
     

Immunisations

Many children and young people of refugee background will have unknown vaccination status, and paediatricians will need to assess the likelihood that standard immunisation protocols / WHO Immunisation Schedules would have been followed in the child or young person’s country of origin (Simmons and Merredew).

The following principles as outlined by Public Health England (PHE) should be followed for individuals with uncertain or incomplete immunisation status (PHE, 2015):

  • Unless there is a reliable vaccine history, individuals should be assumed to be unimmunised and a full course of immunisations planned
     
  • Individuals coming to UK part way through their immunisation schedule should be transferred onto the UK schedule and immunised as appropriate for age
     
  • If the primary course has been started but not completed, continue where left off – no need to repeat doses or restart course
     
  • Plan catch-up immunisation schedule with minimum number of visits and within a minimum possible timescale – aim to protect individual in shortest time possible 

Further detail contained in PHE’s Guidance on Vaccination of individuals with uncertain or incomplete immunisation status.

Sexual and reproductive health

  • Asylum seeking children may have experienced rape and torture and some may have worked as commercial sex workers either before, en route to, or following arrival in the UK, while others will have been in consensual sexual relationships (BAAF Practice Note 53).
     
  • Paediatricians should carry out a full sexual health review including questions about whether a young person is sexually active and whether they are pregnant as well as discussing contraceptive options. Ideally this should be carried out in the context of a comprehensive assessment, and in association with the local GUM service (BAAF Practice Note 53).

Mental health and emotional wellbeing

  • Sleep and behaviour disturbances may be common in younger children.
     
  • Some young people may have been trafficked to the UK and/or experienced past traumas including as a child soldier; this group may suffer a range of psychosocial morbidities related to their experiences in their country of origin, their journey to the UK and entering the country.
     
  • It is recommended that mental health screening tool such as the Strength and Difficulties Questionnaire is completed for all young people as this may give insight into other difficulties (for looked-after children in England this is the responsibility of local authority). If a child or young person deemed high risk of behavioural difficulties an appropriate referral should be made to looked-after children’s CAMHS or CAMHs depending on service provision.
     
  • Paediatricians should ask questions about past experiences including bereavement from war, torture and trafficking, as asylum seeking children are at risk of Post-Traumatic Stress Disorder (PTSD) and may require monitoring for up to 12 months.
     
  • Mental health screening can be useful to identify (PTSD) and other difficulties such as problems with sleeping, anger or self-harm. It is essential that these questions are asked sensitively such as “this is a question that I ask all young people I see - have you ever hurt yourself or felt suicidal?” NICE guidance on management of PTSD in adults and children provides further details on screening of individuals involved in a major disaster, programme refugees and asylum seekers.
     
  • On arrival in a new country children, young people and families may experience bullying or racism, lack of social support and/or a lack of access to education which increases vulnerability.
     
  • Follow up should be arranged with the local GP if there are concerns about any aspect of a child or young person’s developmental physical or emotional wellbeing.

Safeguarding and child protection issues

  •  If an unaccompanied child (see definition) is presenting having not previously been known to social services,  an immediate referral needs to be made to the local authority’s children’s social care.  In these settings there is a significant concern about their vulnerability to being trafficking though they will need to make an asylum application as soon as possible the primal concern is safeguarding and ensuring that they are taken into the care of the local authority who then have a duty to care for them which includes helping with legal representation.  When there are concerns around trafficking they should also be referred to the NSPCC who have statutory powers to intervene on behalf of children.
     
  • Paediatricians should also assess a young person’s vulnerabilities to sexual exploitation and risk of trafficking.
     
  • Exposure to violence and rape and other trauma should be explored sensitively. Not all young people are able to disclose on first assessment if they have been raped and this will need careful inquiry, e.g. ‘Some young people say that they have been injured or raped. Has that ever happened to you?’ This line of questioning should apply to young women as well as young men.
     
  • Paediatricians should ask girls/young women if they have been subjected to female genital mutilation (FGM). They should be informed that FGM is illegal in the UK, including when a child is taken out of the country for the procedure, and be provided with a copy of the health passport. If they have been "cut", a referral should be made to a local specialist unit for a follow-up assessment. See the RCPCH FGM webpage for further information, including mandatory reporting and recording requirements.
     
  • Paediatricians should also be alert to the possibility of radicalisation and to consider making a Prevent referral.
     
  • Paediatricians should ask about current experiences of bullying or racism and consider whether and how a lack of social support or educational place may also increase their vulnerability.
     
  • Safeguarding concerns may also arise following an unsafe environment for the child in temporary accommodation or due to neglect or physical abuse.
     
  • Further information about safeguarding refugees and asylum seeking children can be found in the Child Protection Companion.

Health promotion 

  • Health promotion messages are important and paediatricians play an essential role in providing early health promotion messages to young people.
     
  • Messages should concentrate on well-established areas such as healthy eating, smoking, how to stay safe and avoid danger, good sexual health (including how to access sexual health services) and when to access GP services. Health promotion messages should be continued by other health care professionals, including specialist nurses for looked-after children and school nurses.

Social health and wellbeing

Preschool children:

  • Families may be in serious poverty with little access to play opportunities, particularly for younger children.

Young people:

  • Enquire about a young person’s social networks. This should include questions about who they can talk to; have they started to make friends; do they want to access faith or cultural groups; do they know about college placement or local sports access as a way of starting to carry out normal activities to support good mental health.
     
  • Encourage and support resilience as well as addressing painful issues and ask about aspirations should the child/young person not be caught up in war.
     
  • Sometimes the views and wishes of the young person may be at odds with carers or social workers. Often there is a cultural reason or misunderstanding for this. Having an interpreter present gives an opportunity when the carer and young person are brought together (with the young person’s permission) to allow some of these issues to be addressed in a way that acknowledges their needs, together with those of the carer or society, order to make their future easier. 
     
  • Remember that a young person’s expectations can be very different in different cultures, and they may also have had difficult experiences with people in a position of authority in the past. 
     
  • It is recommended that you also talk to the child, young person or family about their past experience of education.

Care planning and follow-up – checklist of actions

Download the checklist (PDF, 320KB, 2 pages).