What is the most appropriate management for a 2-year-old child presenting with imbalance, dizziness, headaches, and nocturnal epistaxis (nosebleeds) with a normal examination?

Refer to Consultant Paediatrician

This 2-year-old child with recurrent presentations for imbalance/dizziness, headaches, and nocturnal epistaxis requires urgent referral to a consultant paediatrician for comprehensive evaluation, as this constellation of symptoms raises concern for serious intracranial pathology despite a normal examination.

Critical Red Flags Present

This clinical presentation contains multiple concerning features that warrant specialist evaluation:

• Recurrent neurological symptoms in a toddler: The combination of imbalance/dizziness and headaches in a 2-year-old is particularly worrisome, as headaches are uncommon in this age group and difficult to assess reliably 1
• Nocturnal epistaxis: While epistaxis is common in children, the nocturnal timing combined with neurological symptoms raises concern for increased intracranial pressure or posterior fossa pathology 1
• Multiple presentations: The fact that the child has been brought "on several occasions" suggests persistent, concerning symptoms that have not resolved spontaneously 2

Why Specialist Referral is Essential

Posterior Fossa Pathology Concerns

The symptom triad of imbalance, headaches, and epistaxis in a young child should prompt consideration of:

• Chiari malformation: Headache, dizziness, and difficulty with balance are classic indicators of brainstem and cerebellar compression requiring prompt neurology referral and evaluation 3
• Posterior fossa tumors: These can present with ataxia, headaches, and signs of increased intracranial pressure before examination findings become apparent 1
• Hydrocephalus or other structural lesions: May present with subtle neurological symptoms before overt signs develop 1

Limitations of Normal Examination

A normal physical examination does not exclude serious pathology in this context:

• Young children may have serious intracranial pathology before papilledema or other obvious signs develop 2
• Subtle neurological findings may be difficult to detect in a 2-year-old without specialized pediatric assessment 4
• The American College of Radiology emphasizes that imaging is indicated for children with secondary headache features, especially when combined with other neurological symptoms 1

Why Not Admit Directly

While this child requires urgent evaluation, direct admission is not the most appropriate initial step because:

• The examination is currently normal, suggesting the child is not in immediate distress 1
• A consultant paediatrician can perform a comprehensive assessment and arrange appropriate investigations (likely including MRI) in a coordinated manner 1, 2
• Admission without specialist input may lead to fragmented care and unnecessary delays 1

Why Not Social Care Referral

While the mention of "[RELATIVE]" bringing the child might raise questions, social care referral is not indicated as the primary action because:

• The symptoms described are consistent with organic pathology requiring medical investigation 1, 3
• There is no mention of concerning injury patterns, developmental concerns, or other features suggesting non-accidental injury 4
• The appropriate medical evaluation must be completed first to establish whether these are genuine medical concerns 2

Specific Evaluation Needed

The consultant paediatrician should arrange:

• MRI brain with focus on posterior fossa: This is the imaging modality of choice for evaluating headache with neurological symptoms in children, as it provides superior detail of intracranial structures without radiation and can evaluate for mass lesions, Chiari malformation, and hydrocephalus 1
• Detailed neurological examination: Including assessment of cranial nerves, cerebellar function, gait, and fundoscopy to evaluate for papilledema 2, 4
• ENT evaluation if indicated: To assess for structural causes of recurrent epistaxis, though this is secondary to ruling out intracranial pathology 1

Common Pitfall to Avoid

Do not dismiss these symptoms as benign childhood epistaxis or viral illness. The combination of neurological symptoms with epistaxis in a 2-year-old, especially with recurrent presentations, mandates investigation for serious underlying pathology 1, 3, 2.