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Clinical Prioritisation Criteria
Paediatric Surgery
Umbilical and peri umbilical pathology

Umbilical and peri umbilical pathology

PAEDIATRIC

Emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

Paediatric surgery registrars at Queensland Children's Hospital/ GCUH can offer telephone advice to rural HHS. In some areas it would be more appropriate to seek initial advice from local paediatric medical service or general surgery services:

Queensland Children's Hospital: 07 3068 1111
GCUH: 1300 744 284

Burns

All major burns require emergency management and referral

The Paediatric Burns Centre (PBC), Qld Children’s Hospital offers a 24/7 referral service. For a referral coming from regional QLD, an email referral service is available. Criteria for referring to our service is based on the Australian New Zealand Burns Association transfer guidelines for Burns Service referral.

For those burns located in the Mackay region and above, please refer to Townsville Hospital first (07) 4433 1111
For those burns located in the Gold Coast region and below to Grafton NSW, please refer to Gold Coast University Hospital first. Paediatric surgical registrar or on call surgical cover 1300 744 284

If these hospitals are unable to care for the patient, then please follow the information below to refer to PBC

To refer a patient to the Paediatric Burns Centre (Qld Children’s Hospital);

Contact the Burns Register on call via switch (07) 3068 1111
Complete Category 1 Referral to Burns Outpatients (QH staff only)
Submit referral form by clicking ‘submit at the end of the form or by emailing through to burns-opd@health.qld.gov.au
Attach any photos to this email if possible
If advised that the patient can be treated locally, continue to contact the burns Registrar at each dressing change to update progress and send through photos to above email address

All paediatric patients should be referred to the PBC however they may not physically be required to attend the Queensland Children’s hospital. If treatment can be managed in the local area, then this is the preferred treatment

Antenatal & neonatal surgical conditions

Patients with congenital malformations causing bowel obstruction or respiratory compromise are emergency referrals not outpatients. Resuscitation and safe transfer to tertiary paediatric unit is a priority. Notify neonatal unit or appropriate neonatal/paediatric medical specialist of neonatal/fetal diagnosis as per local protocol.
Acute neonatal bowel obstruction

Enlarged lymph nodes/midline neck swelling

Acute infective node with no improvement within 48 hours
Nodes rapidly increasing in size, overlying skin erythema or very tender
Acute infection not responding to treatment/antibiotics present to emergency

Umbilical and peri umbilical pathology

Any painful, red, or irreducible hernia – discuss with on-call paediatric surgical registrar
Suspected vitello-intestinal remnant or patent urachus

Abdominal pain - chronic

Acute abdominal pain (suspected serious pathology) especially severe pain or peritonitis
Intussusception
Hypertrophic pyloric stenosis
Suspected bowel obstruction with bile stained vomiting
Suspected malignancy – discuss with on-call paediatric surgical registrar if serious pathology is suspected

Perineal conditions

Severe pain or peritonitis

Perianal conditions

Acute abscess

Constipation and encopresis

Acute neonatal bowel obstruction

Vomiting

Bile stained vomiting is a surgical emergency – phone the on-call paediatric surgical registrar,
Suspected pyloric stenosis – phone the on-call paediatric surgical registrar

Stomas and abdominal devices

Accidental removal of gastrostomy button or ACE tubing – phone on-call paediatric surgical registrar
Any stomal or abdominal device issues refer to treating hospital

Hernia, hydrocele and testicular conditions

Irreducible, incarcerated or strangulated inguinal hernia
Suspected testicular torsion
Inguinal hernia: If under <52 weeks post conceptual age, call nearest paediatric surgical unit for urgent review
Acute scrotal pain with or without swelling
Ambiguous genitalia and neonatal bilateral undescended testes are urgent referrals to service

Renal and bladder congenital lesions

Acute retention
Poor urinary stream in neonate / suspected valves

Urinary tract infections (UTI)

Acute infant urinary tract infection presenting septicaemia or acutely unwell
Hypertension > 97 percentile for age and/or height
Presumed UTI in infant <3 months

Penile conditions

Paraphimosis (when unable to replace foreskin)
Disorder of sexual development (DSD) – refer to paediatric surgeon or paediatric medicine immediately

Skin and soft tissue masses

Acute breast infection requiring admission or drainage
Acute infection - if unresponsive to treatment or acutely unwell from infection
Suspected solid paediatric tumours should be urgently referred through local paediatric medical service and/or paediatric oncology services

Vascular anomalies/haemangioma

Obstruction of vision, airway compromise, uncontrolled bleeding, ulceration, suspected kapsiform haemangioendothelioma (KHE) or cardiac output compromise - contact paediatric surgical registrar on call

Other useful information for referring practitioners Not an exhaustive list

Refer to local Healthpathways or local guidelines
Provide reassurance
- most are elective surgical conditions
- umbilical hernias are a common condition and more than 95% will self-resolve by 2-3 years
- epigastric hernias are largely asymptomatic and do not necessarily require surgery
Umbilical polyps can be difficult to distinguish from vitello-intestinal tract (VIT) remnants. VIT remnants typically do not respond to silver nitrate
Central short lived colicy abdominal pain without redness, irreducibility or systemic effect is not usually due to the concurrent presence of an umbilical hernia in children
Next of kin or person(s) who is legally responsible for patient consent, with the exception of children under guardianship orders with the Department of Communities, Child Safety and Disability services, should be present at the first outpatient appointment
In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
Paediatric surgery registrars at Queensland Children's Hospital/ GCUH can offer telephone advice to rural HHS. In some areas it would be more appropriate to seek initial advice from local paediatric medical service or general surgery services:
- Queensland Children's Hospital: 07 3068 1111
- GCUH: 1300 744 284

Minimum Referral Criteria

Category 1
(appointment within 30 calendar days)
- Discharging umbilical lesions under 3 months of age
- Polyps not responding to silver nitrate
Category 2
(appointment within 90 calendar days)
- Epigastric or umbilical hernia associated with intermittent redness with pain
- Nodular non-inflamed irreducible lesions representing cystic umbilical remnants
Category 3
(appointment within 365 calendar days)
- Umbilical hernia still present after 2 years of age
- Asymptomatic epigastric hernia where parents wish to discuss surgery
- Parental anxiety not reassured by GP

1. Reason for request Indicate on the referral

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

General referral information

3. Additional referral information Useful for processing the referral

Nature of any umbilical discharge
Treatments that have been applied to date and efficacy

4. Request

General referral information

Patient's Demographic Details

Full name (including aliases)
Date of birth
Residential and postal address
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

Relevant clinical information about the condition

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Reason for request

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

Willingness to have surgery (where surgery is a likely intervention)
Choice to be treated as a public or private patient
Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Notes

Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Version: 6
Last updated: 05 February 2020

© State of Queensland (Queensland Health) 2023

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Paediatric Surgery