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Paediatric obesity (Diabetes and Endocrinology)

PAEDIATRIC

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


Adult conditions

Pancreatic disease

  • Diabetic ketoacidosis  - A
  • Diabetes and severe vomiting -A
  • Acute severe hyperglycaemia
  • Acute severe hypoglycaemia -A
  • Hyperosmolar hyperglycaemic state (HHS) -A
  • Newly diagnosed type 1 diabetes –B (call registrar or consultant on call)
  • Foot ulcer with infection and systemically unwell or febrile -A
  • Invasive infection or rapidly spreading cellulitis of the foot (defined by peripheral redness around the wound >2cm) -A
  • Acute foot ischaemia -A
  • Wet gangrene foot -A

Urgent cases – (refer to key below)
A – client to present to emergency department immediately
B – client to present to diabetes specialist service within 24 hours.  If no specialist service is available, present to an emergency department.

High Risk Foot

  • Foot ulcer with infection and systemically unwell or febrile
  • Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm)
  • Acute ischaemia
  • Wet gangrene
  • Acute or suspected Charcot

Thyroid disorders

  • Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
  • Neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • Hyperthyroidism with hypokalaemia or paralysis
  • Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)
  • Stridor associated with a thyroid mass
  • Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

Adrenal disease

  • Addisonian crisis
  • Suspected or confirmed acute adrenal insufficiency
  • Phaeochromocytoma in crisis with uncontrolled hypertension
  • Malignant hypertension

Pituitary disorders

  • All patients with visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
  • Pituitary tumour with severe headache
  • Pituitary tumour with evidence of symptomatic cortisol insufficiency
  • Hyperprolactinaemia with visual impairment or other neurological signs

Oligo/amenorrhoea, hirsutism, acne, female infertility

  • Signs in the central nervous system that could indicate a pituitary tumour (visual field defect headaches)

Calcium, electrolyte and metabolic bone disorders

  • Acutely symptomatic hypocalcaemia (e.g. tetany) with serum calcium <2.0mmol/L
  • Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
  • Hypernatraemia or hyponatraemia with acute confusion/delirium
  • Suspected or confirmed diabetes insipidus with hypernatraemia

Paediatric Conditions

Paediatric diabetes

  • New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
  • Ketoacidosis in a known diabetic with any of the following
    • systemic symptoms (fever, lethargy) or
    • vomiting or
    • inability to eat (even if not vomiting) or
    • abdominal pain or
    • headache

Growth failure

  • Suspected pituitary mass (visual field loss/CNS signs)
  • Addisonian crisis (including unexplained hyponatraemia & hypoglycaemia)
  • Myxoedema coma
  • New onset diabetes insipidus (including unexplained hypernatraemia)
  • Hypocalcaemia (including acute rickets) with seizures

 

  • Refer to local Healthpathways or local guidelines
  • Use BMI charts to monitor growth.   Interpretation of BMI values in children and adolescents aged 2–18 years is based on sex-specific BMI percentile charts.  Ensure that the same chart is used over time to allow for consistent monitoring of growth
  • Growth of children less than 2 years of age is monitored using World Health Organization (WHO) growth charts. (Australian practice)
  • While waist circumference may not have a place in screening for overweight and obesity in children and adolescents, a waist circumference that is greater than half the height suggests a need for more thorough weight assessment.
  • Consider involvement of other professionals (e.g. aboriginal health worker, multicultural health worker, interpreter) to facilitate communication
  • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)

    NB Refer to general paediatrics

    • Hypertensive >95% for age with appropriate size cuff (BP centile by age and height)
    • Type 2 diabetes
    • Severe obstruction in sleep with repeated arousals and distress
  • Category 2
    (appointment within 90 calendar days)

    NB Refer to general paediatrics

    • An underlying medical or endocrine cause is suspected, or there are concerns about height and growth velocity
    • Obese children <6 years
    • Other symptomatic obesity including obstructive sleep apnoea, hip or knee pain, high levels of psychological distress about weight
    • Signs of insulin resistance
  • Category 3
    (appointment within 365 calendar days)

    NB Refer to general paediatrics

    • Obese children > 6 years

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

  • Current height and weight, including date of measurement
  • Blood pressure
  • Report presence or absence of concerning features:
    • Significant obstruction in sleep with repeated arousals and distress
    • Type 2 diabetes (random glucose > 11 or fasting >7.0) use diabetes CPC referral guide
    • Recent rapid change in weight (gain or loss)
    • Hypertension >95 centile for age with appropriate size cuff https://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf
  • Fasting glucose, insulin, ELFTs, FBC, iron studies, CRP, TFTs

 

 

3. Additional referral information Useful for processing the referral

Highly desirable information – may change triage category

  • History of obesity-related burden of disease – sleep disturbance, exercise limitation, orthopaedic pain, psychological disturbance
  • Height/weight/head circumference and growth charts with prior measurements if available
  • Diet history including if
    • the child has a very restricted diet, or specific dietary restrictions (refer to a dietitian)
    • extreme weight loss behaviours, signs of eating disorders, high level of negative body image and/or negative social experiences are evident (refer to psychological services)

Desirable Information - will assist at consultation

  • Assessment of parental obesity and other familiy history
  • Other past medical history
  • Pregnancy and birth history
  • Immunisation history
  • Developmental history
  • Medication history
  • Allergies
  • Significant psychosocial risk factors (esp. parents mental health, family violence, housing and financial stress, department of child safety involvement)
  • Other physical examination findings inclusive of CNS, birth marks or dysmorphology
  • Any other relevant laboratory results or medical imaging reports

4. Request

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

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

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.)
  • 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.