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Growth failure

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
  • Correct for prematurity (<37 weeks) until 24 months of age
  • A detailed history (personal, family & social), consider the following
    • antenatal complications and maternal health
    • birth weight, length and head circumference
    • significant intercurrent illnesses coinciding with onset of poor growth
    • vomiting and diarrhoea
    • developmental delay, regression or syndromal causes of poor growth
    • mid-parental height and the family history of childhood weight gain
    • lack of financial resources for food requirements
    • lack of suitable housing
    • lack of family/community supports
    • refugee or recent immigrant background
    • parental mental health problems
    • community services history – particularly failure to engage with MCH services and local GP
    • failure to attend hospital or community services appointments
    • previous history of child protection involvement
  • Height/weight/head circumference/percentile charts (measured serially and plotted to note trend, if available). It is recommended that WHO growth standards be used for children under 2 years of age and CDC growth charts for children over 2 years of age.
  • There are growth charts available for specific conditions including Down syndrome, Turner syndrome and Williams syndrome and these should be used
  • A clear follow up plan should be documented
  • The frequency of follow up depends on the child’s weight, age and psychosocial circumstances.  Younger infants need more frequent follow up.
  • If follow-up appointments are not attended, immediate action should be taken to ascertain health status of the child. Refer to child protection if considered to be at risk.

Minimum Referral Criteria

  • Category 1
    (appointment within 30 calendar days)
    • Possible CNS signs (visual disturbance, morning headaches etc)
    • Hypoglycaemia
    • Untreated hypothyroidism
    • Cushing’s syndrome (not iatrogenic)
    • Signs and symptoms suggestive of IBD, renal failure other serious intercurrent illness or significant medical problems
    • Pubertal arrest
  • Category 2
    (appointment within 90 calendar days)
    • Constitutional delay of growth and puberty
    • Delayed puberty >12y females and 13y males
    • Primary or secondary amenorrhoea
    • Small for gestational age with no catch-up growth
    • Abnormal coeliac serology
    • Hypothyroidism started on treatment
    • Syndrome associated short stature
    • Documented channel crossing due to poor height velocity
    • Iatrogenic Cushing’s syndrome
    • Skeletal dysplasias
    • Short stature with increased fracturing
    • Short stature with relative obesity
  • Category 3
    (appointment within 365 calendar days)
    • If there is parental concern
    • Variants of normal growth including familial short stature

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

  • Serial measurements are needed to assess a child’s growth
  • A detailed history (personal, family & social)
  • Details of all treatments offered and efficacy
  • Physical examination
    • signs of neglect or abuse
  • Assessment of psychosocial deprivation
  • Development assessment
  • Feeding history

3. Additional referral information Useful for processing the referral

  • Please include any other information you feel is relevant
  • Accurate parental heights obtained
  • FBC ESR/CRP – to exclude anaemia and inflammation (pointers to further testing required)
  • U&E – to exclude renal disease
  • Bone chemistry (calcium, phosphate and alkaline phosphatase) -  to exclude malabsorption, bone disorders including rickets
  • Coeliac serology (TTG & IgA)
  • TSH & FT4 –to exclude hypothyroidism (peripheral or central)
  • IGF1 – to exclude GH deficiency
  • FSH in girls <2y or >9y - to exclude Turner syndrome –Karyotype between these ages
  • Urine protein & blood – to exclude renal disease

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.