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Paediatric obesity (General Paediatrics)

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.


It is proposed that the following conditions should be sent directly to emergency. This is not a list of all conditions that should be sent to the emergency department, it is intended as guidance for presentations that may otherwise have been directed to general paediatric outpatients:

Brain & Nervous System

  • Headaches
    • that wake at night or headaches immediately on wakening
    • new and severe headaches
    • associated with significant persisting change of personality or cognitive ability or deterioration in school performance
    • recent head injury or head trauma
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • sudden onset headache reaching maximum intensity within 5 minutes  ( = explosive onset)
    • presence of an intracranial csf shunt
    • hypertension above 95th centile by age for systolic or diastolic

  • Seizures
    • all children with new onset of clinically obvious epileptic seizures should be referred to emergency for initial assessment, observation and consideration of emergency investigation or management.
    • any abnormalities on neurological examination, such as: focal weakness, gait disturbance, papilledema, diplopia
    • significant change in seizures for established epilepsy:
      • new onset of focal seizures or
      • a dramatic change in seizure frequency or duration
  • Faints syncope and funny turns
    • loss of consciousness in association with palpitations
    • sudden loss of consciousness during exercise
    • possible infantile spasms. this may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old

 

Respiratory

  • Asthma, stridor and wheeze
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
    • recent onset or escalating stridor and respiratory distress
    • acute respiratory distress not responding to home management
    • acute respiratory symptoms causing inability to feed or sleep in an infant
  • Persistent and chronic cough
    • infants who have apnoea or cyanosis during paroxysms of coughing
    • children with recurrent or persistent respiratory symptoms who have had an episode of choking suggestive of a possible inhaled foreign body
    • prominent dyspnoea, especially at rest or at night
    • cough causing inability to feed or sleep in an infant

Gastroenterology

  • Jaundice
    • Jaundice in infants with elevated liver transaminases or conjugated (direct) bilirubin > 20 microMol per litre or >15% of total bilirubin.
    • Jaundice in ≥38 week infant ≥ 330 UMol/L
    • Jaundice in 35-37 week infant ≥ 280 UMol/L
    • Jaundice in <35 week infant ≥ 230 UMol/L
  • Chronic & Recurrent Abdominal Pain
    • severe pain not able to be managed at home with simple analgesia
    • significant change in location or intensity of chronic abdominal pain suggestive of a new pathology
    • pain associated with vomiting where this has not occurred before
    • bile stained vomiting
  • Chronic Diarrhoea and/or Vomiting
    • vomiting or diarrhoea with weight loss in an infant <1 year
    • suspected pyloric stenosis
    • bile stained vomiting
    • acute onset abdominal distention
    • weight loss with cardiovascular instability, e.g. postural heart rate changes
    • new onset of blood in diarrhoea or vomitus
  • Constipation with or without soiling
    • severe abdominal pain or vomiting with pain

Urinary

  • Urinary Incontinence and enuresis.
    • recent onset of polyuria/polydipsia that might suggest diabetes (mellitus or insipidus)
  • Recurrent Urinary Tract Infections (UTI)
    • acute infant  urinary tract infection presenting septicaemia or acutely unwell

Musculoskeletal

  • Acute joint pain with fever
  • Acute joint pain unable to weight bear.   

Cardiac

  • Chest pain with haemodynamic compromise or history of cardiac disease
  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

Allergies

  • Anaphylaxis
  • Allergic reaction where there are any respiratory or cardiovascular symptoms or signs
  • Reaction to peanut or other nut should be referred to Emergency as these reactions can progress rapidly and should be observed and assessed in Emergency
  • Exposure to a known allergen with a previously identified potential for anaphylaxis in this patient even if the reaction appears currently mild
  • Severe angioedema of face

Growth concerns

  • Faltering growth (failure to thrive in children < 6 years)
    • severe malnutrition
    • temperature instability
    • cardiovascular instability – postural heart rate change
  • Short stature
    • possible CNS signs (visual disturbance, morning headaches)

Developmental concerns

  • Non verbal child with acute distress and unable to examine adequately for medical conditions causing pain  eg tooth abscess, bone infections or osteopaenic fractures

 

Behavioural concerns

  • Suicidal or immediate danger of self-harm
  • Aggressive behaviour with immediate threatening risk to vulnerable family members

Irritable Infant

  • Fluctuating or altered conscious level – weak cry, not waking appropriately for feeds, lethargy, maternal concern of failure of normal interaction
  • Suspicion of harm or any unexplained bruising, especially in infant <3 months
  • Significant escalation in frequency or volume of vomiting
  • New onset of blood mixed in stool
  • Fever
  • Increased respiratory effort
  • Weak or absent femoral pulses in infant <3 months
  • Presence of newly noted heart murmur in infant <3 months

 

Physical findings of concern in an infant <1 year

  • Inguinal hernia that cannot be reduced.
  • Painless firm neck swelling that is increasing in size.
  • White pupil or white instead of red reflex on eye examination.
  • Previously unrecognised intersex genitals (ambiguous as either virilised female or incomplete formation male eg bilateral absent testes).
  • Possible Infantile Spasms. This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old. 
  • Absent femoral pulses.
  • Infant <3 months with newly noted murmur and any of the following:
    • poor feeding
    • slow weight gain
    • weak or absent femoral pulses
    • post ductal (foot) oxygen saturation < 95%
    • respiratory signs (wheeze, recession or tachypnoea)

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)
    • vomiting
    • inability to eat (even if not vomiting)
    • abdominal pain
    • headache
  • 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)
    • 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)
    • 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)
    • 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

  • General referral information
  • Current height and weight, and include date of measurement
  • Fasting glucose  insulin U&E LFT FBC iron studies CRP TFT results
  • 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

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 family history
  • Other past medical history
  • Pregnancy and birth history
  • Immunisation history
  • Developmental history
  • Medication history
  • Allergies
  • Significant psychosocial risk factors (especially 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.