Nutritional and Weight Concerns - Paediatric CPC

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

• Women’s and Children’s Hospital (08) 8161 7000

Exclusions

• anaemia or iron deficiency secondary to haematological, renal, dietary, physiological or gynaecological cause, refer to Iron Deficiency — Paediatric Medicine CPC
  
• intentional weight loss or body dysmorphia, consider referral to Statewide Paediatric Eating Disorder Service
  
• isolated low serum ferritin without anaemia, nutritional or weight concerns
  
  • 3-month trial of adequate iron supplementation – consider coeliac screening and holotranscobalamin if unresolved
    
• normochromic, normocytic anaemia with normal iron studies
  
• weight loss in the neonatal period, refer to Neonatal/Infant Presentation — Paediatric Medicine CPC
  
• failure to thrive in the absence of specific gastrointestinal symptoms and positive coeliac serology, refer to Faltering Growth/Failure to Thrive — Paediatric Medicine CPC

Triage categories

Category 1 (appointment clinically indicated within 30 days)

• ≥ 5% unexplained weight loss in past 1 month or ≥ 10% unexplained weight loss in past 6 months with any of the following:
  
  • features of inflammatory bowel disease, see also Inflammatory Bowel Disease — Paediatric Gastroenterology CPC
    
  • features of coeliac disease, see also Coeliac Disease — Paediatric Gastroenterology CPC
    
  • > 4 weeks of vomiting and/or diarrhoea
    
  • evidence of fat malabsorption
    
  • low serum albumin
    
  • severe malnutrition (body mass index Z-score of -3) with underlying cause or contributing factors warranting specialist review
    
• severe, unexplained iron deficiency anaemia (haemoglobin (Hb) < 90g/L)

Category 2 (appointment clinically indicated within 90 days)

• rate of weight gain significantly below that expected for age and sex, or weight decreased ≥ 2 major percentile lines despite paediatric dietetic intervention for nutrition support (referral should be made from paediatrician)
  
• recurrent, unexplained iron deficiency with or without anaemia, despite appropriate trial of oral iron therapy. See Royal Children’s Hospital Melbourne - Iron Deficiency Clinical Practice Guideline regarding oral iron replacement.

• recurrent vitamin B12 deficiency

Category 3 (appointment clinically indicated within 365 days)

• nil

Essential referral information

Completion required before first appointment to ensure patients are ready for care. 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.

• details of presenting condition including:
  
  • onset and duration of symptoms
  • frequency and severity of symptoms
    
• medical management to date / treatment trialled and response
  
• clinical history including:
  
  • current weight and length or height, with percentiles
    
  • growth chart trends including at least two weight measurements, with percentiles
    
  • any weight loss, including amount and timeframe
    
  • medical history, medications, allergies, immunisations
    
• investigations including:
  
  • full blood count (FBC)
    
  • haematinics (iron studies, red blood cell count, folate, active vitamin B12 – holotranscobalamin), if suspicious of malabsorption, child has a restricted dietary intake, vegan or vegetarian diet
    
  • coeliac serology: tissue transglutaminase immunoglobulin A (TTG IgA), total IgA (where possible) with or without anti-endomysial antibody (EMA), if infant is on solids or feeds contain gluten
    
  • faecal multiplex polymerase chain reaction (PCR)
    
  • stool microscopy and culture (MCS), ova cysts parasites (OCP)

Additional information to assist triage categorisation

• paediatrician report
  
• urinalysis, microscopy and culture, especially infants < 12 months of age as occult urinary tract infection can present with slow weight gain
  
• electrolytes, urea and creatinine (EUC)
  
• thyroid stimulating hormone (TSH)
  
• liver function test (LFT) results
  
• random glucose
  
• presence of fat globules and/or fatty acid crystals on stool microscopy
  
• faecal elastase
  
• C-reactive protein (CRP)
  
• erythrocyte sedimentation rate (ESR)
  
• faecal calprotectin result (in children aged ≥ 4 years)
  

Clinical resources

• Royal Children’s Hospital Melbourne – Iron Deficiency Clinical Practice Guidelines

Reason for request

• to establish a diagnosis
• for treatment or intervention
• for advice and management
• for specialist to take over management
• for a specified test/investigation the General Practitioner cannot order
• for other reason (e.g. rapidly accelerating disease progression)
• transfer of care from another tertiary service
• clinical judgement indicates a referral for specialist review is necessary.

Patient 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

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.
• Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
• Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  
• 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 pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
• All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.

Adolescents transitioning from paediatric to adult specialist services require a formal handover from paediatric specialist clinician to adult specialist clinician as well as a formal referral from the referring specialist to ensure initial transfer of care is completed.

The role of the referring clinician (e.g. General Practitioner, Nurse Practitioner) in this process is to provide support to patients as part of holistic care. All ongoing referrals to specialists can subsequently be provided by the referring clinician once the transfer of care has occurred.