Referral to emergency

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.

  • nil

For clinical advice, please telephone the relevant specialty service.

Women's and Children's Health Network

Exclusions

  • exogenous obesity without co-morbidities where lifestyle modification measures have not been trialled

Triage categories

Category 1 - appointment clinically indicated within 30 days

  • nil

Category 2 — appointment clinically indicated within 90 days

  • obesity where an underlying medical or endocrine cause is suspected

  • obesity with associated significant comorbidities such as:

  • obesity in children < 5 years of age
  • PCOS

Category 3 — appointment clinically indicated within 365 days

  • obesity in children > 5 years of age without significant co-morbidities

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.

History

  • past medical/surgical history, including:
    • age of onset of obesity
    • developmental delay
    • previous growth parameters
    • diet and activity history
  • onset, duration, and progression of symptoms
  • current medications and dosages
  • allergies and sensitivities
  • family history, including obesity, bariatric surgery, cardiovascular disease, and diabetes
  • menstrual history, acne and hirsutism in girls (for PCOS)
  • management history including treatments trialled/implemented prior to referral
  • identification as Aboriginal and/or Torres Strait Islander

Examination

  • examination findings, including:
    • blood pressure (BP)
    • any complications of obesity e.g. sleep apnoea, type 2 diabetes, joint pain, liver dysfunction
    • dysmorphic features
    • acanthosis nigricans
  • height/weight/body mass index (BMI), including head circumference and growth charts with prior measurements if available

Investigations

Obesity complications
  • liver function test (LFT)
  • fasting lipids
  • glycated haemoglobin test (HbA1c)
PCOS
  • luteinizing hormone (LH)
  • follicle-stimulating hormone (FSH)
  • oestradiol
  • testosterone
  • sex hormone-binding globulin (SHBG)
  • free androgen index (FAI)
  • dehydroepiandrosterone sulphate (DHEAS)
  • morning 17-hydroxyprogesterone (17-OHP)
  • human chorionic gonadotropin test (Beta-hCG) if primary or secondary amenorrhoea

Additional information to assist triage categorisation

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.

Significant psychosocial risk factors, esp. parents mental health, family violence, housing and financial stress, department of child safety involvement.

Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

  • 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.
  • Significant psychosocial risk factors esp. parents mental health, family violence, housing and financial stress, department of child safety involvement.
  • Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

Clinical management advice

Obesity

Definitions

  • children > 2 years of age with a body mass index (BMI) > 95th centile for age and gender
  • children < 2 years with weight for length > 97th centile World Health Organisation (WHO) chart.

Referral to assess for an underlying pathological condition should be considered if:

  • obesity onset < 5 years of age
  • obesity associated with hyperphagia and/or dysmorphic features
  • history of developmental delay
  • height < 1st centile or falling height percentiles.

Referral should be considered if:

  • patient has failed first-line management outlined below
    • significant risk of type 2 diabetes
    • concerns of polycystic ovary syndrome (PCOS)

Children presenting with obesity associated co-morbidities:

  • obstructive sleep apnoea (OSA) consider referral to respiratory medicine
  • abnormal liver function tests (LFTs) consider referral to paediatric medicine or Abnormal Liver Function - Hepatology
  • hypertension to paediatric medicine, nephrology or urology
General Practitioner management
  • counselling on diet, exercise and reducing screen time
  • consideration of health care plan to access dietitian/exercise physiologist/psychologist
  • consider commencing metformin if child > 10 years. Start at a dose of 500 mg daily. Titrate dose up weekly by 500 mg to a maximal dose of 1000 mg twice daily, or as tolerated.

PCOS

A diagnosis of PCOS can be considered in adolescents who are > 2 years post menarche and requires the following:

  • irregular menstrual cycles (shorter than 21 days or longer than 45 days)
  • clinical or biochemical evidence of hyperandrogenemia: severe acne, hirsutism, high androgen levels.

Pelvic ultrasound is not required as it is not helpful in the diagnosis of PCOS in adolescence.

General Practitioner management
  • do NOT start oral contraceptive pills (OCP) until investigations are performed
  • start a menstrual calendar
  • consider health care plan for dietitian/exercise physiologist and commencing metformin if obese.

General information

Contact Women’s and Children’s Hospital (WCH) endocrinology on-call on (08) 8161 7000 for advice or to escalate and discuss any clinical concerns.

Recent pathology results will be required prior to outpatient appointment. Consider providing repeat pathology form to patient at time of referral.

Patients who have previously been seen by a specialist are encouraged to be referred back to their care for further review if required.

Clinical resources

Consumer resources

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 General Practitioners role 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 General Practitioner once the transfer of care has occurred.