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.

  • abdominal distention
  • bilious (green) vomiting
  • focal tenderness, guarding
  • gastric outlet obstruction
  • haemodynamic instability
  • overt rectal bleeding
  • peritonism
  • severe/uncontrollable abdominal pain
    • localised tenderness, guarding
  • severe diarrhoea, vomiting with symptoms of dehydration
  • suspected cauda equina syndrome
  • suspected intussusception

Please contact the paediatric medicine on-call registrar or relevant surgical or medical subspecialty to discuss your concerns prior to referral.

For clinical advice, please telephone the relevant specialty service.

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Women's and Children's Health Network

Regional Health Networks 

Eyre and Far North Local Health Network

Flinders and Upper North Local Health Network

Limestone Coast Local Health Network

Exclusions

  • constipation without a trial of clinical guideline recommendations prior to referral

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • constipation in an infant < 12 months old
  • constipation with concerning features including:
    • abnormal neurological features
    • causing significant pain and distress
    • previous abdominal surgery
    • significant co-morbidities
    • unintentional weight loss
    • obstructive defecation
    • suspected malignancy

Category 2 (appointment clinically indicated within 90 days)

  • associated significant behavioural problems
  • anal fissure
  • chronic constipation in child less than 4 years meeting the Rome IV criteria for functional constipation, see ‘clinical management advice’
  • soiling associated with day wetting

Category 3 (appointment clinically indicated within 365 days)

  • constipation in a child less than 4 years meeting the Rome IV criteria for functional constipation see ‘clinical management advice’
  • soiling not associated with faecal retention and overflow

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.

  • past medical history – please provide any relevant features as relating triage categories
    • surgical history especially relevant if previous abdominal surgery
    • blood in stools
    • failure to spontaneously pass meconium in first 48 hours of life
    • presence of concurrent enuresis or urinary dysfunction
  • infant feeding information – breast, formula, solids, dietary fluid, food intolerance
  • children over 12 months of age – diet history
  • medications and allergies
  • presenting symptom history including:
    • dates and frequency of symptoms
    • duration and severity of episodes
    • current management regime including medications and efficacy
    • history of abdominal pain including frequency, duration/level of disruption including emergency presentations
    • medication/treatment regimes used to date including duration and outcomes
    • stool frequency, consistency, frequency of soiling, presence of blood
    • stool withholding behaviour — pain, toilet refusal, hiding during defecation, anxiety and distress
    • association with day wetting
    • treatment trialled and response
  • height and weight
  • neurological examination findings
  • visual examination of rectum and sphincter findings
    • anal inspection for fissures/fistulae
    • digital rectal examinations are not routinely indicated and should only be performed if there is a clinical indication.
  • allied health reports/summaries and other medical specialist involvement if previous medical consultation completed 

Additional information to assist triage categorisation

  • body mass index (BMI) if child is aged ≥ 16 years
  • growth chart trends
  • bowel chart including Bristol stool chart
  • abdominal examination findings
  • quality of life concerns including
    • history of behavioural or psychological disturbance
    • missed work, school, extracurricular activities as a result
  • menstrual history if relevant
  • sexual history if relevant
  • family history of autoimmune disease, inflammatory bowel disease, immunodeficiency syndromes
  • pathology:
    • complete blood examination (CBE)
    • urea, electrolytes, creatinine (UEC)
    • liver function tests (LFTs)
    • c-reactive protein (CRP)
    • erythrocyte sedimentation rate (ESR)
    • iron (Fe) studies
    • coeliac serology
    • urinalysis
    • faecal calprotectin
    • faecal multiplex polymerase chain reaction (PCR)
    • stool microculture and sensitivities (M/C/S)
  • fructose/lactose breath hydrogen testing
  • abdominal ultrasound (US) if suspected mass
  • relevant diagnostic/imaging reports including location of company and accession number

Clinical management advice

Rome IV Diagnostic Criteria for Functional Constipation

Infants up to 4 years

Must include 1 month of at least 2 of the following or 2 or fewer defecations per week:

  • history of excessive stool retention
  • history of painful or hard bowel movements
  • history of large-diameter stools
  • presence of a large fecal mass in the rectum

In toilet-trained children, the following additional criteria may be used:

  • at least 1 episode/week of incontinence after the acquisition of toileting skills
  • history of large-diameter stools that may obstruct the toilet

Children greater than 4 years

Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:

  • 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
  • at least 1 episode of fecal incontinence per week
  • history of retentive posturing or excessive volitional stool retention
  • history of painful or hard bowel movements
  • presence of a large fecal mass in the rectum
  • history of large diameter stools that can obstruct the toilet

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.