5 referral tips that won’t annoy a paediatrician #tipsfornewdocs

Paediatricians have a reputation for being ‘nicer’ than some other branches of medicine. This is probably unfair on the other specialties and more likely to represent the fact that referrals to paediatrics are almost universally accepted. This does not mean that less thought should go into a paediatric one though. In fact Paediatricians can be as unforgiving about poor quality referrals as anyone else (they just might not say so to you directly).

There are a few common bug bears that I thought would be worth sharing with health care professionals working in fields who may be referring to a Paediatric in-patient team. I do this in the context of a Paediatrician (who works in an Emergency Department) often making referral to other Paediatricians. I am sure there are many other points to add to the list but as a starter…

  1. Think before you speak

For any referral run through what you are going to say before you say it. Too often a junior after being told to refer an infant seen in an Emergency Department instantly picks up the phone and dials. This results in an incoherent story based on what the senior has told the junior about the child not what the paediatric team need to know about the child. If you can’t explain the reason for the referral in less than 15s then you haven’t got to grips with the case and probably don’t understand the reason for admission. This is a skill that requires practice and teaching. In August ask more experienced colleagues what they would say and get them to listen to you making referrals.

  1. Don’t confuse stridor and wheeze

Stridor is an inspiratory noise

Wheeze is generally an expiratory noise

Referring a child who you have said has croup but describe them as having only an expiratory wheeze is diagnostically mis-leading. There can be a mixed picture and if you are unsure – say so. During winter there will be a handful of children who it can take a while to work out the primary cause of their respiratory distress. Precision in terminology is a good sign you are able to risk assess correctly. And with that in mind…

  1. Don’t say “I’m worried this well-looking child with a non-blanching rash has meningitis

The primary concern in children with a non-blanching rash is meningococcal septicaemia. They may have meningitis as well but this is not the primary concern. While it is not unreasonable for parents to use one term to cover both a physical sign and a disease process this is not case for the medical profession.

Meningitis: Inflammation of the meninges (can be viral or bacterial)

Meningococcus: The organism Neisseria Meningitidis (a gram negative bacteria). Meningococcus in the blood is the cause of petechiae and subsequently purpura, the non-blanching rash, tested for with the glass test.

Meningococcal disease: Infections (both septicaemia and meningitis) caused by meningococcus.

  1. You may miss seeing the signs of tonsillitis but you must have at least looked for it. 

There is a spectrum of tonsillar appearance and I suspect even between experienced paediatricians there is variation in how much pus or spotting constitutes tonsillitis. In fact disease progression may mean in between General Practice referral and eventual arrival on the wards an exudate may have appeared.

However the answer to:

“Have you looked in the throat?”  should never be “no

Click here for a quick guide on how to look in the throat of a child.

  1. Always, always take a good constipation history in children with abdominal pain

Does your child have constipation?” is not taking a constipation history….

You need to define regularity of bowel habit and its appearance.

Normal‘ is not an appearance. A description is important and in my experience children old enough to speak get the giggles talking about ‘sausages’ or ‘little round balls’ which helps engagement.

Passing a motion should not be painful. It is surprising how often a parent only finds out their child has severe discomfort on the toilet when someone else asks the question. Some more thoughts on constipation on childhood here

I hope these 5 points are helpful, as I say I am sure there are more, and I hope to add to this over time. Please, please never be afraid to ask for advice when dealing with children. Thinking through the question though will always be in the child’s best interest.

All the best

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4 thoughts on “5 referral tips that won’t annoy a paediatrician #tipsfornewdocs”

  1. * post release note:

    The ever observant @HSB42 makes a point that point 2 and 4 may be incompatible (you shouldn’t look into the throat of a stridulous child.) This is a good point and represents the grey, rather than black and white nature of medicine. There is no absolute but junior staff should certainly seek advice on examining the throats of child they perceive to be unwell with potential airway comprise. In the same vein an expert team will be able to cannulate a child with potential epiglottis with causing additional distress. It’s having the appropriate skills, tools and appropriate risk assessment that is key.
    A great addition to the discussion 🙂

  2. Damian,

    With regard to your point 2, I think it is much easier for folk to keep their thinking clear if they work out, anatomically, where the noise is coming from. The thing is that we’ve all seen expiratory (or biphasic) stridor, and you can hear wheeze on inspiration.
    I find it helpful to think of wheeze, stridor and stertor – the last of which doesn’t get taught much outside of ENT circles but is particularly common in children with complex neurodevelopmental problems. It helps, when discussing this, that I can do impressions of stridor and stertor but not, without pharmacological manipulation, wheeze. So you do the impression, point to where you think the sound is coming from – and then that gives you what you need to think about…
    Lastly, I don’t see many people doing it, but the stethoscope held gently near the mouth is very helpful indeed to hear soft stridor in a child who has been mostly “fixed” by the preceding clinician…


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