Referral Pathways to specialist services

Referral pathways depend on local availability of services:

• Trauma cases will be referred to orthopaedics, day care units or emergency departments. Remember that trauma is common in young children; other pathology can be missed and if in doubt, refer. 
• The child with suspected inflammatory disease should be referred urgently to paediatric rheumatology. Do not wait for the results of investigations as they may be normal anyway. 
• The presence of red flags warrants urgent referral - likely to general paediatrics.
• Concern about normal variants (e.g., knock-knees, flat feet), may warrant referral - likely paediatric orthopaedics. 
• Unexplained pain, unresolving limp, systemic symptoms, or regression of motor milestones - all warrant referral - most commonly to general paediatrics or paediatric rheumatology. 
• Delay in walking, gait abnormalities, or any suggestion of weakness – warrant blood test for creatine kinase (CK), followed by a referral – most commonly to general paediatrics or paediatric neurology. Do not delay a CK test if there are concerns; refer even if blood tests or imaging are normal.
• 'Coca-cola-coloured’ urine may also suggest post streptococcal glomerulonephritis and urgent referral to general paediatrics or nephrology or rheumatology is warranted.
• Blood tests can be done in the paediatric day unit - do not traumatise the child (or yourself !) if you are not experienced in taking blood from children. 
• Do not hesitate to speak with a paediatrician on-call or a paediatric rheumatologist on-call if you are unsure of how urgently you should refer a patient or of the tests that need to be requested.