REFERRAL GUIDELINES
FOR PAEDIATRIC CARDIOLOGY OUTPATIENT
CLINICS
Version Control
Version
number
1
2
3
4
5
6
Purpose / Changes
Author/Editor
Date
Initial version for Clinical
Reference Group to
amend
Amended following
comments from Clinical
Reference Group
Amended following
comments from Clinical
Reference Group
Amended following
email comments from
group
Kawasaki guidelines
added and patient leaflet
included
Amendments made
following consultation
with Paediatric
Cardiology Network
members
Jonathon Parsons
24.06.09
Ruth Lund
15.07.09
Ruth Lund
21.10.09
Ruth Lund
28.10.09
Ruth Lund / Fiona
Willcoxson
23.11.09
Ruth Lund
30.11.09
Page 1 of 8
These guidelines should be read in conjunction with the Yorkshire and Humber patient
pathway diagram for children and young people with a suspected cardiac anomaly
(Appendix 1).
Referral pathways
Emergency
Emergency referrals should be made directly to the tertiary paediatric cardiology unit
(Level 3 on the pathway diagram) after assessment and initial management in the
outreach hospital.
Routine
These should be considered for assessment by a Paediatrician or team with expertise
in Paediatric Cardiology in a Level 2 clinic before being referred to Level 3.
Types of patients seen
Patients generally belong to the following categories:
 Prenatal diagnosis
 Follow up of previously diagnosed congenital heart defects either in the tertiary unit
or at the outreach hospital
 Follow up management of arrhythmias
 Follow up of post-operative cardiac surgical or intervention patients
 Referrals from GPs, paediatricians, community paediatricians, nurse specialists
(these referrals should be made to a Paediatrician with expertise in Paediatric
Cardiology).
Prenatal diagnosis
If prenatal diagnosis of a congenital heart defect has been made, then either the
baby will need to be transferred to the tertiary unit or booked into the outreach
paediatric cardiology clinic, as appropriate. Discussions need to take place with the
tertiary centre about the location of delivery of the baby. If the baby is delivered locally
in the outreach hospital, the baby will require evaluation after delivery and discussions
with the tertiary unit will be necessary for transfer or for booking into the outreach
paediatric cardiology clinic, as appropriate.
Page 2 of 8
Neonates and young infants up to 8 weeks
Previously unsuspected congenital heart defect in a newborn with a murmur and
otherwise clinically well:
1. These babies need a review before discharge, including saturation monitoring. If
the murmur is assessed as representing a significant risk of congenital heart disease,
or there are other concerns such as desaturation (<95%), then the case will need to
be discussed urgently with the paediatric cardiology team at LGI.
2. Babies with a murmur ought to be reviewed at 5 to 7 days by a paediatrician
(including saturation monitoring) unless an experienced clinician can confidently
assess them as being at low risk of having significant underlying congenital heart
disease, in which case outpatient follow up should be arranged in 4 to 6 weeks.
The information in appendix 3, along with a verbal explanation should be given to
parents of all babies with a murmur. Clear instructions and guidance should be given
to the parents and GPs if there are clinical concerns.
3. If there is a persistent murmur which is felt to be consistent with congenital heart
disease at the 5 to 7 day review, then the baby should be booked into the local Level 2
paediatric cardiology clinic. The baby should follow the pathway outlined in Appendix
1.
N.B. If the echocardiogram performed locally shows a cardiac defect which is unlikely
to be haemodynamically significant, such as a small atrial septal defect, patent arterial
duct or ventricular septal defect, or a minor degree of outflow obstruction, then the
baby should be reviewed in 4 to 10 weeks in the Level 2 clinic.
Neonates and infants diagnosed with congenital heart defects will require
individual discussion between Levels 2 and 3 on a case by case basis.
Page 3 of 8
New referrals of older infants (> 8 weeks) and children
These referrals generally fall into the following categories:
1. Murmur felt significant enough to require diagnostic evaluation
2. Cyanosis
3. Chest pain
4. Palpitations
5. Syncope or dizziness
6. Referral for screening because of family history of congenital heart defect,
cardiomyopathy or other syndromes
7. Kawasaki disease
These patients should be seen by a paediatrician with expertise in paediatric
cardiology:
1. Murmur: This guidance should not exclude general paediatricians from assessing
the significance of the murmur. If the murmur is considered to be pathological, then
the child should be referred to Level 2 care. If an abnormality is suspected clinically or
found on the echocardiogram the patient should be referred to Level 3 as shown in
Appendix 1. Minor lesions, such as small ventricular septal defects, atrial shunts, or
mild pulmonary valve stenosis may be followed up in Level 2 if appropriate. Persisting
lesions should be reviewed within 1 year by the paediatric cardiologist (Level 3).
2. Cyanosis: Oxygen saturation should be checked. If there is evidence of central
cyanosis, then the patient should be discussed with the paediatric cardiologist.
3. Chest pain: Generally these patients and their parents require reassurance as to
the musculo-skeletal nature of the chest pain. The patients can be seen in a general
paediatric clinic. If a cardiac opinion is required, then they should be seen in the Level
2 clinic and investigations arranged if deemed necessary. If these are normal, then
only in exceptional cases should a referral be made to the Level 3 service, otherwise
the patient/parents can be reassured and discharged.
4. Palpitations: These patients should be seen in the general paediatric clinic and
investigations arranged. These may include ECG, 24-hour ECG tape, and, if indicated,
an echocardiogram and treadmill exercise test. If all these investigations are normal,
the patient can be discharged. If there is still doubt or if there is an abnormality found,
then the patient should be booked into the Level 2 clinic.
Page 4 of 8
5. Syncope or dizziness: Patients should be seen by a paediatrician in the general
paediatric clinic initially to find out whether the symptoms are cardiac or neurological in
origin and so that appropriate investigations can be arranged.
Such cases should be dealt with according to the DH Guidelines, which can be found
on the following webpage, listed under ‘Initial Treatment 4 - Care Pathway for
Children’.
http://www.dh.gov.uk/en/Healthcare/Coronaryheartdisease/DH_4117048
6. Referral for advice because of family history of congenital heart defects,
cardiomyopathy, and other syndromes: Services for Inherited Cardiac Conditions
are provided by Leeds Teaching Hospitals Trust and Sheffield Teaching Hospitals
Trust (in association with the Sheffield Children’s Hospital). These families can be
discussed with the ICC service at the discretion of the paediatrician, rather than being
referred to the paediatric cardiologist. Details of the Inherited Cardiac Conditions
Service can be found by going to the following website and clicking on the relevant
link:
http://www.yorksandhumberhearts.nhs.uk
1. Kawasaki disease:
Indications for early review during acute illness by Level 2:

Atypical Kawasaki’s

Pathological murmur

Pericardial effusion
Otherwise review at 10-14 days once over acute illness.
Continue aspirin until review with Level 2 at 6 weeks - if normal discontinue aspirin
and discharge from follow -up.
If abnormal, continue to review via shared care between paediatric cardiologist (Level
3) and Level 2 clinician.
Page 5 of 8
Children and young people diagnosed with congenital heart defects
Suitable follow up for these patients will be decided jointly between the paediatric
cardiologist and the paediatrician. Follow up will be dependant on the individual
patient and may take place in the general paediatric clinic, the Level 2 clinic or the
Level 3 clinic as appropriate.
Page 6 of 8
Appendix 1
Patient Pathway for Children and Young People with a
Suspected Cardiac Anomaly
Suspected cardiac
anomaly picked up by
by GP, general
paediatrician or
neonatologist
Most common reasons for
referral to Level 2:
• Murmur
• Cyanosis
• Chest Pain
• Palpitations
• Syncope or dizziness
• Family history of
Congenital heart disease
disease*or
or
ICC (i.e. to be screened)
Possible involvement from:
• Surgeons
• Cardiologists
• Specialist Technicians
• Paediatrician
PaediatricianswSI
wSIininCardiology
Cardiology
Discharge back to GP
LEVEL 2 CLINIC
Including diagnostic
tests and results
LEVEL 1 follow-up
(general paediatrician)
LEVEL 2 follow-up
(paediatrician or team
with expertise in
cardiology)
LEVEL 3
jointly agreed
diagnosis,
treatment and care
package
LEVEL 3
LEVEL 2
LEVEL 1
treatment and/or
follow up at Tertiary
Centre
management by
paediatrician or
team with cardiac
expertise in
Secondary Care
return to general
paediatrician
LEVEL 3 is specialist (Tertiary) level care and involves a paediatric cardiologist
LEVEL 2 is Secondary level care from a paediatrician or team with expertise in cardiology
LEVEL 1 is any other care at Secondary level
Page 7 of 8
Appendix 2
Information Leaflet for Parents / Carers of babies found to have a murmur
(embedded electronically – can be opened printed out as a trifold leaflet)
Appendix 3
List of working group participants:












Eva Stuwe; Paediatrician; Scarborough
Fiona Willcoxson; Paediatric Cardiologist; Leeds
Jane Allen; Sonographer; York
Jonathan Parsons; Paediatric Cardiologist; Leeds
Jo Quirk; Nurse Specialist; Leeds
Matthew Babirecki; Paediatrician; Airedale
Mike Fresson; Nurse Specialist; Leeds
Porus Bustani; Neonatologist, Sheffield
Rupal Patel; Paediatrician, Hull
Sam Bainbridge; Sonographer; Bradford
Sam Oddie; Neonatologist; Bradford
Sandeep Kapoor; Paediatrician; North Lincs and Goole
Page 8 of 8