REFREC018
PAEDIATRIC SURGERY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
Signs and symptoms by anatomical
site:
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Abdomen
Anal
Chest
Genitalia
Head and neck
Inguinal and scrotal
Limbs
Skin and subcutaneous
Urinary tract
Evaluation
Thorough history and physical
examination is required to determine
the specific diagnosis (see below).
Child Development or Health
Development Record.
Management Options
Specific treatments depend on the
specific diagnoses, as noted below.
Referral Guidelines
Circumstances for referral are
indicated below with reference to the
appropriate specialty/specialties and
degree of urgency (category).
It should be noted that local access to
this service is variable and should be
taken into account when the referral is
made, particularly acute situations.
Cross reference to both treatment and
first assessment clinical priority access
criteria should be made. In situations
of acute referral, note category 1
treatment clinical priority access
criteria (CPAC).
In category 1 situations, telephone
contact to the appropriate service is
essential.
Last updated February 2006
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REFREC018
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Abdomen
Standard history and examination.
Epigastric Hernia.
Standard history and examination.
Category 4 (OPC) – increases in size.
Pain on exercise.
Abdominal Pain – Acute.
Standard history and examination.
Refer immediately if suspected serious
pathology – Category 1 (ED).
Abdominal Pain – Chronic.
Standard history and examination.
Differential diagnosis will include:
Abdominal Pain – Chronic (Continued).
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Constipation.
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Non specific abdominal pain of
childhood.
 Urinary tract infections.
Investigations: consider abdominal
Reassurance of parents because most
resolve by 3 y.o..
Large defects greater than 2 cm with
enlarging sac should be referred at 1
year – Category 4 (OPC).
Other smaller defects at 3 years –
Category 3 (OPC).
Umbilical Hernia.
Constipation – dietary advice,
laxatives, bowel retraining.
Urinary tract infection – antibiotics as
appropriate according to sensitivities.
Further investigation according to age.
Refer those children with persistent
symptoms longer than 2 weeks –
Category 3 (OPC). If serious
pathology is suspected, refer urgently
– Category 2 (OPC).
x-ray, MSU, stool examinations.
Consider ultrasound if abdominal mass
suspected.
Suspected Gastro-oesophageal
Reflux.
See Paediatric Medicine referral
recommendations.
Swallowed Foreign Bodies.
History of batteries.
Excessive salivation.
Note: Foreign bodies that pass
cricopharyngeus will almost certainly
pass through the GI tract. This
includes sharp objects such as needles
and pins and ends of thermometers.
Ingested Caustic and Acid Substances.
Last updated February 2006
Reassurance.
Review urgently with vomiting or
abdominal pain- Category 1 (ED)
Refer immediately those with ingested
batteries or signs of obstruction, eg
excessive salivation – Category 1
(ED).
Do not induce vomiting. Make nil by
mouth.
Immediate referral to paediatric
surgical service at Princess Margaret
Hospital.
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Standard history and examination.
Urgent referral – Category 2 (OPC).
Otherwise well
If unwell – Category 1 (ED) to Princess
Margaret Hospital
Delayed Passage of Meconium.
Timing of meconium passage.
If no passage of meconium within first
24 hours in a term baby, immediate
referral to paediatric surgical service –
Category 1 (ED).
Constipation – less than 1 month of
age.
Standard history and examination.
Abdominal distension?
Vomiting, especially bile stained?
If either present – refer.
Refer urgently if there is abdominal
distension and/or vomiting – Category
1 (ED). Immediate referral to Princess
Margaret Hospital.
Constipation – more than 1 month of
age.
Standard history and examination.
Abdominal Mass.
Last updated February 2006
Constipation – dietary advice,
laxatives, bowel retraining.
Refer those children with persistent
symptoms longer than 3 months. If
serious pathology is suspected, refer
urgently – Category 2 (OPC)– to
paediatric surgical service.
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Anal
Bleeding.
Standard history and clinical
examination.
Fissure-in-a no standard conservative
management.
Degree of bleeding.
Bleeding with abdominal symptoms,
especially infants – refer urgently –
Category 1 (ED) to Princess Margaret
Hospital.
Bleeding with diarrhoea which persists
– seek paediatric advice.
Associated symptoms, eg diarrhoea,
mucus, abdominal pain, pain on
defaecation, abdominal distension.
Refer cases after 4 weeks of
conservative management as semi
urgent – Category 3 (OPC).
Age of patient.
Note: Rectal bleeding in children is
not usually associated with
malignancy.
Chronic bleeding per rectum greater
than 3 months – refer routinely to
paediatric surgical service – Category
4 (OPC).
Perianal Abscess.
Immediate referral Category 1 (ED) to
paediatric surgical service.
Fistula-in-ano.
Routine – Category 4 (OPC).
Rectal Prolapse.
Last updated February 2006
Internal haemorrhoids are extremely
rare in children.
Laxatives if associated with
constipation.
Routine referral – Category 4 (OPC).
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Chest
Chest Wall Deformities.
Standard history and examination with
particular reference to underlying
respiratory disease.
Investigation: Chest x-ray based on
underlying respiratory disease.
Most chest wall deformities should be
referred to paediatric surgery.
Note: Most cases of pectus excavatum
and carinatum resolve spontaneously
with time. Surgery is not undertaken
until puberty and is for cosmetic and
pulmonary reasons. Early referral is
not required unless for reassurance
and information.
Inhaled Foreign Body.
Careful history. Any young child with a
history of a coughing fit while ingesting
food or mouthing any other small
object requires immediate referral.
Immediate referral to Princess
Margaret Hospital – Category 1 (ED).
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Genitalia
Phimosis/Paraphimosis.
No problem if good urinary stream. A
large percentage of foreskins are fused
to the glans and will separate
spontaneously over a number of
months or years. There is no
necessity to retract or be able to retract
the foreskin (at least before 7 years of
age).
Ballooning with micturition frequently
occurs and is acceptable providing
there is a good urinary stream.
Social/Religious Circumcisions.
Hypospadias.
Last updated February 2006
Phimosis:
Indications for referral:
 Inability to retract after the age of
5.
 Recurrent balanitis.
 Pinhole prepucial orifice with very
poor urinary stream.
 Refer routinely – Category 4
(OPC).
Paraphimosis:
Refer immediately – Category 1 (ED).
Make referral Category 4 (OPC).
Do not circumcise.
Refer at diagnosis routinely – Category
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Urethral Meatal Stenosis.
Evaluate adequacy of urinary stream.
3 (OPC) – to paediatric surgery.
Refer immediately if poor urinary
stream – Category 1 (ED).
Usually neonatally circumcised boys.
Refer semi-urgently – Category 3
(OPC).
Evaluate urinary stream.
Balanitis.
Accumulation of smegma under the
foreskin is common and normal, but
can be mistaken for pus. Referral
and/or intervention is not required. It
will continue to extrude spontaneously
until all the prepucial adhesions have
disappeared. Foreskin retraction and
cleaning is not necessary.
Frank infection requires treatment with
oral antibiotics (eg cotrimoxazole) and
surgery if it is recurrent.
Recurrent balanitis – refer routinely, as
above – Category 4 (OPC).
Fused Labia.
Refer routinely – Category 4 (OPC).
Other Genital Anomalies.
Refer routinely Category 3 (OPC) to
paediatric surgical service.
Last updated February 2006
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Head and neck
Enlarged Lymph node/s.
Standard history and examination:
 Exclude hepatosplenomegaly.
 Exclude infective focus, eg skin
infection, tonsillitis.
 Family history of TB.
 Overseas exposure.
 Consider Cat Scratch disease.
 Consider Atypical TB
Investigations:
 Consider FBC ESR
 Consider Paul Bunnell.
 Consider Mantoux.
 Consider toxoplasmosis titre.
Manage underlying condition,
particularly infection.
Observation for six weeks is
appropriate for most enlarged lymph
nodes <3cm in size.. If unresolved,
refer urgently Category 2 (OPC) to
paediatric surgical service.
Note: FNA is not routinely indicated in
children.
Other Lumps/Sinuses/Skin Tags.
Standard history and examination.
Abscesses.
Standard history and examination.
Tongue Tie.
Key feature – inability to protrude
beyond inferior gingival margin.
Routine referral – Category 4 (OPC)
unless infected- Category1 (ED) or
thyroglossal cyst- Category 2 (OPC) .
Drain abscess.
Routine referral – Category 4 (OPC).
Routine referral – Category 4 (OPC)
unless there is respiratory obstruction,
in which case Category 1 (ED).
Intra oral conditions not related to
teeth, eg ranula, lingual thyroid
haemangioma, mucous retention cyst.
Sternomastoid Tumour (congenital
muscular torticollis).
Immediate referral – Category 1 (ED).
Standard history and examination.
Consider other evidence of postural
deformity such as head shape,
unstable hips etc.
Passive stretching by parent, eg lie
child on abdomen and turn head to the
opposite side.
Refer Category 2 (OPC) to Paediatric
Surgical service.
Check by GP on a regular basis.
Alternatively, physiotherapy education.
Last updated February 2006
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Inguinal and Scrotal
Inguinal and/or Scrotal Swellings.
Non acute herniae and hydrocoeles
can be difficult to differentiate in
children. It is important to recognise a
hernia in a child under the age of 3
months.
If varicocoele is suspected, refer as per
hernia recommendation.
Child under 3 months with Hernia or
uncertain diagnosis:
Refer urgently – Category 2 (OPC) – to
paediatric surgical service.
Herniae over the age of 3 months:
Refer semi-urgently- Category 3 (OPC)
to paediatric surgical service.
Difficult Hernia:
Any hernia that is reduced with
difficulty is at significant risk of
strangulation and should be referred
urgently – Category 2 at PMH (ED) –
irrespective of age.
Hydrocoele:
If a hydrocoele is confidently
diagnosed, it can be treated
expectantly. If it persists past the age
of 2 or causes symptoms or grows
rapidly, it should be referred routinely –
Category 4 (OPC).
Acute Scrotal Pathology.
Undescended Testis.
Last updated February 2006
Epidydimo-orchitis is uncommon in
children and should not be diagnosed
clinically.
The following conditions are included:
 Torsion of testis.
 Torsion of appendix of testis.
 Strangulated hernia.
 Incarcerated hernia.
 Idiopathic scrotal oedema.
 Henoch Schonlein purpura.
Risk of infertility if orchidopexy is
delayed increases with age. It is now
recommended that orchidopexy should
be performed by the age of 1 year.
An undescended testis is one that
Scrotal Pain with or without swelling:
Refer immediately – Category 1 (ED)
to paediatric surgical service.
Refer from the age of 3 months to
paediatric surgery – Category 4 (OPC).
In a clinically obvious associated
hernia, they should be managed as
hernia referral recommendation.
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cannot be manipulated into the bottom
of the scrotum. All testes should be
situated within the scrotum by the age
of 3 months.
Retractile Testis.
Diagnosis / Symptomatology
Retractile testes are not normally
situated within the scrotum, but can be
manipulated into the scrotum. The
current recommendation is that they be
fixed in the scrotum surgically if they
remain retractile after the age of 2.
Evaluation
Refer routinely at the age of 2 to
paediatric surgery – Category 4 (OPC).
Management Options
Referral Guidelines
Limbs
Cellulitis/Myositis.
Blood culture + full blood count.
Culture and antibiotic sensitivity test if
pus available.
Polydactyl/Syndactyl.
X-ray of foot or feet as appropriate.
Ingrown Toenail.
Last updated February 2006
Intravenous antibiotics.
Refer to paediatric surgical service –
Category 1 (ED).
Refer to paediatric plastic surgical
service – Category 4 (OPC).
Treat with antibiotics when infected.
Surgical treatment differ in infants and
older children.
Refer to paediatric surgical service –
Category 4 (OPC).
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Skin and Subcutaneous
Skin Lesions/Cysts/Sinuses.
Refer to paediatric surgical service –
Category 4 (OPC).
Subcutaneous Mass.
Refer to paediatric surgical service –
Category 4 (OPC).
Molluscum Contagiosum.
Prick the head of the lesion with needle
or forceps.
Refer if unresolved – Category 4
(OPC).
Viral Warts.
Podophyllin application.
Refer if unresolved – Category 4
(OPC).
Treat with antibiotics until fluctuation
present.
Refer to paediatric surgical service –
Category 1 (ED).
Abscess.
[c.f. Head and Neck].
Drain abscess.
Refer to paediatric surgical service –
Category 4 (OPC).
Pigmented Skin Lesions. This will
include:
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Strawberry Naevus.
Venous Malformation.
Cafe-au-lait Spots.
Giant Hairy Naevus.
Male Gynaecomastia.
Common in peri-pubertal boys.
Sacral Sinus.
Spina Bifida Occulta
This will include:
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Hairy patch in sacral area.
Cystic or firm mass.
Last updated February 2006
X-ray of sacral spine.
Spinal Ultrasound if <1 month old
Reassurance.
Analgesics if painful.
Refer if not resolving or causing
symptoms, ie pain, tenderness or
itchiness – Category 4 (OPC) – to
paediatric surgical service.
Do not instrument.
Antibiotics if infected.
May need surgical treatment.
Refer to paediatric surgical service –
Category 4 (OPC).
Refer for investigation and treatment –
Category 3 (OPC) – to paediatric
surgical service.
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Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Urinary Tract
Antenatally Diagnosed
Hydronephrosis.
Applies to hydronephrosis at any
gestation. Post natal examination for
abdominal mass. Put on prophylactic
antibiotics Ultrasound after 5 days of
age and MCU.
LMC has responsibility to ensure GP is
informed.
Urinary Tract Infection
Many urological abnormalities will
present as a urinary tract infection.
These include:
Evaluation or urinary tract infections:
The diagnosis of UTI requires great
care and skill.
Clear evidence of UTI is essential.
Note: Guidelines: Diagnosis of UTI in
Children attached.
Urine results must be provided with the
referral.
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Vesicoureteric reflex.
Pelvi-ureteric junction obstruction.
Vesicoureteric junction obstruction.
Primary Mega-ureter.
Neurogenic bladder.
Duplex system +/- ureterocoele.
Posterior urethral valves.
Neurogenic Bladder.
Referral to paediatric surgery if
dilatation is present – Category 2
(OPC).
Note: Majority of urinary abnormalities
present as either UTI or as
hydronephrosis following antenatal
ultrasound. Most require referral to a
paediatric centre for evaluation.
Start antibiotics pending culture report.
Five day course. Consider long term
surveillance and prophylactic
antibiotics until investigations are
completed.
Treat constipation, toileting hygiene.
Refer recurrent urinary tract infections.
Routine Category 4 (OPC).
Investigation:
With reference to local
recommendation.
Check for spinal abnormality, ie mass
or spina bifida occulta. Exclude
constipation.
Refer for assessment patients with
abnormal imaging results or if requiring
investigations noting local
recommendations. Routine Category 3
(OPC). If imaging shows obstruction
and infection – Category 1 (ED) at
PMH.
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Treat constipation.
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Long term antibiotics.
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Clean intermittent catheterisation.
Refer to paediatric surgery at PMH if
diagnosis suspected – Category 3
(OPC).
Regular urine check ups.
Last updated February 2006
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