Pediatric Endocrinology Consult and Referral Guidelines

Transcription

1 Pediatric Endocrinology Consult and Referral Guidelines Diagnosis/Symptoms Page Diabetes New Onset Referral.. 2 Transfer Referral 2 Growth Disorders Short Stature or Failure to Thrive. 3 Tall Stature 4 Obesity 5 Pubertal Disorders Precocious Puberty. 6 Early Childhood Breast Development 7 Delayed Puberty 8 Premature Menses. 9 Thyroid Disorders Congenital Hypothyroidism.. 10 Acquired Hypothyroidism (Hashimoto s Thyroiditis). 11 Acquired Hyperthyroidism (Grave s Disease). 12 Goiter 13 Calcium Disorders 14 Hypoglycemia 15 Adrenal Insufficiency.. 16 Co-management Guidelines CONTACT US: To make an urgent referral or if you have additional questions regarding these referral guidelines, please contact us through HDVCH Direct by calling and you will be connected with the Endocrinologist on call. Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 1

2 Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Diabetes New Onset Referral Urgent referral recommended for New Onset Diabetes. Call HDVCH direct 1 (877) Diabetes Transfer Referral Patients transferring diabetes care to HDVCH Endocrinology typically scheduled for next available office appointment Fax referral to clinic or History and physical exam: Height, weight, BMI Symptoms : history of excessive thirst or urination, weight loss, vomiting, abdominal pain, or fatigue and other significant history Labs: A1C Urine and or serum Ketones Blood glucose(fasting, random) History and physical exam: Height, weight, BMI Last known insulin regimen Labs: A1C Ketones Blood sugar (fasting, random) If any of the following: Hemoglobin A1C 6.5% or greater Positive urine or blood ketones and fasting blood sugar = 126 or greater Random blood sugar 200 or greater with symptoms of diabetes For Type 2 Diabetes co-management guidelines, please click here or reference page 19. Growth chart Relevant laboratory studies Previous physician notes Growth chart Relevant laboratory studies Previous physician notes History Physical exam Evaluation of growth labs if available Point of care testing: Hemoglobin A1c, blood sugar, urinalysis Other labs may be necessary: TSH, Free T4, Total IgA, GAD-65, IA-2, Transglutaminase IgA History Physical exam Evaluation of growth labs if available Point of care testing: Hemoglobin A1c, blood sugar, urinalysis Other labs may be necessary: TSH, Free T4, lipid panel, Transglutaminase IgA Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 2

3 for Growth Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Short Stature or Failure to Thrive Note: Linear growth is better evaluated after age 2 years. Please consider a referral to Nutritional Services or the Intensive Feeding Program in a child with poor weight gain in the face of normal linear growth. Exceptions include infants with midline abnormalities or males with hypospadias or cryptorchidism History and physical exam: TSH Free T4 CMP (Comprehensive Metabolic Panel) CBC, ESR IGF-1 IGFBP3 Karyotype for Turners, 30 cell count (in all girls) Transglutaminase IgA IgA level RADIOGRAPHIC STUDIES: Bone Age Strongly recommend referral if child is > 2 years old and growth velocity less than 4 cm a year for greater than 1 year. If after age 3, crossing centile downward Child is growing more than 2 centile lines below midparental height* centile, with a non-delayed bone age Child is less than 3rd percentile in height Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring bone age X-ray to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth labs if available Monitoring of interval growth *Midparental height (boy) in inches = (Mother s height + Father s height)/ *Midparental height (girl) in inches = (Mother s height + Father s height)/2-2.5 Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 3

4 for Growth Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Tall Stature History and physical exam: TSH Free T4 CMP (Comprehensive Metabolic Panel) CBC Growth Hormone IGF-1 Karyotype Bone Age Child is > 2 years old and is greater than 97 th percentile for height and greater than 2 centile lines above midparental height centile Child is > 2 years old and progressively crossing centiles for height Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring bone age X-ray to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth Monitoring of interval growth Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 4

5 Obesity We recommend referral to endocrinology for children with BMI greater than 99% tile and less than 3 years of age. If older than 3 years and younger than 17 years consider referral to the Helen Devos Childrens Hospital Healthy Weight Center. The clinic can be reached at Before referral to this program, please follow American Academy of Pediatrics guidelines for stage I and stage II treatment of obesity in children. The healthy weight program is only for motivated patients. Referring provider s initial evaluation and History and physical exam: I. Laboratory evaluation a. Fasting (at least 8 hours) comprehensive metabolic panel b. Hemoglobin A1c c. Urine analysis d. Fasting lipid panel (at least 8 hours), or non-fasting Total & HDL-cholesterol e. See also co-management guidelines of lipids, screening of T2DM and PCOS II. Formal nutritional consultation (see referral options on separate sheet) a. 3 5 day diet diary evaluation and calorie count b. On-going continuity of care and follow-up with a nutritionist. III. Establishment of a regular exercise regimen (see referral options on separate sheet) When to initiate referral: Less than 3 years of age Clear evidence of endocrine disorder Secondary causes of obesity (e.g. genetic syndromes such as Prader-Willi Syndrome), are evident or strongly suspected Poor linear growth or short stature in comparison with excessive weight gain Short history (< 12 months) of marked weight gain History of brain injury, brain tumor, CNS disease Suggestive phenotypic features (developmental delay, significant obesity beginning before 3 years of age) When an obesityrelated complication such as type 2 diabetes mellitus has been confirmed. What can referring provider send? Essential: o Prior growth data/growth o Relevant laboratory studies o Pertinent medical records Results of any additional tests exam, evaluation of growth labs if available Imaging studies may be necessary For Type 2 Diabetes or Lipid Management guidelines, please click here or reference pages For Weight Management resources, please click here or reference page 20. Our providers appreciate having the information ahead of time. Please provide relevant clinical notes, labs, X rays and a growth chart. Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 5

6 for Pubertal Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Precocious Puberty History and physical exam: Please include Tanner staging LH by ECL (Electrochemiluminescence) at Esoterix specialty laboratory (CPT code 83002) FSH Testosterone (males and virilized females) Estradiol, ultrasensitive assay (esoterix code )in females and boys with gynecomastia TSH Free T4 DHEAS, 17 OH Progesterone RADIOGRAPHIC STUDIES: Bone Age Breast development or pubic hair in girls <8 years old Testicular enlargement (3 cc or >2.5 cm), increased penile size, or pubic hair in boys <9 years old Linear growth increasing, with advanced bone age Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring bone age X-ray (actual film or CD) to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth Imaging studies may be necessary Our providers appreciate having the information ahead of time. Please provide relevant clinical notes, labs, X rays and a growth chart. Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 6

7 for Pubertal Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Early Childhood Breast Development Palpable breast buds in girls less than 24 months of age is not uncommon and usually not of concern. History and physical exam (girls): LH, by ECL at Esoterix specialty laboratory (CPT code 83002) FSH Estradiol, ultrasensitive assay (esoterix code ) TSH Free T4 Progressing over time Accelerated growth Vaginal bleeding Café au lait spots on physical exam (possible McCune- Albright syndrome) Essential: o Prior growth data/growth o Relevant laboratory studies o Pertinent medical records Results of any additional tests exam, evaluation of growth Imaging studies may be necessary Our providers appreciate having the information ahead of time. Please provide relevant clinical notes, labs, X rays and a growth chart. Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 7

8 for Pubertal Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Delayed Puberty (chronic illness must be considered) History and physical exam: CBC, ESR, Comprehensive Metabolic Panel TSH free T4 or T4, total Transglutaminase IgA IgA level Prolactin LH, FSH Estradiol, ultrasensitive assay (esoterix code ) (female) Testosterone in the AM (male) RADIOGRAPHIC STUDIES: Bone Age For boys: no testicular enlargement by 14 years of age For girls: no breast development by 13 years of age, or no menses by 16 years of age or no menses > 4 years after onset of breast development More than 6 months without a period Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring bone age X-ray to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth Additional labs such as karyotype may be indicated Imaging studies may be necessary Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 8

9 for Pubertal Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Premature Menses Consider vaginal foreign body History and physical exam: LH by ECL at Esoterix specialty laboratory (CPT code 83002) FSH Prolactin Estradiol, sensitive TSH Free T4 RADIOGRAPHIC STUDIES: Bone Age Pelvic Ultrasound Vaginal bleeding in girls < 10 years of age Vaginal bleeding in any girls without signs of puberty Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring bone age X-ray to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth Imaging studies may be necessary Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 9

10 for Thyroid Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Congenital Hypothyroidism History and physical exam: Thyroid Function (TSH and freet4) Abnormal newborn screen Please follow instructions of the state newborn screening program- For further questions please call Pediatric Endocrinology On Call # at Thyroid function tests, including results from state newborn screening program and any other labs obtained Birth history, gestational age, weight and height exam Imaging studies such as a nuclear medicine thyroid scan or thyroid ultrasound may be indicated >Urgent referral recommended for congenital/newborn hypothyroidism Refer to clinic immediately. Mark referral URGENT as most often baby will need to be seen in 1-2 days Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 10

11 for Thyroid Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Acquired Hypothyroidism If thyromegaly, please see referral for goiter History and physical exam: TSH Free T4 Thyroid peroxidase antibody If TSH elevated and free T4 is normal please see co-management guideline Refer if Free T4 is low No referral is necessary if TSH and free T4 are normal even if thyroid antibodies are positive, but consider repeating TFTs q3-6 months Pertinent medical records Relevant laboratory studies (including thyroid peroxidase antibody if obtained) Radiographic studies: Thyroid scan and ultrasound is not but report if studies obtained Results of any additional tests Prior growth data/growth exam, evaluation of growth Imaging studies may be necessary Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 11

12 for Thyroid Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Acquired Hyperthyroidism (Grave s Disease) Usually goiter present but not always History and physical exam: TSH Free T4 Total T3 TSI (Thyroid Stimulating Immunoglobulin) TBII (Thyroid Binding Inhibitory Immunoglobulin) RADIOGRAPHIC STUDIES: (not absolutely ) Thyroid scan Ultrasound Suppressed TSH Elevated T4, total, or free T4 Elevated total T3 (or free T3) Pertinent medical records Relevant laboratory studies Results of any additional tests Prior growth data/growth exam, evaluation of growth Imaging studies (not absolutely ) o Thyroid scan o Ultrasound Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 12

13 for Thyroid Disorders Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Goiter/Thyromegaly History and physical exam: Thyroid Function: include TSH and free T4. Total T3 or free T3 may be helpful if TSH is suppressed and free T4 is normal thyroid peroxidase antibody Abnormal thyroid function tests Palpable nodules or asymmetry Increasing in size Causing discomfort Pertinent medical records Relevant laboratory studies Results of any additional tests Prior growth data/growth exam, evaluation of growth Imaging studies may not be Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 13

14 Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Calcium Disorders Consider urgent referral for symptomatic hypocalcemia or hypercalcemia and for Total Calcium less than 7 mg/dl or greater than 12 mg/dl ; or ionized calcium less than 0.9 mmol/l or greater than 1.6 mmol/l History and physical exam: Calcium Ionized Calcium Phosphorus Magnesium Alkaline Phosphorus PTH 25-OH Vitamin D 1,25 OH Vitamin D Rickets x-rays Low or Elevated Calcium Elevated Phosphorus Evidence of Rickets with a normal or elevated 25 OH Vitamin D Please note: Nutritional Rickets (i.e. low 25OH Vitamin D) is a common disorder that can be managed by the primary care provider. No referral or DEXA scan is required though we are available to answer and questions or concerns Essential: o Prior growth data/growth o Relevant laboratory studies o Have patient bring X-rays to clinic, if done o Pertinent medical records Results of any additional tests exam, evaluation of growth Monitoring of interval growth Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 14

15 Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Children s workup will Hypoglycemia Definition: The definition of hypoglycemia in infants and children continues to be controversial. History and physical exam: Serum Glucose If possible, may obtain the following critical sample at the time of hypoglycemia o venous serum glucose (not POC) o Insulin level o C-peptide o Beta hydroxybutyrate o Cortisol o Growth Hormone o Free Fatty acids o Lactate o Urine ketones Documented hypoglycemia (plasma glucose < 50mg/dl) Essential: o Prior growth data/growth o Relevant laboratory studies o Pertinent medical records Results of any additional tests exam, evaluation of growth Evaluation of prior labs if available Monitoring of interval growth and further hypoglycemic episodes Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 15

16 Referring provider s initial evaluation and When to initiate referral: What can referring provider send? Children s workup will Adrenal Insufficiency History and physical exam: CMP Glucose AM cortisol and ACTH (before 9 am) If primary adrenal disease is suspected consider also obtaining: Renin Aldosterone Low AM cortisol level Essential: o Prior growth data/growth o Relevant laboratory studies o Pertinent medical records Results of any additional tests exam, evaluation of growth Monitoring of interval growth Please call the Pediatric Endocrinlogist on call for new diagnosis/positive newborn screen for congenital adrenal hyperplasia Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 16

17 COMANAGEMENT GUIDELINES ELEVATED TSH Elevated TSH with normal free T4 Obtain TPO antibodies TPO antibodies positive? NO YES TSH >10 miu/ ml? TSH >6 miu/ ml? NO YES NO YES Repeat free T4 and TSH every 3-6 months, frequency to be dictated by symptoms Refer to Pediatric Endocrinology Repeat free T4 and TSH every 3-6 months, frequency to be dictated by symptoms Refer to Pediatric Endocrinology No referral is necessary if TSH and free T4 are normal even if thyroid antibodies are positive, but consider repeating TFTs q3-6 months frequency to be dictated by symptoms Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 17

18 COMANAGEMENT GUIDELINES LIPID MANAGEMENT Lipid Management Age < 2 years Weight for height >95 th percentile Age > 2 years BMI >85 th percentile No Lipid Testing If drinking milk, use low fat milk Fasting lipids with LDL Low Risk LDL < 110 mg/dl And fasting triglycerides <150 mg/dl Moderate Risk LDL mg/dl OR fasting triglycerides mg/dl High Risk LDL >160 mg/dl risk factors* OR LDL>190mg/dl + no risk factors OR Fasting triglycerides >350 mg/dl OR Total Cholesterol >250 mg/dl Weight Management Repeat Lipids in 1-2 years Refer to Pediatric Endocrinology *Risk Factors for Cardiovascular Disease Diabetes Mellitus Fasting glucose >126 2 hr OGTT >200 Pre-diabetes Impaired fasting glucose >100 Impaired glucose tolerance >140 HDL<35 mg/dl and over age 14 years Hyperinsulinemia Polycystic Ovarian Syndrome Hypertension (>95 th percentile) Systemic Lupus s/p any solid organ transplant Smoker or passive smoker h/o cancer Parent/grandparent history of premature Cardiovascular Disease (age at diagnosis <55 years): Coronary atherosclerosis Peripheral Vascular disease Cerebrovascular disease Weight Management- General Recommendations Diet Fat- 30% of total calories Saturated Fat < 7% Polyunsaturated fate up to 10% Monounsaturated fat up to 20% Trans fat <1% Cholesterol <200 mg Carbohydrate- 50% of total calories Whole grains, fruits, vegetables Protein- 15% of total calories Exercise- 60 minutes each day Consider Referral to Healthy Weight Center Refer to attached list of a sampling of resources for families interested in help with lifestyle factors and for dietary referral sources Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 18

19 COMANAGEMENT GUIDELINES TYPE 2 DIABETES ADA screening recommendations for T2DM childhood: Overweight BMI >85 th percentile for age and sex and >10 years of age or onset of puberty if puberty occurs at younger age plus any two of the following risk factors: Family history of T2DM in first or second degree relatives race/ethnicity (Native American, African-American, Latino, Asian-American, Pacific Islander. Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovarian syndrome Normal Fasting glucose <100 OR Hgb A1c <5.8% OR 2 hr OGTT <140 mg/dl Impaired Glucose Tolerance Fasting glucose OR Hgb A1c 5.8% - 6.5% OR 2 hr OGTT mg/dl Diabetes Fasting glucose >126 OR Hgb A1c >6.5% OR 2 hr OGTT >200 mg/dl Continue to screen every 2 years if screening criteria are met Perform 2 hr OGTT if not done already Baseline fasting glucose Glucola 1.75 mg/kg up to 75 grams orally 2 hour serum glucose Urgent referral to Pediatric Endocrinology NO OGTT >140 or fasting glucose >100? YES OGTT >200 or fasting glucose >126? Please note these are screening recommendations for asymptomatic T2DM. Any child who presents with symptoms of diabetes (e.g. polyuria, polydipsia, weight loss) should be tested immediately. Impaired Glucose Tolerance Routine referral to Pediatric Endocrinology Diabetes Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 19

20 Resources Healthy Weight Center at Helen DeVos Children s Hospital / Fax: Fit Kids 360: FitKids360 is a healthy lifestyle program developed to fight childhood obesity. This comprehensive program combines basic education about nutrition, behavior and exercise with a wide range of physical activities. Nutrition Counseling Appointment: Spectrum Health All locations - Daytime appointments are available Monday to Friday. Services are offered at convenient locations throughout West Michigan. Call for more information or to make an appointment. A physician referral is necessary. We recommend patients check with their health insurance to confirm coverage of this service. Metropolitan Hospital Saint Mary s Health Services Websites: Pediatric Referral Guidelines For the most updated version of the Referral Guidelines, please visit 20