Paediatric general surgery referrals

COVID 19 and Paediatric General Surgery Referrals

In common with all other specialities, we are changing the way we work over the next few months and in particular who we see in outpatient clinics. Elective surgery is being greatly curtailed. We therefore plan to restrict outpatients to urgent referrals. These will only be seen at NNUH. Please do not refer to our peripheral clinics meaning JPH, QEH, Ipswich and Bury clinics.
All referrals will be vetted using following criteria:

Cutaneous Lumps and swellings – Most lumps in the skin can wait and be referred later. Hard, irregular and rapidly growing lumps beneath the skin that raise concerns of malignancy should still be referred on 2 week wait pathway. These are rare in paediatric surgery. Purely cosmetic lumps
can wait and we never operate on these less than 1 year in normal circumstances.
Common lumps that can wait are:
• Pilomatrixoma – Hard irregular but characteristic chalky appearance seen through skin.
• Lymphangioma- Soft, variable size. Can become infected – if so treat with antibiotics. Can wait unless large around neck.
• Angular Dermoid- Firm swelling at the outer edge of the eyebrow in babies. Can wait and certainly until over 1 year of age.
• Neck lumps- Thyroglossal and Branchial cysts can wait but please treat infections and discuss with us if you are concerned.
• Epigastric hernias- These referrals will not be accepted at this time. Divarification of the recti resolves naturally.
• Umbilical hernia- These referrals will not be accepted at this time. These commonly resolve naturally before the age of 4 years and rarely need to be operated on.
• Smegma- Soft yellowish lump of the penile shaft. Natural secretions of no concern. Do not refer.
• Groin or Scrotal Swellings: Please refer to Paediatric Urology guidelines.

Thoracic conditions– Acquired deformity of the chest will not be seen during this time. Commissioning for these conditions is already limited in normal circumstances.

Vomiting: This is usually an acute referral. Paediatric Surgeons will continue to review Green Bilious Vomiting urgently via the emergency referral pathway as this can sometimes signify volvulus of the

Abdominal pain– Please continue to refer acute abdominal pain through the Children’s assessment unit.

For chronic abdominal pain: If no specific symptoms or red flags (vomiting, change in bowels, worsening pain, weight loss or loss of appetite) then consider routine blood tests if available for inflammatory markers. Rule out a urinary tract infection. Consider empirical treatment for
constipation and deworming. Please review patients with continued pain after interval before referral.

Constipation and soiling– This service will currently only see patients with red flags such as:
• Failure to pass meconium within 48 hours
• Abnormal appearance of anus
• Ribbon stools
• Severe abdominal distension with vomiting
Please refer to NICE guidance for management of constipation in children and young people. In addition we have locally adapted information incorporating the NICE guidance and our specialist referral pathways on the Knowledge Anglia website.
We recognise that children who have chronic constipation and soiling have a distressing condition. They usually are referred to paediatric surgery via paediatrics or the Children’s Community
Continence Service at NCHC. As all services will be under pressure to reduce referrals and patient
contact we would suggest offering parents advice about the use of laxatives (Movicol or similar, and or a stimulant laxative such as senna), regular toileting regimen after meals and learning to use the
toilet or potty effectively with a step if needed. Parents may find that while they are isolating or home schooling their children it is a great opportunity to work on these issues without the pressure of the school day. The website can help.

Rectal Bleeding– Please consider if this is a presentation of Inflammatory Bowel Disease and refer to guidelines from Paediatric Gastroenterology.
Fresh red blood on the toilet paper in children is usually from a fissure (painful) associated with constipation. Please treat appropriately and do not refer.
Sudden large bleeds of fresh or altered blood may be due to a meckels diverticulum which is rare. Please refer to the acute team for assessment.