Pediatric Endocrinology Referral Guidelines
Thank you for referring your patients to our division. We are striving to provide the best possible experience for your patients and also meet your needs as a primary care provider. To that end, we have created referral guidelines that will help you perform preliminary laboratory and radiologic evaluations prior to your patient seeing one of our subspecialists. Remember, these are just guidelines and if you are unable to perform a work up, we will still see your patient in a timely manner. Also, we are not expecting anyone to interpret the lab or radiology results, thus please call our clinic if you feel there is an urgent consult required. We have attempted to delineate specific cases where an urgent referral is indicated.
While we would like all laboratories to be created equal and perform the same test in the same way, they are not. Thus, we usually prefer lab tests to be performed at CPL, LabCorp, Quest, or Esoterix. However, even amongst these facilities, they don’t always have the ideal endocrine tests available and we may send blood to special reference laboratories. We ask that you inform your patients while you are performing a preliminary work up, that there may be other labs or tests that are warranted.
We generally prefer to review our own bone ages, as there is a lot of variation amongst radiologists. We have access to studies performed at ARA, ARC, Seton, CPRMC, and some Telerad facilities. If you perform a bone age outside of one of these facilities, please send the image on a CD with your patient. This will help us give a more complete, efficient work up of your patient.
We have attempted to label which tests should be performed at 8am, fasting, or both. If a work up calls for these special conditions, all the labs can be performed at that time (there should not be a need for 2 separate lab draws).
The referral guidelines have several sections of “Key Facts” about certain conditions. Please review these when you are making a referral, as this information may guide your work up.
We have also included an algorithm for treating Vitamin D deficiency. This treatment protocol is one of many ways to treat this condition; however, it should only be followed if the patient has normal Ca, Phos, and PTH levels. If the patient has abnormal levels, multiple fractures or signs of rickets, please contact our office for a referral or more instructions.
If you have any questions or concerns about these guidelines, please contact the MD on call and we will be happy discuss them with you. As always, if you feel you have an Endocrine Emergency, please call our clinic (512-628-1830) or the after-hours MD on call (Medlink 512-323-5465).
We look forward to working with you as we care for the children of Central Texas.
Regards,
The Division of Pediatric Endocrinology ‘Specially for Children Dell Children’s Medical Center of Central Texas Pediatric Endocrinology Referral Guidelines
Table of Contents: 1a) Congenital Hypothyroidism (Neonate) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] 1b) Congenital Hypothyroidism (Child) [ICD -9 Code: 243.0] [ICD-10 Code: E03.1]
2a) Acquired Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E03.8] 2b) Autoimmune Thyroiditis/Hypothyroidism [ICD-9 Code: 245.2] [ICD-10 Code: E06.3]
3) Central Hypothyroidism [ICD-9 Code: 253.4] [ICD-10 Code: E23.6]
4a) Acquired Hyperthyroidism [ICD-9 Code: 242.9] [ICD-10 Code: E05.90] 4b) Autoimmune Hyperthyroidism (Grave’s Disease) [ICD-9 Code: 242.0] [ICD-10 Code: E05.00]
5) Neonatal Hyperthyroidism [ICD-9 Code: 775.3] [ICD-10 Code: P72.1]
6) Goiter [ICD-9 Code: 240.9] [ICD-10 Code: E04.9]
7) Thyroid Nodule [ICD-9 Code: 243.0] [ICD-10 Code: E04.1] Thyroid: Key Facts (page 8) 8a) Diabetes Mellitus - Type 1 [ICD-9 Code: 250.03; ICD-10: E10.65] Type 2 [ICD-9 Code: 250.02; ICD-10: E11.65] 8b) Hyperglycemia [ICD-9 Code: 790.29] [ICD-10 Code: R73.09]
9a) Impaired Glucose Tolerance [ICD-9 Code: 790.22] [ICD-10 Code: R73.02] 9b) Impaired Fasting Glucose [ICD -9 Code: 790.21] [ICD-10 Code: R73.01]
10a) Morbid Obesity [ICD-9 Code: 278.01] [ICD-10 Code: E66.01] 10b) Acanthosis Nigricans [ICD-9 Code: 701.2] [ICD-10 Code: L83]
Diabetes: Key Facts (page 10) (Table of contents continued on next page) For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 1 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
Table of Contents (continued): 11) Short Stature [ICD-9 Code: 783.43] [ICD-10 Code: R62.52]
12) Failure to Thrive [ICD-9 Code: 783.41] [ICD-10 Code: R62.51] Growth: Key Facts (pages 13 & 14)
13a) Precocious Puberty/Premature Thelarche - Girls [ICD-9 Code: 259.1] [ICD-10 Code: E30.1] 13b) Precocious Puberty - Boys [ICD-9 Code: 259.1] [ICD-10 Code: E30.1]
Precocious Puberty: Key Facts (page 16)
14a) Premature Adrenarche - Girls [ICD-9 Code: 255.2] [ICD-10 Code: E27.0] 14b) Premature Adrenarche - Boys [ICD-9 Code: 255.2] [ICD-10 Code: E27.0]
15) Delayed Puberty [ICD-9 Code: 259.0] [ICD-10 Code: E30.0]
16) Algorithm for Treating Vitamin D Deficiency [ICD-9 Code: 268; ICD-10 Code: E55.9]
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 2 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
1a) Congenital Hypothyroidism (Neonate) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Neonate with abnormal ► URGENT: ► Confirmatory TSH, Total T4 or Free T4 ► All clinical notes and laboratory Newborn Screening Test Call MD on-call to results including growth chart discuss and start treatment. On -Call Phone # Day: (512) 628-1830
After Hours: (512) 323-5465
1b) Congenital Hypothyroidism (Child) [ICD-9 Code: 243.0] [ICD-10 Code: E03.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Known or treated child with ► First available ► Current TSH, Total or Free T4 ► All clinical notes and laboratory results including growth chart abnormal thyroid function appointment, but call the test MD on-call to begin therapy until patient can be seen.
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 3 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
2a) Acquired Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E03.8]
2b) Autoimmune Thyroiditis/Hypothyroidism [ICD-9 Code: 245.2] [ICD-10 Code: E06.3] Clinical Findings Referral Timeframe Pre- Referral Workup Referral Requirements
• Elevated TSH ► First available ► Current TSH, Total T4 or Free T4, Anti- ► All clinical notes and laboratory
appointment, but call the Thyroglobulin Antibody and Anti-TPO records including growth chart • Low Total T4 or Free T4 MD on-call to begin Antibody
therapy until patient can ► If TSH is abnormal but <10 uU/ml and the be seen Total T4 or Free T4 are normal, obtain thyroid antibodies and repeat the TSH, Total T4 or Free T4 in 1-2 months. If TSH rising and antibodies are positive, refer
► Thyroid ultrasound is unnecessary unless the gland is asymmetric or nodules are palpable
3) Central Hypothyroidism [ICD-9 Code: 253.4] [ICD-10 Code: E23.6] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Low to Low normal TSH with ► URGENT: ► Confirmatory TSH, Total T4 ► All clinical notes and laboratory or Free T4 records including growth chart low Total T4 or Free T4 Call MD on-call to discuss and start
treatment. ► Consider repeat of labs prior • History of traumatic brain to referral to assure validity injury, midline facial On-Call Phone #
defects, brain irradiation, Day: hypoxic brain injury (512) 628-1830
After Hours: (512) 323-5465 ► After discussion with MD on-call, may be asked to obtain MRI of the brain and pituitary with and without contrast For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 4 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
4a) Acquired Hyperthyroidism [ICD-9 Code: 242.9] [ICD-10 Code: E05.90] 4b) Autoimmune Hyperthyroidism (Grave’s Disease) [ICD-9 Code: 242.0] [ICD-10 Code: E05.00] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Hypertension ► URGENT: ► Current TSH, Total T4 or Free T4, ► All clinical notes and laboratory Total T3, Thyroid Stimulating records including growth chart Call MD on-call to • Tachycardia discuss and start Immunoglobulin (TSI), Thyrotropin Binding treatment. Immunoglobulin (TBII), Anti-Thyroglobulin Goiter • Antibody, Anti-TPO Antibody On-Call Phone # • Exophthalmos Day:
• TSH < 0.1 uU/ml (512) 628-1830
• Elevated Total T4 or After Hours: Free T4,T3 (512) 323-5465
5) Neonatal Hyperthyroidism [ICD-9 Code: 775.3] [ICD-10 Code: P72.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Maternal history of Graves ► URGENT: ► TSH, Total T4 or Free T4, Total T3, ► All clinical notes and laboratory Disease Call MD on-call to Thyroid Stimulating Immunoglobulin (TSI), records including growth chart Thyrotropin-Binding Immunoglobulin (TBII) discuss and start • Hypertension treatment. ► If possible, check maternal Anti-TPO
• Tachycardia On-Call Phone # Antibody, Anti-Thyroglobulin Antibody and TSI/TBII Day: • Failure to Thrive (512) 628-1830
Low TSH • After Hours:
• Elevated Total T4 or Free T4 (512) 323-5465
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 5 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
6) Goiter [ICD-9 Code: 240.9] [ICD-10 Code: E04.9] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements URGENT REFERRAL IF: ► URGENT: ► If asymmetric, enlarging in size, or palpable ► All clinical notes and laboratory Call MD on-call to node, obtain thyroid ultrasound records including growth chart • Asymmetric gland discuss and start ► Current TSH, Total T4 or Free T4, Anti-
• Increasing size or causing treatment. If Thyroglobulin Antibodies and Anti-TPO discomfort symptomatic, call Antibodies MD on-call to • Abnormal thyroid biopsy discuss On -Call Phone # Day: (512) 628-1830 After Hours: (512) 323 5465
ROUTINE REFERRAL IF:
• Abnormal TSH, Total T4, or ► If questions, call MD ► Current TSH, Total T4 or Free T4, Anti- ► All clinical notes and laboratory Free T4 on-call to discuss Thyroglobulin Antibodies and Anti-TPO records including growth chart Antibodies ► Imagins studies
• Abnormal thyroid antibodies ► If palpable nodule, see • Abnormal thyroid ultrasound Thyroid Nodule section showing goiter, multiple ► If abnormal thyroid function small nodules tests, see Hypothyroid or Hyperthyroid section
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 6 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
7) Thyroid Nodule [ICD-9 Code: 243.0] [ICD-10 Code: E04.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements URGENT REFERRAL IF: ► URGENT: ► Current TSH, Total T4 or Free T4, ► All clinical notes,
Palpable nodule >1.0 cm Call MD on-call to discuss and start Anti-Thyroglobulin Antibodies and laboratory or ultrasound Anti-TPO Antibodies results and growth chart treatment. If symptomatic, call
• Family history of thyroid cancer MD on-call to discuss ► Calcitonin if recommended by ► Fine Needle Aspiration may or MEN (multiple endocrine On-Call Phone # Dell Children’s Specialist in be indicated neoplasia) Endocrinology Day: ► Thyroid Ultrasound • Increasing size of nodule (512) 628-1830
After Hours: (512) 323-5465
ROUTINE REFERRAL IF:
Non-palpable nodule < 1.0 cm ► If concern for thyroid cancer, please ► Current TSH, Total T4 or Free T4, ► All clinical notes, call MD on-call to discuss Anti-Thyroglobulin Antibodies and laboratory or ultrasound • Nodule on thyroid ultrasound Anti-TPO Antibodies results and growth chart
► Calcitonin if recommended by Dell Children’s Specialist in Endocrinology ► Thyroid Ultrasound
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 7 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
Thyroid: Key Facts to Remember
Facts to Remember:
• We often see slight elevations in TSH (5-10 uU/ml) in obese children secondary to metabolic syndrome and obesity. No endocrine referral is indicated unless the thyroid antibodies are positive.
• Alopecia or hair loss with normal TSH, Total T4 or Free T4 does not indicated an endocrinopathy and referral is unnecessary.
• Obtaining a T3 Uptake or Free T4 Index is not usually helpful. Instead it should be a Total T3 level or Free T4.
• Children with Trisomy 21 often have mildly elevated TSH levels (hyperthyrotropenemia) with normal Total T4 or Free T4. Generally referral is not needed unless there are positive thyroid antibodies, or rising TSH. Call with questions.
• Children with positive thyroid antibodies but normal thyroid function tests may never go on to develop hypothyroidism. The thyroid function tests just need to be followed periodically and if abnormal, referral is appropriate.
• Thyroid Nodules: There is a rising incidence of thyroid nodules in the pediatric population. Small nodules (<1.0 cm) with thyroid antibodies are less concerning. Solitary nodules or nodules >1.0 cm require an urgent referral to r/o thyroid cancer. A fine needle aspiration may be indicated.
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 8 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
8a) Diabetes Mellitus - Type 1 [ICD-9 Code: 250.03; ICD-10: E10.65] Type 2 [ICD-9 Code: 250.02; ; ICD-10: E11.65] 8b) Hyperglycemia [ICD-9 Code: 790.29] [ICD-10 Code: R73.09] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Increased thirst and ► URGENT: ► Finger Stick Blood Glucose ► IF fasting BG over 126 mg/dl or a urination Call MD on-call to ► Urinalysis for KETONES and glucose random BG 2 hour or OGTT over 200 discuss and start treatment. mg/dl, then call is URGENT • Weight loss ► If NOT acutely ill, consider STAT If symptomatic, call ► FOR ALL NEW DIAGNOSES of Diabetes Emergency Dept. (911) chemistry panel to determine • Vomiting (DKA) disposition (direct admit vs. ER) Mellitus, please inform phone On-Call Phone # concierge call is URGENT
• Lethargy (DKA) Day: ► DKA is likely if patient is vomiting,
• Deep Respirations (DKA) (512) 628-1830 lethargic or abnormal respirations. Send immediately to Emergency
After Hours: Department AND notify Endocrine MD (512) 323-5465 on-call.
9a) Impaired Glucose Tolerance [ICD-9 Code: 790.22] [ICD-10 Code: R73.02] 9b) Impaired Fasting Glucose [ICD -9 Code: 790.21] (see pre-referral workup section for definitions) [ICD-10 Code: R73.01] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Obesity (BMI >97%ile) ► Routine: ► Impaired Fasting Blood Glucose (100- ► Growth chart 125 mg/dl) First available appointment ► Laboratory results • Acanthosis ► Impaired 2 hour OGTT (140-199 ► Recent clinical notes • Positive Family History of mg/dl)
Diabetes ► HgA1C (abnormal >6%)
• May NOT have increased ► 2 hour OGTT (8 years and over) - 1.75 thirst and urination grams of glucola/kg to max of 75 grams
► Renal Function and Liver Function tests
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 9 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
10a) Morbid Obesity [ICD-9 Code: 278.01] (If Early Onset, e.g. before age 5, may be genetic condition) [ICD-10 Code: E66.01] 10b) Acanthosis Nigricans [ICD-9 Code: 701.2] [ICD-10 Code: L83] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Obesity (BMI >97%ile) ► Routine: ► HgA1C (abnormal if >6%) ► Growth chart Referrals will be evaluated ► Fasting Blood Glucose (Abnl 100-125) ► Laboratory results • Darkening & Thickening of skin around neck, elbow, ► 2 hour OGTT (abnl 2 hour level above ► Recent clinical notes waist, knuckles, axilla 140 mg/dl). FOR 8 years and over, use 1.75 grams of glucola/kg to max • Irregular Menses of 75 grams
(If Obesity starts after age 5, and no lab abnormalities, then refer out to community weight management programs.
*NO ENDOCRINOLOGY REFERRAL NEEDED*)
Diabetes: Key Facts to Remember
Facts to Remember:
• Signs of DKA warrant an urgent call and immediate referral to Emergency Department (call 911)
► Vomiting, Deep Respirations, Altered Level of Consciousness - Signs of Diabetic Ketoacidosis - Refer to Emergency Department (911) with call to PICU/Endocrine - Day: (512) 628-1830 or After Hours: (512) 323-5465 ► Large Ketones in Urine ► CO2 <15 on chemistry panel
• If Diabetes is clinically apparent, then a separate fasting glucose or 2 hour OGTT are not required, please call immediately. • Obesity before age 5 is considered Early Onset and may indicate a genetic cause of the obesity.
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 10 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
11) Short Stature [ICD-9 Code: 783.43] [ICD-10 Code: R62.52] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements • Poor height velocity ► URGENT: ► May need lab tests as below but please call to discuss. ► All clinical notes and laboratory results or crossing Call MD on-call to including growth chart ► May need urgent MRI of brain and pituitary to rule out percentiles) AND discuss and start treatment. tumor. associated with On-Call Phone # severe headaches Day: and/or blurry vision (512) 628-1830
After Hours: (512) 323-5465
• Current Height less ► Routine- likely will be seen ► Evaluation of mid-parental target height ► Growth chart in next 1 to 3 months than 3rd percentile ► IGF-I (Insulin like growth factor-I)- CPL test 4920, QUEST ► Thyroid function tests
for age Test code 839, Esoterix code 500282 ► Laboratory results
► IGF-BP3 (Insulin like growth factor binding protein 3) ► Bone age results - Please have parent or CPL test 4361, Esoterix code 500281 bring a copy of bone age x-ray (CD or
► TSH, Free T4, CBC, CMP, Urinalysis film) to visit • Crossing percentiles ► Celiac screening (Anti-Tissue Transglutaminase –IgA) ► Relevant clinical notes on repeated growth IgA level; CPL test codes 4725 and 2751 measurements. ► All non-urgent patients referred for short ► Bone age x-ray if more than 2 years of age stature will be sent to a growth seminar ► Please have parent bring CD or film of bone age x-ray prior to Endocrine visit
to appointment
► For females, consider HIGH RESOLUTION karyotype for Turner syndrome
• Current Height ► May NOT need referral ► Must screen with TSH level at minimum. ► Growth chart based on initial evaluation greater than 3rd ► Consider above laboratory testing and bone age x-ray if ► Thyroid function tests
percentile but still >2 years old depending on symptoms. ► Laboratory results
concern for growth ► Evaluation of mid-parental target height. (MPTH) **See ► Bone age results - Please have parent page 10 for MPTH equation. bring a copy of bone age x-ray (CD or film) to visit ► Relevant clinical notes For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 11 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
12) Failure to Thrive [ICD-9 Code: 783.41] [ICD-10 Code: R62.51] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Hypoglycemia and ► URGENT: ► May need same lab tests as below, but please call ► All clinical notes and laboratory Failure to Thrive Call MD on-call to to discuss. results including growth chart discuss and start treatment. On -Call Phone # Day: (512) 628-1830
After Hours: (512) 323-5465
• Height less than ► Routine- likely will be ► IGF-BP3 (Insulin like growth factor binding protein ► Growth chart seen in next 1 to 3 3) CPL test code 4361, Esoterix code 500281 3rd percentile and ► Thyroid function tests months ► TSH, Free T4, CBC, CMP. weight less than ► Laboratory results 3rd percentile ► Celiac screening (Anti-Tissue Transglutaminase –IgA) IgA level; CPL test codes 4725 and 2751 ► Bone age results - Please have parent bring a copy of bone age x-ray (CD or film) to visit ► Relevant clinical notes
• Height 3rd ► May NOT need referral ► Consider evaluation by Gastroenterology ► Please call MD on-call for any percentile or based on initial (512) 628-1810 questions. evaluation greater, but weight less than 3rd percentile
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 12 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
Growth: Key Facts to Remember
When to worry:
• Poor height velocity associated with severe headaches and/or blurry vision may be a brain tumor.
• If a child is short and in puberty, this may increase the urgency of referral.
• Short stature is more concerning if a child has a predicted height that is more than 4 inches shorter than expected for family
Facts to Remember:
• Constitutional delay is the MOST common cause of short stature.
• FDA criteria for growth hormone treatment in idiopathic short stature is a predicted adult height of less than 4’11” for girls or 5’4” for boys
• Random growth hormone levels are NOT useful, please measure IGF-I and IGF-BP3 instead.
• If the bone age shows fused growth plates > 14 in girls or > 16 in boys, then NO Endocrine referral is needed. There are NO treatment options to increase height once growth plates are fused.
• Consider genetics referral if dysmorphic features are present.
(Growth: Key Facts to Remember continued on next page)
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 13 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
Growth: Key Facts to Remember
Facts to Remember (continued):
• Midparental target height (MPTH) equation is DIFFERENT for boys and girls.
► MPTH(boys) = [(mom’s height + 5 in) + (dad’s height)] ÷ 2
► MPTH(girls) = [(mom’s height) + (dad’s height - 5 in)] ÷ 2
► MPTH is the average genetic target but normal children can be 2 to 4 inches shorter or taller than their target.
• Key to evaluation of growth requires comparison of weight and length/ height curves.
• If weight is decreasing more than length/ height, refer to gastroenterology PRIOR to Endocrinology.
• IGF-I (Insulin like growth factor-I) levels will often be low in patients with low weight and may NOT be indicative of growth hormone deficiency.
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 14 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
13a) Precocious Puberty/Premature Thelarche (Girls) [ICD-9 Code: 259.1] [ICD-10 Code: E30.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements Girls < 8 years ► URGENT: ► Bone age ► Growth chart
• Breast development with Call MD on-call to ► TSH and T4 or Free T4 by dialysis ► Bone age results- Please have one or more of the following discuss and start ► Pediatric LH (CPL 2776, Esoterix parent bring a copy of film/CD to signs: treatment. appointment. 500234, Lab Corp 502286) • Progressing over time On-Call Phone # ► Lab results ► Pediatric FSH (CPL 2700, Esoterix • Accelerated growth Day: 500192, LabCorp 502280) ► Relevant clinical notes with • Vaginal bleeding (512) 628-1830 ► Ultrasensitive Estradiol (CPL 5678, physical examination including Headaches and/or visual Tanner stage. • After Hours: Esoterix 500152, Lab Corp 500108) changes (512) 323-5465 ► Please get labs at 8am • Multiple Café au lait spots > 1.5 cm (possible McCune Albright Syndrome)
Girls 6 - 8 years ► Routine ► Same as above ► Same as above
• Breast development without the above signs
Girls 2 - 6 years ► URGENT: ► Same as above ► Same as above Call MD on-call to • Breast development without discuss and start the above signs treatment.
Girls < 2 years ► May NOT need referral ► None ► Call Endocrine with any questions or concerns • Breast development without the above signs
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 15 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
13b) Precocious Puberty (Boys) [ICD-9 Code: 259.1] [ICD-10 Code: E30.1] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements Boys < 9 years ► URGENT: ► TSH and T4 or Free T4 by dialysis ► Growth chart
• Testicular enlargement Call MD on-call to ► Bone age ► Bone age results- Please have discuss and start (> 4ml or > 2.5 cm) ► Pediatric LH (CPL 2776, Esoterix parent bring a copy of film/CD to treatment. appointment. 500234, Lab Corp 502286) • Penile enlargement On-Call Phone # ► Lab results Day: ► Pediatric FSH (CPL 2700, Esoterix 500192, LabCorp 502280) ► Relevant clinical notes with (512) 628-1830 physical examination including ► Pediatric Testosterone (CPL 2833, Tanner stage. After Hours: Esoterix 500286, Lab Corp 500159) (512) 323-5465 ► AFP and hCG Tumor Markers ► Please get labs at 8am
Precocious Puberty: Key Facts to Remember
Facts to Remember:
• Standard LH, FSH, Estradiol or Testosterone assays are not reliable for children, please use test codes provided.
• Consider imaging testing such as pelvic ultrasound or brain and pituitary MRI if warranted.
• In benign premature thelarche, the nipples are not usually dark or enlarged as seen in precocious puberty.
• Fine downy and non-pigmented short hair is not considered secondary sexual pubic hair.
• Pubic hair on the suprapubic area is more indicative of precocious puberty than hair on the labial majora or scrotum.
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 16 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
14a) Premature Adrenarche (Girls) [ICD-9 Code: 255.2] [ICD-10 Code: E27.0] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements Girls < 7 years with one or more ► URGENT: ► Bone age ► Growth chart of the following signs: pubic ► 8am 17-HydroxyProgesterone (CPL 4304, Call MD on-call to ► Bone age results- Please have hair, axillary hair, body odor, Esoterix 500270, LabCorp 500163) discuss and start parent bring a copy of film/CD to clitoral enlargement, but NO treatment. ► Pediatric Testosterone (CPL 2833, appointment. breast development Esoterix 500286, LabCorp 500159) ► Lab results On-Call Phone # Day: ► DHEAS(CPL 4225, Esoterix 500116, LabCorp 500156) ► Relevant clinical notes with (512) 628-1830 ► Pediatric LH (CPL 2776, Esoterix physical examination including Tanner stage After Hours: 500234, Lab Corp 502286)
(512) 323-5465 ► Pediatric FSH (CPL 2700, Esoterix 500192, LabCorp 502280)
Girls 7 - 8 years with one or ► URGENT: more of the above signs AND Call MD on-call to ► Same as above ► Same as above accelerated growth or clitoral discuss and start enlargement treatment.
Girls 7 - 8 years with one or ► Routine ► Same as above ► Same as above more of the above signs, but NO accelerated growth or clitoral enlargement
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 17 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
14b) Premature Adrenarche (Boys) [ICD-9 Code: 255.2] [ICD-10 Code: E27.0] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements Boys < 7 years with one or more ► URGENT: ► Bone age ► Growth chart of the following signs: pubic ► 8am 17-HydroxyProgesterone (CPL 4304, Call MD on-call to ► Bone age results- Please have hair, axillary hair, body odor, Esoterix 500270, LabCorp 500163) discuss and start parent bring a copy of film/CD to penile enlargement, treatment. ► Pediatric Testosterone (CPL 2833, appointment. accelerated growth; but NO Esoterix 500286, Lab Corp 500159) ► Lab results testicular enlargement (<4 ml or On-Call Phone # ► DHEAS(CPL 4225, Esoterix 500116, <2.5 cm) Day: LabCorp 500156) ► Relevant clinical notes with (512) 628-1830 ► Pediatric LH (CPL 2776, Esoterix physical examination including Tanner stage After Hours: 500234, Lab Corp 502286)
(512) 323-5465 ► Pediatric FSH (CPL 2700, Esoterix 500192, LabCorp 502280)
Boys 7 - 9 years with one or ► URGENT: ► Same as above ► Same as above more of the above signs AND Call MD on-call to accelerated growth treatment.discuss and start
Boys 7 - 8 years with one or ► Routine ► Same as above ► Same as above more of the above signs, but NO accelerated growth
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 18 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
15) Delayed Puberty [ICD-9 Code: 259.0] [ICD-10 Code: E30.0] Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Boys: no testicular ► Routine ► Bone age ► Growth chart enlargement (<4 ml or <2.5 ► TSH and T4 or Free T4 by dialysis ► Bone age results- Please have
cm) by 14 years of age ► Pediatric LH (CPL 2776, Esoterix parent bring a copy of film/CD to appointment 500234, Lab Corp 502286) • Girls: no breast ► Lab results ► Pediatric FSH (CPL 2700, Esoterix development by 13 years of 500192, LabCorp 502280) ► Relevant clinical notes with age or no menses by 15 ► Boys- Pediatric Testosterone (CPL 2833, physical examination including years of age Tanner stage Esoterix 500286, Lab Corp 500159)
Note: Girls with no menses ► Girls- Ultrasensitive Estradiol (CPL 5678, by 15 years and notable Esoterix 500152, Lab Corp 500108) short stature, consider ► HIGH RESOLUTION Karyotype Turner Syndrome. (if suspect Turner Syndrome)
► Please get labs at 8am)
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 19 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
16) Algorithm for Treatment of Vitamin D Deficiency [ICD-9: 268; ICD-10: E55.9] Only follow this treatment plan if the Ca, Phos, and PTH are NORMAL in the setting of a low Vitamin D. If they are abnormal, then please contact the clinic for referral or advice. Age Vitamin D Level Treatment Follow-Up > 5 yrs <20 ng/ml Ergocalciferol 50,000 iu x 16 weeks Recheck Vitamin D 25,OH on week 17 + < 30 continue the same treatment for another 16 weeks – recheck level again Cholecalciferol 3,000 iu/day on week 17. If level still <30 address possible non-compliance > 30 maintain on Cholecalciferol 3000 iu/daily > 5 yrs 20-25 ng/ml Ergocalciferol 50,000 iu x 16 weeks Recheck Vitamin D 25,OH on week 17 + < 30 continue the same treatment for another 16 weeks – recheck level again Cholecalciferol 2000 iu/day on week 17. If level still <30 address possible non-compliance > 30 maintain on Cholecalciferol 2000 iu/daily > 5 yrs 25-30 ng/ml Cholecalciferol 2000 iu/day Recheck Vitamin D 25,OH prior to next visit > 5 yrs > 40 If on supplement and Vitamin D > 40, Recheck prior to next office visit continue 800 IU daily < 5yrs <30 ng/ml Ergocalciferol (Drisdol) 8,000 iu x16 weeks Recheck level at next office visit + Drink milk No daily supplement needed ** Goal is to maintain Vitamin D 25,OH > 30ng/ml ** For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015 Pediatric Endocrinology Referral Guidelines
Sources used in development of these Referral Guidelines:
• Kappy MS, Allen DB, Geffner ME ed. Pediatric Practice Endocrinology, McGraw Hill Medical. 2010
• Styne DM, Pediatric Endocrinology. Lippincott Williams and Wilkins, 2004
• Sperling MA ed. Pediatric Endocrinology 3rd edition, Saunders Elsevier 2008.
• Lifshitz, F ed. Pediatric Endocrinology Volume 1. Obesity, Diabetes Mellitus, insulin Resistance, and Hypoglycemia.
5th ed. Informa Health Care, 2009
• Lifshitz, F ed. Pediatric Endocrinology Volume 2. Growth, Adrenal, Sexual, Thyroid, Calcium and Fluid Balance Disorders.
5th ed. Informa Health Care, 2009
• Adapted from Pediatric Endocrinology Referral Guidelines from Children’s Hospital of Cincinnati, Division of Pediatric Endocrinology
For appointments, please call the Endocrinology Center at (512) 628-1830 Website: Fax ALL pertinent medical records to (512) 628-1831 http://www.speciallyforchildren.com/ Page 21 To speak with a Dell Children’s Specialist in Endocrinology, please call: specialties/endocrinology.asp
Endocrinology On-Call Phone# Day: (512) 628-1830 or After Hours (Medlink): (512) 323-5465 September 1, 2015