Referral 26

Faltering growth:

Will be accepted if they meet the NICE (2017) threshold for concern about faltering growth in infants and children: 

• A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile 
• A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles 
• A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile 
• When current weight is below the 2nd centile for age, whatever the birthweight.

All children with a BMI under 2nd centile. Children may be accepted into the service if losing weight secondary to prescribed medication to manage a diagnosed condition. 

Details of any investigations undertaken.

Previous growth (weight and height) history including copy of growth chart if available.

Faltering growth: recognition and management of faltering growth in children (NICE, 2017)

History of suspected or proven food intolerance or allergy:

We will accept all referrals where non IgE mediated reactions are suspected or diagnosed.

We recommend that children with suspected IgE food allergy are referred to a specialist allergy team.

Children with non-IgE suspected cow’s milk protein allergy should be confirmed by home reintroduction after 4 weeks. 

All children should be referred if on a cow’s milk free diet for more than 8 weeks (NICE, CG57 Atopic Eczema in Children 2007).

Children with a clear diagnosis of non-IgE mediated cow’s allergy may be booked directly into a virtual group information session.

Details of history and diagnosis (as per CG116, NICE 2011).

If a patient has had allergy testing (skin prick, RAST, serology), a copy of the results should be included with the referral.

Referrals for diet-related eczema will only be accepted for children:

• Who have reacted immediately to a food.
• Infants and young children with moderate or severe uncontrolled eczema, particularly with gut dysmotility or faltering growth.

Home enteral feeding:

We will accept all referrals that are not under regular review with a consultant at an acute Trust, and where care is being moved to community paediatrics.

• Primary diagnosis.
• Details of other healthcare professionals involved.
• Details of type of feeding tube and date placed.
• Enteral feeding regime.
• Any previous feeding issues encountered, and long term plans discussed with the family.

Extreme selective eating including those with sensory eating difficulties:

Extreme selective eating, for example where whole essential food groups are excluded and / or less than 10 foods are consumed.

Trialled on restricted diet for other ethical or perceived therapeutic reasons where entire foods groups are being eliminated, and there is cause for concern for the child’s health.

Healthy lifestyle programmes:

Beezee

Birmingham Community Healthcare:

Our Is Your Child a Fussy Eater video is also available in:

• Arabic,
• Bengali,
• Kurdish,
• Pashto,
• Punjabi
• Romanian
• Somali,
• Tigrinya,
• Urdu.

NHS webinar recordings:

Fussy eating

Forward Thinking Birmingham resources and support

Non-Asian

• BMI: greater than or equal to 40 kg/m².
• BMI: greater than 35 kg/m², with co-morbidities.

South Asian

• BMI: greater than or equal to 37.5 kg/m².
• BMI: greater than 32.5 kg/m², with co-morbidities.

With previous attempts at weight loss and are able to attend appointments. Have not had input from Tier 3 service in previous 12months

• Type 2 Diabetes, who have declined or attended XPERT.

Please send Type 1 and those for XPERT to the Community Diabetes Team BCHNT.CDTAppointments@nhs.net. 

• BMI: less than or equal to 18.5 kg/m² with clinical concern.
• BMI: less than or equal to 18.5 kg/m² with unintentional weight loss greater than 5% in the last 3 to 6 months.
• Unintentional weight loss greater than 10% in last 3 to 6 months.
• Above, with or without organic disease cause.

• Existing CVD, for example, post-MI.
• Multiple CVD Risk factors, such as dyslipidaemia and hypertension.

• CKD G1-G4 (if not under acute nephrology team).
• Please send up-to-date blood results with referral

• Suspected or diagnosed.

Please complete suitable investigations before referring.

• Newly diagnosed and on-going care.

• Irritable Bowel Syndrome.
• Inflammatory Bowel Diseases.

• Suspected eating disorder.

For confirmed, eating disorders, please refer to Birmingham and Solihull Mental Health NHS Trust, or to Forward Thinking Birmingham.

• Please contact us and we will be happy to discuss the suitability of a referral with you.

• BMI less than 18.5 kg/m² and unintentional weight loss greater than 5% within the last 3 to 6 months.
• Unintentional weight loss greater than 10% within the last 3 to 6 months.
• MUST score of 2 or more post implementation of the correct care plan. *
• Unintentional weight loss due to being on a texture modified diet post Speech and Language Therapy assessment.
• Receiving established enteral nutrition (tube feeding) in the community and are medically stable, not in an active phase of treatment and receiving majority of medical care from a GP.
• Needing enteral nutrition (tube feeding) initiated in the community. Phone first to discuss.
• Pressure ulcer grade 3 or above and not healing.

• All referrals should have a MUST score. A correct care plan should have been implemented and monitored. * Refer to the dietitian only when the care plan states this.

• The discharging dietitian needs to ensure a GP letter is done with clear guidelines on how long the supplements need to be prescribed for. Only those patients that meet the listed criteria will be followed up in the community.

• Patients with chronic kidney disease (stage 3b - if unstable, 4 or 5).
• Patients who are under regular review by a dietitian already.
• Eating disorders (please refer to our primary care team).
• Patients not consenting to see a dietitian.
• Patients not willing to make dietary changes.
• Patients who have a swallowing difficulty and have not been assessed by Speech and language Therapy.
• Patients who are for end of life care.

• BMI less than 18.5 kg/m² and unintentional weight loss greater than 5% within the last 3 to 6 months.
• Unintentional weight loss greater than 10% within the last 3 to 6 months.
• MUST score of 2 or more post implementation of the correct care plan. *
• Unintentional weight loss due to being on a texture modified diet post Speech and Language Therapy assessment.
• Receiving established enteral nutrition (tube feeding) in the community and are medically stable, not in an active phase of treatment and receiving majority of medical care from a GP.
• Needing enteral nutrition (tube feeding) initiated in the community. Phone first to discuss.
• Pressure ulcer grade 3 or above and not healing.

Specialist Nutrition Nurses will accept referrals for:

• PEG assessments.
• Training for passing NG or replacement gastrostomy’s.
• Placement of nasal bridles.
• Troubleshooting for enteral tube problems.

• Patients with chronic kidney disease (stage 3b - if unstable, 4 or 5).
• Patients who are under regular review by a dietitian already.
• Eating disorders (please refer to our primary care team).
• Patients not consenting to see a dietitian.
• Patients not willing to make dietary changes.
• Patients who have a swallowing difficulty and have not been assessed by Speech and language Therapy.
• Patients who are for end of life care.

• BMI less than 18.5 kg/m² and unintentional weight loss greater than 5% within the last 3 to 6 months.
• Unintentional weight loss greater than 10% within the last 3 to 6 months.
• MUST score of 2 or more post implementation of the correct care plan. *
• Unintentional weight loss due to being on a texture modified diet post Speech and Language Therapy assessment.
• Receiving established enteral nutrition (tube feeding) in the community and are medically stable, not in an active phase of treatment and receiving majority of medical care from a GP.
• Needing enteral nutrition (tube feeding) initiated in the community. Phone first to discuss.
• Pressure ulcer grade 3 or above and not healing.

• All referrals should have a MUST score. A correct care plan should have been implemented and monitored. * Refer to the dietitian only when the care plan states this.

• The discharging dietitian needs to ensure a GP letter is done with clear guidelines on how long the supplements need to be prescribed for. Only those patients that meet the listed criteria will be followed up in the community.

Specialist Nutrition Nurses will accept referrals for:

• PEG assessments.
• Training for passing NG or replacement gastrostomy’s.
• Placement of nasal bridles.
• Troubleshooting for enteral tube problems.

• Patients with chronic kidney disease (stage 3b - if unstable, 4 or 5).
• Patients who are under regular review by a dietitian already.
• Eating disorders (please refer to our primary care team).
• Patients not consenting to see a dietitian.
• Patients not willing to make dietary changes.
• Patients who have a swallowing difficulty and have not been assessed by Speech and language Therapy.
• Patients who are for end of life care.

Support is provided for patients with Coeliac Disease following life-long gluten exclusion. Comprehensive education on Coeliac Disease is provided to include appropriate prescribing guidance for gluten-free prescriptions following diagnosis, following this the service offers Coeliac Annual Review appointments to provide on going support.

Individualised elimination diets are used where appropriate to aid diagnosis of food intolerances and allergies, whilst maintaining nutritional adequacy within a patient’s diet. After a 6 to 8 week elimination has taken place, follows a structured reintroduction, which allows accurate diagnosis of the trigger foods (intolerance / allergy).

Following diagnosis of Chronic Pancreatitis and discharge to the community, patients can become unclear on how PERT is to be taken and at which dose. PERT dosing depends on the severity of the pancreatic exocrine insufficiency and symptoms experienced, in addition to the volume, energy density and fat content of foods consumed. The service can offer clear guidance with supportive literature to both patient and GP to improve patient experience and consistency in care.