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Referral Guidelines

Pediatric Rheumatology - Referral Guidelines


Caring for children with rheumatic and inflammatory diseases, our physicians are skilled in diagnosis, treatment, and longterm monitoring of therapeutic effectiveness and coordination of care. With three full-time pediatric rheumatologists, our team treats 1,500 outpatient visitors and 200 inpatients each year. We offer a multidisciplinary approach to patient care and collaborate closely with Nephrology, Orthopedic Surgery, Ophthalmology, Pain Medicine, and Physical and Occupational Therapy.

Rheumatic diseases are an important cause of disability in childhood. Proper diagnosis and early aggressive intervention can minimize both short and long term morbidity of these conditions. The goals of treatment of childhood rheumatologic diseases are to control disease activity, preserve normal physical, social and emotional growth and development, minimize chronic disability and deformity, and achieve remission of disease.

Condition Pre-Referral Workup When to Refer
 Dermatomyositis /
Muscle Weakness
Skin rashes (eyelids, knuckles, knees, elbows)
Photosensitivity
Weakness (proximal muscles)
Swallowing difficulties
Fatigue
Nail fold erythema
Calcium nodules
Suggested labs: CBC w/diff, CMP, CK, LDH, Aldolase,
ESR, CRP, ANA w/titer, TB skin test
Abnormal labs
Muscle weakness (severe weakness or abdominal
pain can be a medical emergency)
Swallowing problems
 Fever of Unknown Origin /
Periodic Fever Syndromes
 Fever pattern and duration
Associated symptoms (e.g., rashes, weight loss)
Diary or calendar of fevers episodes
Ethnicity and family history
Infections ruled out
Clear sinuses and chest X-rays
Labs: CBC w/diff, ANA w/titer, ESR, CRP, AST, LDH,
blood cultures, TB skin test, stool for occult blood
Persistent fevers over 2 weeks with
source
Mouth sores
Swollen joints
Abnormal labs (e.g., high ESR)
 Generalized Arthralgia Check for presence of: joint swelling, hypermobility,
flat feet, sleep disorder, mood disorder
If patient has persistent joint swelling, persistent
limp or joint contracture, not attributable to an
Orthopedic problem
If there is a specific source of pain, i.e. arthritis or
myositis or there is lab evidence of inflammation
(elevated ESR)
Refer to Pain Medicine and/or PT for Fibromyalgia
Possible SLE
Evidence of multisystem disease –
may present as arthritis, chronic
ITP, hemolytic anemia, or renal disease
Rashes (malar, discoid), photosensitivity, hair loss
fatigue, fevers, Raynaud’s, mouth ulcers, swollen
joints, bruising, bleeding, edema
Family history of autoimmune disease
Suggested labs: CBC w/diff, ESR, CRP, CMP, ANA
w/titer, ENA, Anti-dsDNA, C3, C4, UA, TB skin test
Strongly positive ANA and other abnormal labs
Low ANA with absence of clinical or other lab
findings is unlikely to be SLE
 Raynaud’s Triphasic color change (white, purple, and red) in
response to cold or stress
Primary more common in adolescent females
Evidence of other organ involvement (secondary)
Digital ulcers
Labs: CBC w/diff, CMP, ESR, ANA w/titer, UA
Severe symptoms or frequent episodes
Digital ulcerations
Signs of other autoimmune disease
Abnormal labs
 Scleroderma Syndromes Skin changes (thickening, tightening, sclerodactyly)
Multisystem disease in generalized form (e.g.,
esophageal dysmotility, calcinosis, pulmonary
hypertension, renal involvement)
Labs: CBC w/diff, CMP, ESR, ANA w/titer, UA, TB
skin test
Chest x-ray
Suspected scleroderma of any type
Skin tightening


Pediatric Rheumatology - Referral Guidelines - Departments & Programs - Children's National Medical Center