Download Children`s Fast Track Referral – 2 Week Wait Fax to: 0114 2757836

Children’s
Fast Track Referral – 2 Week Wait
Fax to: 0114 2757836
Patient Details:
Patient Name
Address
DOB
Home Tel. No.
Mobile Tel. No.
Preferred Tel.
No.
Main Spoken
Language
Transport
required?
NHS No.
Gender
Ethnicity
Email Address
Interpreter needed?
Registered GP Details:
Practice Name
Registered GP
Registered GP
Address
Tel No.
Email
Date of referral:
Usual GP
Fax No.
Practice Code
Time of referral:
Dear Colleague
I would be grateful for your opinion on the patient named above who presents with clinical findings I consider
suspicious of malignancy.
I have discussed the possibility of cancer with this patient. Has the patient confirmed that they can be available to
attend an appointment within the next two weeks? Yes
No
Sections deal with:



Leukaemia
Lymphoma
Brain tumour
Form to be reviewed annually



Neuroblastoma
Wilms’ tumour
Soft tissue sarcoma
Page 1 of 8



Bone tumour
Retinoblastoma
Thyroid tumour
Revised: August 2016

X if
chosen
Leukaemia (0-16 years)
Contact on call
consultant
One or more of the following symptoms and signs requires investigation with full blood count
and blood film:
X if
X if
If full blood
chosen
chosen
count or blood
film indicates
leukaemia,
Pallor
Persistent or recurrent infections
Contact on call
consultant
If
full
blood count
Fatigue
Generalised lymphadenopathy
or
blood
film do
Unexplained
Persistent or unexplained bone pain
not
indicate
irritability
leukaemia but
still high level of
suspicion from
Unexplained fever
Unexplained bleeding, bruising or purpura
history
2ww referral
Hepatosplenomegaly

X if
chosen
Lymphoma (0-16 years)
Contact on call
consultant
Lymphoma is suspected if one or more of the following are present, particularly in the absence of
local infection:
X if
X if
chosen
chosen
Lymph nodes non-tender, firm
Other features of general illor hard
health, fever or weight
2ww referral
The axillary nodes are involved
Lymph nodes greater than
(in the absence of local infection
2cm in size
or dermatitis)
Lymph nodes progressively
The supraclavicular nodes are
enlarging
involved
Mediastinal or hilar mass on chest X-ray

X if
chosen
Brain tumour (0-16 years)
Reduced level of consciousness
Contact on call
consultant
Any symptoms suggestive of spinal cord compression
AGED <2
The development of any of the following symptoms may suggest a CNS tumour:
Form to be reviewed annually
Page 2 of 8
Revised: August 2016
X if
chose
n
X if
chosen
AGED >2
X if
chosen
New onset seizures
Extensor attacks
Bulging fontanelle
Persistent vomiting
Abnormal increase in head size
Arrest or regression of motor
development
Altered behaviour
Abnormal eye movements
Lack of visual following
Contact on call
consultant
2ww referral
Poor feeding/failure to thrive
Squint (Referral urgency contingent on other features)
The presence of any of the following should prompt urgent or immediate referral:
Headache and vomiting causing early morning waking
New and persistent headache
Contact on call
consultant
If unable to undertake
an adequate
neurological
examination,
2ww referral
New onset seizures with any associate neurological signs.
Cranial nerve abnormalities
Visual disturbances
Gait abnormalities
2ww referral
Motor or sensory signs
Unexplained deteriorating school performance or developmental
milestones
Unexplained behavioural and/or mood changes

X if
chosen
Neuroblastoma (all ages) Refer to NICE CG27 Page 92
Infant younger than 1 year with abdominal or thoracic mass
Contact on call
Child with abdominal mass and either leg weakness and /or unexplained
consultant
urinary retention as this may be due to cord compression.
The presence of the following symptoms and signs requires investigation with full blood count:
X if
X if
chosen
chosen
If results indicate
Persistent or unexplained
Unexplained fever
anaemia,
consider
bone pain
neuroblastoma
Persistent or recurrent upper
Pallor
2ww referral
respiratory tract infections
Fatigue
Generalised lymphadenopathy
Unexplained irritability
Unexplained bruising
In children or young people with symptoms that could be explained by neuroblastoma, an
abdominal examination and/or urgent abdominal ultrasound should be undertaken and FBC and
chest X-ray considered
In children or young people with symptoms that could be explained by neuroblastoma, an
abdominal examination and/or urgent abdominal ultrasound should be undertaken and FBC and
chest X-ray considered
Form to be reviewed annually
Page 3 of 8
Revised: August 2016
Any mass identified
Proptosis
Leg weakness (see above)
Unexplained urinary retention
(see above)
Unexplained back pain

Wilm’s Tumour (all ages) Refer to NICE CG27 Page 92
X if
chosen
X if
chosen
Progressive abdominal
distension
Contact on call
consultant
Contact on call
consultant
Abdominal mass
Abdominal examination not
possible
2ww referral
Haematuria

Soft Tissue Sarcoma (all ages)
An unexplained mass at almost any site that has one or more of the following features:
X if
X if
chosen
chosen
Associated with regional lymph node
Deep to the fascia
2ww referral
enlargement
Non-tender
Size >2 cm in diameter
Progressively enlarging
A soft tissue mass in an unusual location:
X if
chosen
Proptosis
Persistent unexplained unilateral nasal
obstruction with or without discharge and/or
bleeding
X if
chosen
X if
chosen
Scrotal swelling
Consider
Sarcoma
Bloodstained vaginal
discharge
Aurul polyps/discharge

Urinary retention
Bone Sarcoma (all ages)
Persistent localised bone pain and/or swelling
Rest pain, back pain or unexplained limp
X-ray suggestive of osteosarcoma
Form to be reviewed annually
Page 4 of 8
X-ray required
Discuss with paediatric
orthopedic surgeon or
paediatrician, and/or X-ray
2ww referral
Revised: August 2016

X if
chosen
Retinoblastoma (mostly under 2 years)
2ww referral
to paediatric ophalmologist
White papillary reflex (leukocoria)
X if
chosen
X as
applicable
New squint or change in visual
acuity

X if
chosen
Suspicion of
cancer
Discrete Lump with Thyroid
Pre-pubertal and adolescents with new thyroid mass

X
chosen
2ww referral
to paediatric ophalmologist
Skin Cancer
2ww referral
to Paediatric Endocrinologist
X as
applicable
Rapidly changing skin lesion
2ww referral to dermatology
Changing pigmented skin lesion
2ww referral to dermatology
Clinical Information
Medical History
Current Medications
Known Allergies
Family history
Patient anxiety level
Form to be reviewed annually
Page 5 of 8
Revised: August 2016
Patient information and support needs
Information given to the patient
Other information
WHO performance status: (please tick)
0 – normal activity
1 – restrictive light work
2 – self-care but no work > 50% of working day
3 – limited self-care – confined to bed/chair > 50% of waking day
4 – completely disabled – totally confined to bed/chair
To be completed by the Data Team
Date of decision to refer
Date of appointment
Date of earliest offered appointment (if different to
above)
Specify reason if not seen at earliest offered
appointment
Periods of unavailability
Booking number (UBRN)
Final Diagnosis:
Form to be reviewed annually
Malignant
Benign
Page 6 of 8
Revised: August 2016
Summary of the NICE 2015 suspected cancer guidelines
Childhood cancers
Leukaemia
Refer for immediate
specialist assessment
Offer FBC within 48h
Lymphoma: Non Hodgkin
Consider very urgent referral
(for appointment within 48
hours)
Brain Tumour
Consider very urgent referral

Unexplained petechiae or hepatosplenomegaly (may
indicate severe marrow suppression therefore a
medical emergency).

Children and young people with any of the following:
o Pallor
o Persistent fatigue
o Unexplained fever
o Unexplained persistent infection
o Generalised lymphadenopathy
o Persistent or unexplained bone pain
o Unexplained bruising
o Unexplained bleeding

Unexplained lymphadenopathy or splenomegaly.
Take into account any associated symptoms, particularly
fever, night seats, SOB (from mediastinal mass), pruritus or
weight loss.

Children and young people with newly abnormal
cerebellar or other central neurological function.
Neuroblastoma
Most occur in children <5y.
Consider specialist
assessment within 48h

Children with a palpable abdominal mass or
unexplained enlarged abdominal organ.
Wilm’s Tumour
Consider specialist
assessment within 48h
Soft Tissue Sarcoma
Consider a very urgent direct
access ultrasound scan
within 48 hours
Consider a very urgent
referral within 48h
Bone Sarcoma
Consider a very urgent
Form to be reviewed annually
Usually children 1-3y. Embryonal tumour of the kidney.
 Children with a palpable abdominal mass or
unexplained enlarged abdominal organ or
unexplained visible haematuria.

Children and young people with an unexplained lump
that is increasing in size.

Children and young people if they have ultrasound
scan findings that are suggestive of soft tissue
sarcoma or if ultrasound findings are uncertain and
clinical concern persists.

Children and young people if an X-ray suggests the
Page 7 of 8
Revised: August 2016
referral within 48h
Consider a very urgent direct
access X-ray within 48h
Retinoblastoma
Consider urgent referral
(within 2w) for
ophthalmological
assessment
Discrete Lump with Thyroid
possibility of bone sarcoma.

Children and young people with unexplained bone
swelling or pain.

Children with an absent red reflex.
Skin cancer
Non- site specific symptoms in children
Consider referral for children
 If there parent/carer has persistent concern or
anxiety about the child’s symptoms even if most likely
to have a benign cause. Take into account insight
and knowledge of parents/carers when considering
referral.
N.B. The positive predictive value of parental concern has
not been studied.
Form to be reviewed annually
Page 8 of 8
Revised: August 2016