Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 1 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
Table of Contents:
A. Congenital Hypothyroidism (Neonate) pg. 3
B. Congenital Hypothyroidism (Child) pg. 3
C. Acquired Hypothyroidism pg. 4
D. Autoimmune Thyroiditis/Hypothyroidism pg. 4
E. Central Hypothyroidism pg. 4
F. Acquired Hyperthyroidism pg. 5
G. Autoimmune Hyperthyroidism (Grave’s Disease) pg. 5
H. Neonatal Hyperthyroidism pg. 5
I. Goiter pg. 6
J. Thyroid Nodule pg. 7
Thyroid: Key Facts pg. 8
K. Diabetes Mellitus - Type 1 and Type 2 pg. 9
L. Hyperglycemia pg. 9
M. Impaired Glucose Tolerance pg. 9
N. Impaired Fasting Glucose pg. 9
O. Morbid Obesity pg. 10
P. Acanthosis Nigricans pg. 10
Diabetes: Key Facts pg. 10
(Table of contents continued on next page)
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 2 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
Table of Contents (continued):
Q. Short Stature pg. 11
R. Failure to Thrive pg. 12
Growth: Key Facts pg. 13 - 14
S. Precocious Puberty/Premature Thelarche - Girls pg. 15
T. Precocious Puberty - Boys pg. 16
Precocious Puberty: Key Facts pg. 16
U. Premature Adrenarche - Girls pg. 17
V. Premature Adrenarche - Boys pg. 18
W. Delayed Puberty pg. 19
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 3 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
A. Congenital Hypothyroidism (Neonate) [ICD-9 Code: 243.0] [ICD-10 Code: E00.*, E03.*]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Neonate with abnormal
Newborn Screening Test
►
URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Confirmatory TSH, Total T4 or Free T4
► All clinical notes and laboratory
results including growth chart
B. Congenital Hypothyroidism (Child) [ICD-9 Code: 243.0] [ICD-10 Code: E00.*, E03.*]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Known or treated child with
abnormal thyroid function
test
►
First available
appointment, but call the
NP/MD on-call to begin
therapy until patient can
be seen.
► Current TSH, Total or Free T4 ► All clinical notes and laboratory
results including growth chart
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 4 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
C. Acquired Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E01.8, E03.8, E02, E03.3]
D. Autoimmune Thyroiditis/Hypothyroidism [ICD-9 Code: 245.2] [ICD-10 Code: E06.3]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Elevated TSH
• Low Total T4 or Free T4
►
First available
appointment, but call the
NP/MD on-call to begin
therapy until patient can
be seen
► Current TSH, Total T4 or Free T4, Anti-
Thyroglobulin Antibody and Anti-TPO
Antibody
► If TSH is abnormal but <10 uU/ml and the
Total T4 or Free T4 are normal, obtain
thyroid antibodies and repeat the TSH,
Total T4 or Free T4 in 2-3 months. If TSH
rising and antibodies are positive, refer
► Thyroid ultrasound is unnecessary unless
the gland is asymmetric or nodules are
palpable
► All clinical notes and laboratory
records including growth chart
E. Central Hypothyroidism [ICD-9 Code: 244.8] [ICD-10 Code: E01.8, E02, E03.3, E03.8]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Low to Low normal TSH with
low Total T4 or Free T4
• History of traumatic brain
injury, midline facial
defects, brain irradiation,
hypoxic brain injury
►
URGENT:
Call NP/MD on-call to discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► After discussion with NP/MD on-call, may
be asked to obtain MRI of the brain and
pituitary with and without contrast
► Confirmatory TSH, Total T4
or Free T4
► Consider repeat of labs prior
to referral to assure validity
► All clinical notes and laboratory
records including growth chart
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 5 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
F. Acquired Hyperthyroidism [ICD-9 Code: 242.90] [ICD-10 Code: E05.90]
G. Autoimmune Hyperthyroidism (Grave’s Disease) [ICD-9 Code: 242.00] [ICD-10 Code: E05.00]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Hypertension
• Tachycardia
• Goiter
• Exophthalmos
• TSH < 0.1 uU/ml
• Elevated Total T4 or
Free T4,T3
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Current TSH, Total T4 or Free T4,
Total T3, Thyroid Stimulating
Immunoglobulin (TSI), Thyrotropin Binding
Immunoglobulin (TBII), Anti-Thyroglobulin
Antibody, Anti-TPO Antibody
►
All clinical notes and laboratory
records including growth chart
H. 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
Disease
• Hypertension
• Tachycardia
• Failure to Thrive
• Low TSH
• Elevated Total T4 or Free T4
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► TSH, Total T4 or Free T4, Total T3,
Thyroid Stimulating Immunoglobulin (TSI),
Thyrotropin-Binding Immunoglobulin (TBII)
►
If possible, check maternal Anti-TPO
Antibody, Anti-Thyroglobulin Antibody and
TSI/TBII
►
All clinical notes and laboratory
records including growth chart
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 6 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
I. Goiter [ICD-9 Code: 240.9] [ICD-10 Code: E01.2, E04.9, E01.0]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
URGENT REFERRAL IF:
• Asymmetric gland
• Increasing size or causing
discomfort
• Abnormal thyroid biopsy
►
URGENT:
Call NP/MD on-call to
discuss and start
treatment. If
symptomatic, call
NP/MD on-call to
discuss
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
►
If asymmetric, enlarging in size, or palpable
node, obtain thyroid ultrasound
► Current TSH, Total T4 or Free T4, Anti-
Thyroglobulin Antibodies and Anti-TPO
Antibodies
►
All clinical notes and laboratory
records including growth chart
ROUTINE REFERRAL IF:
• Abnormal TSH, Total T4, or
Free T4
• Abnormal thyroid antibodies
• Abnormal thyroid ultrasound
showing goiter, multiple
small nodules
► If questions, call NP/MD
on-call to discuss
► Current TSH, Total T4 or Free T4, Anti-
Thyroglobulin Antibodies and Anti-TPO
Antibodies
► All clinical notes and laboratory
records including growth chart
► Imagins studies
► If palpable nodule, see
Thyroid Nodule section
► If abnormal thyroid function
tests, see Hypothyroid or
Hyperthyroid section
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 7 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
J. Thyroid Nodule [ICD-9 Code: 242.10] [ICD-10 Code: E05.10]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
URGENT REFERRAL IF:
Palpable nodule >1.0 cm
• Family history of thyroid cancer
or MEN (multiple endocrine
neoplasia)
• Increasing size of nodule
►
URGENT:
Call NP/MD on-call to discuss and start
treatment. If symptomatic, call
NP/MD on-call to discuss
On-Call Phone #
Day:
714- 509-8634
After Hours:
714-765-7679
►
Current TSH, Total T4 or Free T4,
Anti-Thyroglobulin Antibodies and
Anti-TPO Antibodies
► Calcitonin if recommended by
CHOC Children’s Specialist in
Endocrinology
► Thyroid Ultrasound
►
All clinical notes,
laboratory or ultrasound
results and growth chart
► Fine Needle Aspiration may
be indicated
ROUTINE REFERRAL IF:
Non-palpable nodule < 1.0 cm
• Nodule on thyroid ultrasound
► If concern for thyroid cancer, please
call NP/MD on-call to discuss
► Current TSH, Total T4 or Free T4,
Anti-Thyroglobulin Antibodies and
Anti-TPO Antibodies
► Calcitonin if recommended by
CHOC Children’s Specialist in
Endocrinology
► Thyroid Ultrasound
► All clinical notes,
laboratory or ultrasound
results and growth chart
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 8 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
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.
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 9 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
K. Diabetes Mellitus - Type 1 [ICD-9 Code: 250.03] [ICD-10 Code: E10.65] Type 2 [ICD-9 Code: 250.02] [ICD-10 Code: E11.65]
L. Hyperglycemia [ICD-9 Code: 790.29] [ICD-10 Code: R73.09, R73.9]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Increased thirst and
urination
• Weight loss
• Vomiting (DKA)
• Lethargy (DKA)
• Deep Respirations (DKA)
► URGENT:
Call NP/MD on-call to
discuss and start treatment.
If symptomatic, call
Emergency Dept. (911)
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
►
Finger Stick Blood Glucose
► Urinalysis for KETONES and glucose
► If NOT acutely ill, consider STAT
chemistry panel to determine
disposition (direct admit vs. ER)
►
IF fasting BG over 126 mg/dl or a
random BG 2 hour or OGTT over 200
mg/dl, then call is URGENT
► FOR ALL NEW DIAGNOSES of Diabetes
Mellitus, please inform phone
concierge call is URGENT
► DKA is likely if patient is vomiting,
lethargic or abnormal respirations.
Send immediately to Emergency
Department AND notify Endocrine MD
or NP on-call.
M. Impaired Glucose Tolerance [ICD-9 Code: 790.22] [ICD-10 Code: R73.02]
N. Impaired Fasting Glucose [ICD-9 Code: 790.21] [ICD-10 Code: R73.01] (see pre-referral workup section for definitions)
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Obesity (BMI >97%ile)
• Acanthosis
• Positive Family History of
Diabetes
• May NOT have increased
thirst and urination
►
Routine:
First available appointment
► Impaired Fasting Blood Glucose (100-
125 mg/dl)
► Impaired 2 hour OGTT (140-199
mg/dl)
► HgA1C (abnormal >6%)
► 2 hour OGTT (8 years and over) – 1.75
grams of glucola/kg to max of 75
grams
► Renal Function and Liver Function
tests
► Growth chart
► Laboratory results
► Recent clinical notes
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 10 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
O. Morbid Obesity [ICD-9 Code: 278.01] [ICD-10 Code: E66.01] (If Early Onset, e.g. before age 5, may be genetic condition)
P. Acanthosis Nigricans [ICD-9 Code: 701.2] [ICD-10 Code: L83]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Obesity (BMI >97%ile)
• Darkening & Thickening of
skin around neck, elbow,
waist, knuckles, axilla
• Irregular Menses
►
Routine:
Referrals will be evaluated
► HgA1C (abnormal if >6%)
► Fasting Blood Glucose (Abnl 100-125)
► 2 hour OGTT (abnl 2 hour level above
140 mg/dl). FOR 8 years and over,
use 1.75 grams of glucola/kg to max
of 75 grams
► Growth chart
► Laboratory results
► Recent clinical notes
(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: (714) 509-8634 or After Hours: (714) 765-7679
► 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.
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 11 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
Q. Short Stature [ICD-9 Code: 783.43] [ICD-10 Code: R62.52]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
Poor height velocity
or crossing
percentiles) AND
associated with
severe headaches
and/or blurry vision
URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone # Day:
714-509-8634
After Hours:
714-765-7679
► May need lab tests as below but please call to discuss.
► May need urgent MRI of brain and pituitary to rule out
tumor.
► All clinical notes and laboratory results
including growth chart
•
Current Height less
than 3
rd
percentile
for age
or
• Crossing percentiles
on repeated growth
measurements.
► Routine- likely will be seen
in next 3 to 4 months
► Evaluation of mid-parental target height
► IGF-I (Insulin like growth factor-I)- QUEST test code
839, Esoterix code 500282
► IGF-BP3 (Insulin like growth factor binding protein 3)
QUEST test code 34458, Esoterix code 500281
► TSH, Free T4, CBC, Panel 18, Urinalysis
► Celiac screening (Anti-Tissue Transglutaminase –IgA and
IgG), IgA level QUEST test codes 11073 and 539
► Bone age x-ray if more than 2 years of age
► Please have parent bring CD or film of bone age x-ray
to appointment
► For females, consider karyotype for Turner syndrome
► Growth chart
► Thyroid function tests
► Laboratory results
► Bone age results – Please have parent
bring a copy of bone age x-ray (CD or
film) to visit
► Relevant clinical notes
► All non-urgent patients referred for short
stature will be sent to a growth seminar
prior to Endocrine visit
•
Current Height
greater than 3
rd
percentile but still
concern for growth
► May NOT need referral
based on initial evaluation
► Consider above laboratory testing and bone age x-ray if
>2 years old depending on symptoms.
► Evaluation of mid-parental target height. (MPTH) **See
page 10 for MPTH equation.
► Growth chart
► Thyroid function tests
► Laboratory results
► Bone age results – Please have parent
bring a copy of bone age x-ray (CD or
film) to visit
► Relevant clinical notes
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 12 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
R. Failure to Thrive [ICD-9 Code: 783.41] [ICD-10 Code: R62.51]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Hypoglycemia and
Failure to Thrive
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► May need same lab tests as below, but please call
to discuss.
► All clinical notes and laboratory
results including growth chart
•
Height less than
3
rd
percentile and
weight less than
3
rd
percentile
► Routine- likely will be
seen in next 3 to 4
months
3) QUEST test code 34458, Esoterix code 500281
► TSH, Free T4, CBC, Panel 18.
► Celiac screening (Anti-Tissue Transglutaminase –
IgA and IgG), IgA level QUEST test codes 11073
and 539
► Growth chart
► Thyroid function tests
► Laboratory results
► Bone age results – Please have parent
bring a copy of bone age x-ray (CD or
film) to visit
► Relevant clinical notes
•
Height 3
rd
percentile or
greater, but
weight less than
3
rd
percentile
► May NOT need referral
based on initial
evaluation
(714) 509-4099
► Please call NP/MD on-call for any
questions.
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 13 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
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)
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 14 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
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.
• NOTE: All non-urgent patients referred for short stature will be sent to a CHOC growth seminar.
• 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.
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 15 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
S. Precocious Puberty/Premature Thelarche (Girls) [ICD-9 Code: 259.1] [ICD-10 Code: E30.1, E30.8]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
Girls < 8 years
• Breast development with
one or more of the following
signs:
• Progressing over time
• Accelerated growth
• Vaginal bleeding
• Headaches and/or visual
changes
• Multiple Café au lait spots
> 1.5 cm (possible McCune
Albright Syndrome)
►
URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Bone age
► TSH and T4 or Free T4 by dialysis
► Pediatric LH (Quest 36086, Esoterix
500234, Lab Corp 502286)
► Pediatric FSH (Quest 36087, Esoterix
500192, LabCorp 502280)
► Ultrasensitive Estradiol (Quest 30289,
Esoterix 500152, Lab Corp 500108)
► Growth chart
► Bone age results- Please have
parent bring a copy of film/CD to
appointment.
► Lab results
► Relevant clinical notes with
physical examination including
Tanner stage.
Girls 6 – 8 years
• Breast development without
the above signs
► Routine
► Same as above
► Same as above
Girls 2 – 6 years
• Breast development without
the above signs
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
► Same as above
► Same as above
Girls < 2 years
• Breast development without
the above signs
► May NOT need referral
► None
► Call Endocrinology 714-509-8634
with any questions or concerns
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 16 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
T. Precocious Puberty (Boys) [ICD-9 Code: 259.1] [ICD-10 Code: E30.1, E30.8]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
Boys < 9 years
• Testicular enlargement
(> 4ml or > 2.5 cm)
• Penile enlargement
►
URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Confirmatory TSH, Total T4 or Free T4
► Bone age
► TSH and T4 or Free T4 by dialysis
► Pediatric LH (Quest 36086, Esoterix
500234, Lab Corp 502286)
► Pediatric FSH (Quest 36087, Esoterix
500192, LabCorp 502280)
► Pediatric Testosterone (Quest 15983,
Esoterix 500286, Lab Corp 500159)
► Growth chart
► Bone age results- Please have
parent bring a copy of film/CD to
appointment.
► Lab results
► Relevant clinical notes with
physical examination including
Tanner stage.
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.
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 17 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
U. Premature Adrenarche (Girls) [ICD-9 Code: 255.2] [ICD-10 Code: E25.0, E25.8, E25.9]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
Girls < 7 years with one or more
of the following signs: pubic
hair, axillary hair, body
odor, clitoral enlargement, but
NO breast development
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Bone age
► 17-HydroxyProgesterone (Quest 17180,
Esoterix 500270, LabCorp 500163)
► Pediatric Testosterone (Quest 15983,
Esoterix 500286, Lab Corp 500159)
► DHEAS(Quest 402, Esoterix 500116,
LabCorp 500156)
► Growth chart
► Bone age results- Please have
parent bring a copy of film/CD to
appointment.
► Lab results
► Relevant clinical notes with
physical examination including
Tanner stage
Girls 7 – 8 years with one or
more of the above signs AND
accelerated growth or clitoral
enlargement
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
► Same as above
► Same as above
Girls 7 – 8 years with one or
more of the above signs, but NO
accelerated growth or clitoral
enlargement
► Routine
► Same as above
► Same as above
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 18 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
V. Premature Adrenarche (Boys) [ICD-9 Code: 255.2] [ICD-10 Code: E25.0, E25.8, E25.9]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
Boys < 7 years with one or more
of the following signs: pubic
hair, axillary hair, body odor,
penile enlargement,
accelerated growth; but NO
testicular enlargement (<4 ml or
<2.5 cm)
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
On-Call Phone #
Day:
714-509-8634
After Hours:
714-765-7679
► Bone age
► 17-HydroxyProgesterone (Quest 17180,
Esoterix 500270, LabCorp 500163)
► Pediatric Testosterone (Quest 15983,
Esoterix 500286, Lab Corp 500159)
► DHEAS(Quest 402, Esoterix 500116,
LabCorp 500156)
► Growth chart
► Bone age results- Please have
parent bring a copy of film/CD to
appointment.
► Lab results
► Relevant clinical notes with
physical examination including
Tanner stage
Boys 7 – 9 years with one or
more of the above signs AND
accelerated growth
► URGENT:
Call NP/MD on-call to
discuss and start
treatment.
► Same as above
► Same as above
Boys 7 – 8 years with one or
more of the above signs, but NO
accelerated growth
► Routine
► Same as above
► Same as above
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 19 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
W. Delayed Puberty [ICD-9 Code: 259.0] [ICD-10 Code: E30.0]
Clinical Findings Referral Timeframe Pre-Referral Workup Referral Requirements
• Boys: no testicular
enlargement (<4 ml or <2.5
cm) by 14 years of age
• Girls: no breast
development by 13 years of
age or no menses by 15
years of age
Note: Girls with no menses
by 15 years and notable
short stature, consider
Turner Syndrome.
►
Routine
► Bone age
► TSH and T4 or Free T4 by dialysis
► Pediatric LH (Quest 36086, Esoterix
500234, Lab Corp 502286)
► Pediatric FSH (Quest 36087, Esoterix
500192, LabCorp 502280)
► Boys- Pediatric Testosterone (Quest 15983,
Esoterix 500286, Lab Corp 500159)
► Girls- Ultrasensitive Estradiol (Quest
30289, Esoterix 500152, Lab Corp 500108)
► Karyotype (if suspect Turner Syndrome)
► Growth chart
► Bone age results- Please have
parent bring a copy of film/CD to
appointment
► Lab results
► Relevant clinical notes with
physical examination including
Tanner stage
Pediatric Endocrinology Referral Guidelines
For appointments, please call the Patient Access Center at (888) 770-2462 (888-770-CHOC)
Complete the CHOC Children’s Specialists Endocrinology Referral Request Form located at http://www.choc.org/referralguidelines
Fax ALL pertinent medical records to (855) 246-2329 (855-CHOC-FAX) 20 | Page
Endocrinology On-Call Phone# Day: (714) 509-8634 or After Hours: (714) 765-7679 September 25, 2015
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