Table 4

Recommendations of when to refer to a paediatric subspecialist

CardiologyPresence of other significant cardiac symptoms and/or signs, particularly colour change (cyanosis or pallor), syncope, dizziness, palpitations, sweating, nausea, dyspnoea
Presence of a crushing, poorly localised pain with radiation to the left arm
Exercise-induced pain (assuming not due to asthma)
Strong family history of heart disease (especially hypertrophic obstructive cardiomyopathy, arrhythmias, sudden death or premature ischaemic heart disease)
Suspicion of Marfan syndrome or other connective tissue disorders
RespiratoryPresence of other significant respiratory symptoms and/or signs, particularly breathlessness, cough, noisy breathing, sputum production, haemoptysis
When asthma is likely but has not responded to standard asthma therapy, especially when pain is exercise induced
GastroenterologyPresence of other significant gastrointestinal symptoms and/or signs, particularly dysphagia
When gastro-oesophageal reflux is likely but has not responded to adequate reflux therapy
  • This assumes no underlying diagnosis has been made, as referral may be required depending on the presence of an identified cause. Referral may sometimes be necessary to offer further reassurance, even if a significant diagnosis is unlikely.