A good referral shortens the diagnostic process considerably, and the difference is rarely length. It is whether the pattern is described clearly, whether previous investigations are attached, and whether the specific question is stated. This is written for referring colleagues, though parents may find it useful in knowing what to gather.
The core of a useful referral
State the question
The single most useful line. "Chronic wet cough, six months, three antibiotic courses, query PBB versus bronchiectasis" directs the entire assessment. "Please see and advise" does not. If the concern is a specific diagnosis, say so; if the concern is that something does not fit, say that instead.
Characterise the symptom precisely
- Cough: wet or dry; duration in weeks; continuous or recurrent with well intervals; diurnal pattern; whether present during sleep
- Wheeze: who has heard it and on auscultation or reported; during colds only or between; response to bronchodilator
- Noisy breathing: inspiratory or expiratory; age at onset; positional variation
- Snoring: frequency per week; witnessed apneas; mouth breathing; daytime consequences
Onset in the neonatal period is disproportionately important and easily omitted. A term infant who needed unexplained oxygen, or a cough present from the first weeks of life, shifts the differential substantially toward PCD, structural airway disease or aspiration.
Document the treatment trial properly
Not just what was prescribed, but the dose, duration, adherence, technique if checked, and whether it helped. "Salbutamol prn, no clear benefit" is far more useful than "on inhalers". If a preventer has been tried, state the dose and for how long. Prescription collection data, where available, is often more informative than reported adherence.
Growth
Plotted height and weight, with previous points. Faltering growth alongside respiratory symptoms changes urgency and differential more than almost any other single variable.
Attach previous investigations
Particularly previous chest imaging, including films from other countries. Recurrent changes in the same lobe are among the most useful findings in pediatric respiratory medicine and are only visible by comparison. Please send images or report copies rather than a note that an X-ray was normal.
Relevant background
Neonatal history, feeding and any choking with feeds, atopy and family atopy, consanguinity, affected siblings, travel and country of origin, TB contact, smoke or shisha exposure in the household, and immunisation status.
Useful to complete before referral, where accessible
- Chest X-ray for any chronic wet cough or recurrent focal infection
- Spirometry with reversibility in children over about five or six with suspected asthma
- Growth plotted on a centile chart
- Sweat test where accessible if cystic fibrosis is plausible, particularly in children without documented newborn screening
- Basic immune screen in recurrent infection: immunoglobulins and vaccine responses
Absence of these is not a reason to delay referral where the clinical concern is high. It is better to refer early with an incomplete workup than to wait.
Presentations warranting urgent rather than routine assessment
- Suspected inhaled foreign body, at any interval from the event
- Hemoptysis
- Faltering growth with respiratory symptoms
- Finger clubbing
- Stridor, particularly if progressive or biphasic
- Recurrent pneumonia in the same lobe
- Chronic wet cough with reduced exercise tolerance
- Suspected obstructive sleep apnea under three, or in a child with Down syndrome, craniofacial anomaly or neuromuscular disease
- A child with neuromuscular disease and new morning headache, orthopnea or weight loss — consider nocturnal hypoventilation
Common referral patterns and what helps most
- Chronic cough: character, duration, prior antibiotics with duration and response, chest X-ray. See wet versus dry cough
- Difficult asthma: current regimen with doses, adherence and collection data, technique assessment, exacerbation and steroid course history, atopy status. See when to refer asthma
- Recurrent infection: number and site of episodes, whether the same lobe, growth, immune screen if done. See recurrent chest infections
- Snoring or suspected OSA: frequency, witnessed apneas, tonsil size, comorbidity, daytime and behavioural consequences. See pediatric sleep assessment
- Neuromuscular disease: current function and ambulation, scoliosis and surgery, cough effectiveness, any prior lung function or sleep studies. See home NIV
What the family should bring
It helps to tell families explicitly to bring all inhalers and spacers, previous imaging and reports including from abroad, the immunisation record, a symptom diary or a short phone video of the breathing or cough at its worst, and the growth chart. Video of stridor, wheeze or a coughing bout is frequently more informative than anything observed in a clinic room.
What I will send back
A working diagnosis and differential, the investigations arranged and the reason for each, treatment started with the expected response and timeframe, what should prompt earlier review, and a clear statement of who is holding which part of the follow-up. If I think the original diagnosis was right and nothing further is needed, I will say so plainly.
Clinical references
- Morice AH, et al. ERS guidelines on the diagnosis and treatment of chronic cough in adults and children. Eur Respir J 2020;55:1901136. View source →
- Kantar A, et al. ERS statement on protracted bacterial bronchitis in children. Eur Respir J 2017;50:1602139. View source →
- Chang AB, et al. European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis. Eur Respir J 2021;58:2002990. View source →
Frequently asked questions
What should a pediatric respiratory referral include?
Which investigations should be done before referring?
Which pediatric respiratory presentations need urgent referral?
Why does previous chest imaging matter so much?
What should families be asked to bring to the appointment?
