Appendix 6 – Nutrition and dietetics service
Leaflets and referral forms
Barnet paediatric dietetic (general) service: only accept referrals from Paediatric consultants and do not accept referrals for patients with the following conditions.
Simple overweight / obesity, unless have a comorbidity e.g. Down Syndrome / Autism
Fussy eaters (if no faltering growth).
Please refer back to GP to be seen by Health Visitors / Children’s Centres.
General Weaning Advice
Please refer back to GP to be seen by Health Visitors / Children’s Centres.
Iron Deficiency Anaemia
Constipation
Eating disorders
The following forms can be found here:
Referrals can be made online using the EPR system (dietician – paediatric form) or in writing. https://www.clch.nhs.uk/about-us/publications/referral-forms
New home enteral feeders (HEFT) (this is a different part of the dietetic service)
Note: Some children with DS who also have a significant cardiac history as well may well have a period of non-oral feeding/ NGT (nasogastric tube) feed - some children go on to have PEG (gastrostomy) and these children need to be seen by both SLT (Dysphagia team/speech and language therapist) and specialist HEFT (home enteral feeding) Dietitian.
Children’s Dietetics home enteral feeding referral form:
https://www.clch.nhs.uk/about-us/publications/referral-forms
Parent leaflet:
https://www.clch.nhs.uk/application/files/8115/1370/0300/Paediatric_Service_leaflet.pdf
Contact information:
rf-tr.bcfhdieteticpaeds@nhs.net
Referrals and appointments:
Internal referrals – there is currently an internal EPR issue with some referrals being cancelled automatically by EPR. Please refresh after the referral is made.
When raising a paediatric dietetic referral:
Click on “request/care plan” on the left-hand tab
Click on the “add” tab
Please type “dietitian” and that should quickly take you to
Diet – Paed OP referral (BH)
and complete the referral as before.
If the referral has been cancelled please email nivethitha.rasakanthan@nhs.net (Operational lead for Outpatients) who can support you further.
If you have a Barnet Hospital general patient query, please email the generic Paediatric DT email on rf-tr.bcfhdieteticpaeds@nhs.net and one of the Paediatric DT’s will respond to your query.
For Royal Free Hospital patients 0207 794 0500 ext 35716.
Obesity
1Clinical assessment
History
· Syndromic or monogenic causes – early onset of rapid weight gain in infancy with severe obesity in children aged under 2 years, hyperphagia, learning disability
· Obstructive sleep apnoea – disturbed sleep, pauses in breathing at night, daytime sleepiness, loud snoring with gasping
· Genetic predisposition – family history of familial dyslipidaemia (eg. early ischaemic heart disease or stroke) or type 2 diabetes
· Polycystic ovary syndrome – hirsutism, oligomenorrhoea
· Psychological conditions – depression, self-harm, suicidal ideation, eating disorder
· Psychosocial issues – social history, social care involvement, safeguarding concerns
Examination
· Insulin resistance and/or type 2 diabetes – acanthosis nigricans
· Syndromic obesity – dysmorphic features
· Genetic or endocrine causes of obesity – short stature or slowed growth velocity (calculate genetic height potential), Cushingoid features
· Cardiovascular comorbidity – blood pressure (ensure correct technique and cuff size, and plot on centile chart available on https://www.bsuh.nhs.uk/library/wp-content/uploads/sites/8/2020/07/Paediatric-guidelines-hypertension-tables.pdf)
– First line blood tests
Indicated if BMI on or above 98th centile, or if comorbidities or complex features are present.
· Fasting lipid profile
· Fasting insulin*, glucose* and HbA1C
· Liver function tests (LFTs)**
· Thyroid function tests (TFTs)
· Vitamin D
*Insulin and glucose are used to calculate the Homeostatic Model Assessment Score (HOMA-IR or HOMA-B), which helps to ascertain insulin resistance and long-term risk of type 2 diabetes.
**An ultrasound scan of the abdomen should be arranged if LFTs are abnormal.
Referrals
Universal services (Tier 1) – prevention
These include Health Visitors, School Nurses, GP, and Early Help Services.
Community services (Tier 2) – lifestyle management
Child Weight Management Service – Healthy Living Practitioner
· Age 5-17 years, BMI on or above 95th centile
· Home/GP/school in Camden https://gps.northcentrallondon.icb.nhs.uk/services/child-weight-management
· Home/GP/school in Islington https://gps.northcentrallondon.icb.nhs.uk/services/healthy-living-service-islington
Brandon Centre – Families, Food and Feelings Parent Programme
· For parents or carers of CYP aged 5-17 years who are above a healthy weight
· Home/GP in Camden or Islington
· https://brandon-centre.org.uk/services/families-food-and-feelings-parent-programme
Families for Life – Healthy Lifestyles Programme
· Age 2-11 years, home/GP/school in Islington
· https://findyour.islington.gov.uk/kb5/islington/directory/service.page?id=ZMmPrtiVHmc
Xplore Lifestyle Weight Management Programme
· Age 4-13 years, BMI above 91st centile, no comorbidities or additional psychological/psychiatric/behavioural needs
· Home/GP/school in Barnet
· https://gps.northcentrallondon.icb.nhs.uk/services/xplore-child-weight-management
Specialist services (Tier 3) – multi-disciplinary weight management
Consultant Paediatricians with special interest in Endocrine and Diabetes – Dr Nirit Braha/Dr Victoria Dublon (Royal Free Hospital), Dr Esther Freeman (Barnet Hospital)
· Suspected endocrine cause of obesity, such as but not limited to:
o Insulin resistance (high HOMA-IR or low HOMA-B)
o Type 2 diabetes
o Cushingoid features (needing a dexamethasone suppression test)
o Abnormal TFTs
o Polycystic ovary syndrome
· To investigate for medical complications of obesity
Familial hypercholesterolaemia (FH) clinic at Royal Free Hospital
· FH detected on genetic screening or fasting LDL cholesterol > 3mmol
· Note:
o Paediatric clinic for CYP up to age of 18 years
o Recommendation for parents’ fasting lipid profile (including LDL cholesterol) to be done via GP prior to referral
Consultant Paediatrician with special interest in Diabetes and Obesity at University College London Hospital (UCLH) – Dr Billy White
· For CYPs who live local to UCLH
· Management of medical complications of obesity requiring medical management, such as but not limited to:
o Abnormal LFTs
o Idiopathic/benign intracranial hypertension
o Other medical symptoms relating to obesity
London Complications of Excess Weight (CEW) clinic at Great Ormond Street Hospital (GOSH) in collaboration with UCLH
· Morbid obesity (BMI Z score > 3.33) and family wants help to change
· Obesity (BMI on or above 98th centile) and significant obesity-related medical comorbidity which would benefit from weight loss (eg. Type 2 diabetes, obstructive sleep apnoea, NAFLD with fibrosis, benign intracranial hypertension, physical immobility) that has not responded to treatment with specialist team and family wants help to change