Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
ALT, GGT, Bili
| Within 3-6 months
Albumin
| Within 3-6 months
CBC, ESR/CRP
| Within 3-6 months
Celiac screen on gluten
| Within 3-6 months
Description of symptoms (if relevant)
| Within 1 month
Pediatric consult
| Within 3-6 months
Abdominal Pain (chronic or recurrent)
1. Refer to pediatrician.
2. Referral from pediatrician to pediatric gastroenterology must include the indicated information/investigations.
Red flags include;
*weight loss
*diarrhea +/- blood
*vomiting
*nocturnal waking
*fever
*fatigue
*age <3 years old
Autoantibody screening for celiac disease positive
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
CBC
| Within 3-6 months
Celiac screen on gluten
| Within 3-6 months
Ferritin
| Within 3-6 months
Celiac Screen: positive finding
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
C. Diff toxin (age >1 year)
| Within 1 month
CBC, ESR/CRP
| Within 1 month
Celiac screen on gluten
| Within 1 month
Description of symptoms (if relevant)
| Within 1 month
Electrolytes, TCO2
| Within 1 month
Iron studies
| Within 1 month
Stool O&P, culture
| Within 1 month
Total protein/albumin
| Within 1 month
Chronic diarrhea = duration >4 weeks
1. Refer to pediatrician.
2. Referral from pediatrician to pediatric gastroenterology must include the indicated information/investigations.
Red flag;
*>5% weight loss
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Liver disease (chronic)/Portal Hypertension
Conjugated hyperbilirubinemia
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
ALT, AST, GGT
| < 1 week
Abdominal U/S
| < 1 week
Bili T/D
| < 1 week
INR
| < 1 week
Stool color
| < 1 week
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Ca
| Within 3-6 months
Celiac screen on gluten
| Within 3-6 months
Description of stool
| Within 3-6 months
Electrolytes, TCO2
| Within 3-6 months
Pediatric consult
| Within 3-6 months
TSH
| Within 3-6 months
Treatment (dose, duration, results)
| Within 3-6 months
1. Refer to pediatrician.
2. Referral from pediatrician to pediatric gastroenterology must include the required information/investigations.
Diet / texture progression difficulty
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Diet/Texture progression difficulty
| Within 1 month
1. Refer to pediatrician.
2. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
Referral Form3. For feeding issues refer to Eating, Feeding, Swallowing Services- Fax 403-476-7756 ph 403-955-7107
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Description of symptoms
| Within 1 month
Dysphagia or Odynophagia
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
CBC, ESR/CRP
| Within 1-3 months
Ca, Phos, ALT
| Within 1-3 months
Celiac screen on gluten
| Within 1-3 months
Electrolytes, BUN, Creat.
| Within 1-3 months
Pediatric and/or Nutrition Services consult
| Within 1-3 months
Total protein/albumin
| Within 1-3 months
1. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
2. For feeding issues refer to Eating, Feeding, Swallowing Services- Fax 403-476-7756 ph 403-955-7107
Fatty liver with elevated BMI
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
AST, ALT, GGT, ALP
| Within 3-6 months
Abdominal U/S
| Within 3-6 months
BIL, ALB
| Within 3-6 months
Lipid profile
| Within 3-6 months
Fatty Liver with elevated BMI (BMI 85th percentile or greater for age)1. Refer to pediatrician.
2. Refer to Pediatric Center for Weight and Health (PCWH)
Link3. Referral from pediatrician to pediatric gastroenterology must include required information/investigations.
Fatty liver without elevated BMI
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
AST, ALT, GGT, ALP
| Within 3-6 months
Abdominal U/S
| Within 3-6 months
BIL, ALB
| Within 3-6 months
Lipid profile
| Within 3-6 months
Fatty Liver without elevated BMI (BMI 85th percentile or less)
Feeding difficulty with suspected aspiration
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
1. Refer to Eating, Feeding, Swallowing Services- Fax 403-476-7756 ph 403-955-7107
2. May require a prior referral to pediatrician and/or Pediatric Nutrition Counselling for a clinical assessment.
Feeding difficulty without failure to thrive
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
1. Refer to pediatrician.
2. Consider referral to Nutrition Services if one or more food groups are missing from diet or very low food variety with suspected nutrient deficiency.
3. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
4. Refer to Eating, Feeding, Swallowing Services- Fax 403-476-7756 ph 403-955-7107
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
History and type of allergy
| Within 1 month
1. Refer to pediatrician.
2. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
Gastroesophageal reflux disease
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Pediatric consult
| Within 1 month
1. Refer to pediatrician.
2. Persistent complicated (FTT, hematemesis, respiratory symptoms) or medication-dependent GE reflux may be referred to pediatric gastroenterology for long term management.
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
CBC
| Within 1 month
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
ALT, AST, GGT
| < 1 week
Bili, T/D
| < 1 week
CBC
| < 1 week
INR
| < 1 week
Hepatitis: Acute (ALT >10x normal, normal INR)
Hepatitis B and hepatitis C
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Hepatitis B, C - serology positive
Imaging of abdomen abnormal
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Image finding (optional)
| Within 1 month
Consider contacting pediatric gastroenterology service directly to determine the optimal approach.
Inflammatory bowel disease
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
ALT, GGT, lipase
| Within 1 month
Albumin
| Within 1 month
C. difficile toxin
| Within 1 month
CBC
| Within 1 month
Description of symptoms (if active send abnormal labs, if suspected send normal labs)
| Within 1 month
ESR/CRP
| Within 1 month
Ferritin/Iron studies
| Within 1 month
Stool C&S, O&P
| Within 1 month
Active/suspected/inactive
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
CBC
| Within 1 month
Celiac screen on gluten
| Within 1 month
ESR/CRP
| Within 1 month
Iron studies
| Within 1 month
Potential reason for deficiency
| Within 1 month
1. Refer to pediatrician.
2. For anemia with suspected GI cause, refer to pediatric gastroenterology.
3. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
ALT, GGT, Bili T/D
| Within 1 month
Abnormal ultrasound
| Within 1 month
Albumin
| Within 1 month
CBC
| Within 1 month
CK
| Within 1 month
INR
| Within 1 month
IgG
| Within 1 month
Viral hepatitis screen (B&C)
| Within 1 month
Abnormal on 2 occasions over 3-6 months
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Nutrition/Nutrient Deficiency
1. Consider referral to Pediatric Nutrition Counselling (PNC) Fax- 403-476-9621
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Abdominal U/S
| Within 1 month
Lipase
| Within 1 month
Chronic/recurrent
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Abdominal U/S
| Within 3-6 months
Barium swallow
| Within 3-6 months
CBC
| Within 3-6 months
Electrolytes
| Within 3-6 months
Persistent vomiting/nausea
1. Pediatric gastroenterologists may refer to surgery for confirmed malrotation.
Red flag;
*bilious vomiting (emergency)
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Family history (mutation and/or names of polyps if available)
| Within 1 month
Previous screening/colonoscopy if available
| Optional
Polyposis, family history
1. May require referral to medical genetics.
Rectal bleeding age 1 year or older
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Albumin
| Within 1 month
CBC
| Within 1 month
ESR/CRP
| Within 1 month
Age >1 year without constipation
Rectal bleeding age < 12 months
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Albumin
| Within 1 month
CBC
| Within 1 month
ESR/CRP
| Within 1 month
Pediatric consult
| Within 1 month
Age <12 months without constipation
1. Refer to pediatrician.
2. Referral from pediatrician to pediatric gastroenterology must include the indicated information/investigations.
Unconjugated hyperbilirubinemia
Medication List (including dose, frequency and route)
| Within 1 month
Growth chart (or at least current height/weight)
*BMI should be calculated and plotted for children ages 2-17 years
| Within 1 month
Summary of medical and treatment history
| Within 1 month
Bili T/D
| Within 1 month
CBC
| Within 1 month
Pediatric consult
| Within 1 month
1. Refer to a pediatrician.
2. Referral from pediatrician to pediatric gastroenterology must include the indicated information/investigations.