Rheumatology Referral Guidelines

The Rheumatology experts care for children with rheumatic and inflammatory diseases. Our physicians are skilled in diagnosis, treatment and long-term monitoring of therapeutic effectiveness and coordination of care. With three full-time pediatric rheumatologists, our team treats 1,500 outpatient visitors and 200 inpatients each year. We offer a multidisciplinary approach to patient care and collaborate closely with Nephrology, Orthopedic Surgery, Ophthalmology and Physical and Occupational Therapy.

Rheumatic diseases are an important cause of disability in childhood. Proper diagnosis and early aggressive intervention can minimize both short and long term morbidity of these conditions. The goals of treatment of childhood rheumatologic diseases are to control disease activity, preserve normal physical, social and emotional growth and development, minimize chronic disability and deformity and achieve remission of disease.

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When to Refer a Patient

Dermatomyositis/Muscle Weakness

Pre-Referral Workup:

Skin rashes (eyelids, knuckles, knees and elbows)
Photosensitivity
Weakness (proximal muscles)
Swallowing difficulties
Fatigue
Nail fold erythema
Calcium nodules
Suggested labs: CBC w/diff, CMP, CK, LDH, Aldolase, ESR, CRP, ANA w/titer and TB skin test

When to Refer:

Abnormal labs
Muscle weakness (severe weakness or abdominal pain can be a medical emergency)
Swallowing problems

Fever of Unknown Origin/Periodic Fever Syndromes

Pre-Referral Workup:

Fever pattern and duration
Associated symptoms (e.g., rashes, weight loss)
Diary or calendar of fevers episodes
Ethnicity and family history
Infections ruled out
Clear sinuses and chest X-rays
Labs: CBC w/diff, ANA w/titer, ESR, CRP, AST and LDH
Blood cultures, TB skin test, stool for occult blood

When to Refer:

Persistent fevers over two weeks with source
Mouth sores
Swollen joints
Abnormal labs (e.g., high ESR)

Generalized Arthralgia

Pre-Referral Workup:

Check for presence of: joint swelling, hypermobility, flat feet, sleep disorder or mood disorder

When to Refer:

If patient has persistent joint swelling, persistent limp or joint contracture, not attributable to an orthopaedic problem
If there is a specific source of pain, i.e. arthritis or myositis or there is lab evidence of inflammation (elevated ESR), refer to PT for Fibromyalgia

Possible SLE Evidence of Multisystem Disease – May Present as Arthritis, Chronic ITP, Hemolytic Anemia or Renal Disease

Pre-Referral Workup:

Rashes (malar, discoid), photosensitivity, hair loss, fatigue, fevers, Raynaud’s, mouth ulcers, swollen, joints, bruising, bleeding or edema
Family history of autoimmune disease
Suggested labs: CBC w/diff, ESR, CRP, CMP, ANA w/titer, ENA, Anti-dsDNA, C3, C4, UA and TB skin test

When to Refer:

Strongly positive ANA and other abnormal labs
Low ANA with absence of clinical or other lab findings is unlikely to be SLE

Raynaud’s

Pre-Referral Workup:

Triphasic color change (white, purple and red) in response to cold or stress
Primary more common in adolescent females
Evidence of other organ involvement (secondary)
Digital ulcers
Labs: CBC w/diff, CMP, ESR, ANA w/titer and UA

When to Refer:

Severe symptoms or frequent episodes
Digital ulcerations
Signs of other autoimmune disease
Abnormal labs

Scleroderma Syndromes

Outpatient Appointment Referral Pads

Children's National Hospital offers convenient outpatient locations for specialty care. To help connect your patients with our specialists, please complete the form to request a referral pad from your physician liaison.

Request referral pads