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REMEDY : BNSSG referral pathways & Joint Formulary

Children & Young People - 2WW

Checked: 25-11-2022 by vicky.ryan Next Review: 25-11-2023

Service Overview

Services provided by UHBristol at Bristol Children’s Hospital. Referrals should be in accordance with the Referral Guidelines for a Child With Suspected Cancer, South West Region, which in turn reflect NICE Guidance.

General Tips on Referral:

Consider routine referral to general paediatrics if there is parental anxiety about cancer where you do not suspect cancer in your clinical judgement, and examination and initial investigations are normal.

Consider referral when a child or young person presents with persistent back pain (an examination is needed and a full blood count and blood film).


Benign reactive lymphadenopathy is very common in children and not of concern. Palpable benign lymph nodes may remain present for many months without regressing completely, which is normal. Characteristics of benign lymphadenopathy are listed on the 2WW proforma and include:

  • Small mobile lymph nodes that often wax and wane in size with intercurrent infections.

  • Usually cervical, in anterior or posterior triangle and or occipital region.

  • Generally well child.

  • Not associated with any concerning systemic symptoms as listed in the 2WW proforma (or see lymphoma and leukaemia section below).

Please also see Referral guidance for suspected cancer in children and young people produced by Children’s Cancer and Leukaemia Group


Suspected cancer referrals should be made to UHBristol only (not NBT or Weston) using then standard Suspected Childhood Cancers Referral Guidance and Form.

At time of referral please issue the BNSSG Understanding Your Urgent Fast Track Referral patient information leaflet.

Referrals should be made by one of the following routes:

By telephone : If a child presents acutely unwell then contact the Bristol Children's Hospital Emergency Department by telephone (0117 3428666) for advice and to arrange admission if necessary.

Otherwise submit 2WW referral by e-referral.

If advised to refer into MDT, then please submit a 2WW referral to the relevant secondary care team who will ensure that all the required information is available to enable an effective MDT discussion.

If a child does not meet criteria for 2WW referral but GP would still like an urgent opinion or assessment then consider referral to either:

Paediatric Advice and Guidance


Paediatric rapid access clinic 

Referrals - Lymphoma and Leukaemia


Refer patients for suspected cancer if presenting with any of the following:

  • Hepatosplenomegaly (immediate referral)

  • Mediastinal or hilar mass on chest x-ray (immediate referral)

  • With one or more of the following (particularly if there is no evidence of local infection):

    • Non-tender, firm or hard lymph nodes

    • Lymph nodes greater than 2cm in size that have persisted for 4-6 weeks or more.

    • Lymph nodes progressively enlarging

    • Axillary node involvement (in the absence of local infection or dermatitis)

    • Supraclavicular node involvement  

    • Other features of general ill-health, fever or weight loss

  • With lymphadenopathy and associated concerning symptoms such as unexplained fever, night sweats, shortness of breath (especially when lying flat), pruritis, unexplained petechiae, unexplained weight loss or hepatosplenomegaly.


Refer patients for suspected cancer if presenting with any of the following:

  • Unexplained petechiae

  • Hepatosplenomegaly

  • Offer a very urgent full blood count (within 48 hours) to assess for leukaemia in children and young people with any of the following  (NICE guidelines 2015):

    • pallor

    • persistent fatigue

    • unexplained fever

    • unexplained persistent infection

    • generalised lymphadenopathy

    • persistent or unexplained bone pain

    • unexplained bruising

    • unexplained bleeding. 

Referrals - Brain & CNS Tumors

If you have a high index of suspicion that a child has a possible brain or CNS tumour you should discuss concerns with the paediatric emergency department on the same day (Tel: 0117 3428666).

Please note:

  • Symptoms can fluctuate - resolution and recurrence does not exclude a brain tumour.

  • A normal neurological examination does not exclude a brain tumour

A guide to signs and symptoms to look for and how to refer is included within the standard Suspected Childhood Cancers Referral Guidance and Form.

The Head Smart website decision support tool also has some useful advice on assessment and when to refer.

Referrals - Retinoblastoma

Refer patients to a paediatric ophthalmologist for suspected cancer (mostly children less than 2 years of age) presenting with any of the following:

  • A white pulpillary reflex (leukocoria).

  • Parents reporting an odd appearance in their child’s eye.

  • A new squint or change in visual acuity if cancer is suspected. (Refer non-urgently if cancer is not suspected).

Refer urgently if there is a family history of retinoblastoma and visual problems. (Screening should be offered soon after birth).

Abnormal red reflex – If there is a white pupil/lens, not just a reflex that is darker than usual in a child with pigmented skin refer URGENTLY to paediatric ophthalmology by fax (0117 342 4686) Remember to ask if there is a family history of retinoblastoma?


Referrals - Sarcoma

Soft Tissue Sarcoma

Refer for suspected cancer and/or urgent USS if a child or young person presents with an unexplained mass at any site that has one or more of the following features.

The mass is:

  • Deep to the fascia

  • Non-tender

  • Progressively enlarging

  • Associated with a regional lymph node that is enlarging

  • Greater than 2cm in diameter in size.

Bone Sarcoma (osteosarcoma and Ewing's sarcoma)

Refer for urgent plain film xray in children of all ages presenting with bone swelling or persistent and unexplained bone pain. If xray is suspicious of bone sarcoma then refer using 2WW proforma. If xray is normal but there are still concerns then refer routinely to paediatric orthopaedics.

Requesting urgent USS and xrays

All urgent requests for imaging can be sent via ICE (tick the suspect cancer box). If UHB ICE is not available to your practice then requests may be e-mailed to: 

Pease note that NBT do not do USS for children.

Referrals - Wilms' Tumour

Refer for suspected cancer a child or young person presenting with any of the following (NICE cancer guidelines 2015):

  • A palpable abdominal mass

  • An unexplained enlarged abdominal organ

  • Unexplained visible haematuria.

Children with non-visible haematuria are very unlikely to have a urological cause. UTI and localised causes should be treated if indicated. If no other cause identified then patient should be referred to a general paediatrics initially for assessment

Referrals - Neuroblastoma

Refer patients for suspected cancer  presenting with any of the following:

  • Proptosis

  • Unexplained back pain

  • Leg weakness

  • Unexplained urinary retention

Skin Cancer

Please note that skin cancer is exceptionally rare in children. Please see advice from the BNSSG cancer transformation team (updated June 2018):

Fast growing skin lesions without a diagnosis should be considered for referral, please include history and examination findings of the lesion to support this referral.

When melanoma occurs in childhood it is usually atypical or amelanotic.

Moles that appear in childhood that gradually grow/ become more raised or are very dark are normal and should not raise a concern about melanoma.

If a skin lesion is suspicious of cancer then refer using the Suspected Childhood Referral Guidance and Form.


Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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