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Children & Young People – USC (2WW)

Checked: 30-04-2024 by 3 Vicky Ryan Next Review: 29-04-2026

Service Overview

Services are provided by UHBW at Bristol Children’s Hospital and the Seashore centre at Weston General 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.

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 UHBW only with the child being seen at the hospital closest to their home address (BRHC for children in Bristol and South Glos, The Seashore Centre for children in North Somerset)

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

The majority of children with suspected cancer require assessment on the same day or within 48hours. Please consider whether referral to ED is appropriate.

Children with suspected lymphoma (not isolated lymphadenopathy), leukaemia, Wilms tumour, hepatoblastoma or brain tumour (with red flag signs) should be referred to the children’s ED for same day assessment.

Retinoblastoma - Please give the parents a referral letter and advise them to take the child to BEH A+E on the same/next day.

For those children where referral to outpatients is appropriate, please refer on the same day by ERS using the Suspected Childhood Cancers Referral Form and guidance below

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

If advised to refer into MDT, then please submit a USC 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 the criteria for an USC referral but the GP would still like an urgent opinion/assessment then the child can be discussed with the on call paediatrician or referred to: Paediatric Advice and Guidance or Paediatric rapid access clinic 

Referrals - Lymphoma and Leukaemia

An unwell child with symptoms consistent with leukaemia or lymphoma needs immediate (same day) referral to hospital by telephone.

Children with hepatosplenomegaly and petechiae need immediate (same day) referral to hospital by telephone.

Well children with a single sign/symptom of leukaemia should be offered a very urgent FBC (48hrs).

Please see Referral guidance for suspected cancer in children and young people produced by Children’s Cancer and Leukaemia Group for detail on symptoms/signs of lymphoma and leukaemia and further referral guidance.


Benign reactive lymphadenopathy is very common in children and not of concern. It is normal for palpable benign lymph nodes to remain present for many months without regressing completely.

Please see Management of Lymphadenopathy in children in Primary Care guidelines produced by Bristol Children's Hospital.

Characteristics of benign lymphadenopathy 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

Consider referral to secondary care for assessment of lymphadenopathy if any of the following:

  • Lymphadenopathy of axillae or supra-clavicular regions
  • Large nodes >2cm diameter (not small ‘shotty’ ones) in the groins or neck
  • Accompanied by concerning symptoms such as unexplained fever, night sweats, shortness of breath (especially when lying flat), pruritis, unexplained back pain, or unexplained weight loss

If a child has potentially concerning lymphadenopathy, please examine the whole body and describe the size and location of the nodes in the ‘clinical details’ section of the referral form, plus any associated symptoms.

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

Presentation, symptoms and signs depend upon the age of the child. Many of the potential symptoms listed are common in children and young people and are not the result of a brain or CNS tumour. A combination of symptoms is more worrying and so children presenting with one of the symptoms below should be assessed for others.


Signs and Symptoms of a potential brain or CNS tumour

Same day discussion with Paediatric Emergency Department  (Tel: 0117 3428666).

+/- referral for neuroimaging

  • Signs of raised intracranial pressure:
    • Early morning waking with headache on most days over a four week period
    • Early morning waking with headache accompanied by vomiting on most days over a two week period
    • Bulging fontanelle in a younger child
    • Papilloedema
  • Persistent unexplained vomiting (occurring on most days over a two week period)
  • Reduced level of consciousness
  • New onset cerebellar signs e.g. demonstrable unsteadiness, stumbling/falling more often
  • Development of a head tilt, holding the head or neck at an awkward angle or twisted position
  • Development of wry neck (difficulty in turning the head)
  • Blurred or double vision, or a sudden worsening in vision /eyesight
  • Cranial nerve abnormalities
  • New-onset afebrile seizures with focal onset/symptoms
  • Symptoms of spinal cord compression (back or neck pain, sensory or motor disturbance, bladder or bowel problems)

Refer via e-referral to Paediatric Rapid Access Clinic

  • Visual disturbances (that do not meet the threshold described in the box above)
  • Gait abnormalities (that do not meet the threshold described in the box above)
  • Motor or sensory signs
  • Persistent back pain can be a symptom of a tumour involving the spine and is indication for an examination, investigation with a full blood count and blood film, and consideration of referral

In infants and young children

  • Abnormally rapid increase in head size
  • Arrest or regression of motor development
  • Altered behaviour
  • Abnormal eye movements
  • Lack of visual following
  • Poor feeding/failure to thrive

Other symptoms to consider that could be associated with a brain tumour 

  • Unexplained deteriorating school performance or developmental milestones
  • Unexplained behavioural and/or mood changes
  • Precocious puberty (in girls before the age of 8, in boys before the age of 9), particularly in boys, accompanied by at least one other symptom from the list above
  • Delayed or arrested puberty, accompanied by at least two other symptoms from the list above


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.

The current guidance in BNSSG is that these babies should be referred for assessment either same day or next working day to exclude retinoblastoma rather than being referred through e-referral which can cause delay.

Please give the parents a referral letter and advise them to take the child to BEH A+E on the same/next day.

Remember to ask if there is a family history of retinoblastoma.

Referrals - Sarcoma

Soft Tissue Sarcoma

Refer on the USC pathway and for 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.

Clinical features are related to the mass, its impact on surrounding tissues. It may also release a bloody/purulent discharge.

Some clinical features of sarcomas are

  • Deep to the fascia
  • Firm/hard
  • Tethered
  • 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 high clinical concern then refer on USC pathway at the same time as requesting imaging.

If imaging is suspicious of bone sarcoma then refer on the urgent suspected cancer pathway.

If imaging 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

If a child has a palpable abdominal mass or unexplained enlarged abdominal organ, they should be referred for same day assessment in the Paediatric Emergency Department.

If a child has unexplained visible haematuria then they should be referred via ERS on the urgent suspected cancer pathway for urgent assessment.

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

Neuroblastoma presentation depends on the child’s age and dissemination of tumour

Please see Referral guidance for suspected cancer in children and young people produced by Children’s Cancer and Leukaemia Group for detail on symptoms/signs of neuroblastoma.

These children should be referred directly to ED or via the USC pathway depending on clinical scenario.

Referrals – Testicular Cancer

Children with a possible testicular cancer should be referred via ERS on the urgent suspected cancer pathway. Paediatric urology will arrange urgent imaging and clinical review.

Patients with examination findings that are not felt to be malignant (e.g. epididymal cyst, varicocele) can be referred for a routine testicular ultrasound but if there is a clinical suspicion of cancer then please refer on the USC pathway.

Please see  testicular ultrasound section on the Children's Radiology page for guidance on testicular ultrasound.

Referrals - 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 Cancers Referral 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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