I practice in northern Virginia, where we have access to all pediatric specialists, making it easy to refer out for many problems. Although tempting, this is not how I was trained, and not how I like to practice. Here are some common conditions/findings that are often, but unnecessarily, referred. In all the examples below, assume the child is otherwise well.
1. Most heart murmurs in children are innocent, and there is no hurry about referring a hemodynamically insignificant one anyway. If it sounds functional (eg, a vibratory systolic ejection murmur that fades on sitting up), and you are comfortable you are not missing something major such as cyanotic heart condition or co-arctation, you can follow it in your office for a few visits to see if it goes away.
2. The occasional premature ventricular contraction in a baby is worth an electrocardiogram (EKG) to confirm but can be seen by you at checkups thereafter to see if it resolves on its own.
3. You can handle a first afebrile seizure in a child who is otherwise well. Standard of care is not to get an electroencephalogram or start medicine anyway.
4. I do not refer a toothless child until they are aged 15 months.
5. A classic first faint (eg, teenaged girl on a hot day, with a prodrome) does not necessarily need evaluation beyond the history and physical, and if you do, an EKG is sufficient.
6. Benign-appearing, nontender, nonmatted, nonfixed lymph nodes, in typical locations, can be seen in the office in a few weeks to monitor their progress. (This does not apply to supraclavicular nodes.)
7. Mild tics are usually transient, and do not need a workup, nor do they usually interfere enough with activities to warrant treatment.
8. Congenital laryngomalacia, in the thriving child with good oxygenation, can forego an ears/nose/throat evaluation unless it does not improve on its own.
9. It is reasonable to have an endocrinologist see a patient with hypothyroidism the first time, but once on replacement therapy you should be able to handle the medicine and lab work yourself.