When should I consider referring a patient with folate deficiency for further investigation?

Consider referring a patient with folate deficiency for further investigation if:

• There is suspicion of an underlying cause that requires specialist assessment, such as malabsorption syndromes, gastrointestinal surgery, or other conditions affecting folate absorption.
• The patient has risk factors or clinical features suggesting a more complex nutritional deficiency or haematological disorder that cannot be managed in primary care.
• The patient is pregnant or planning pregnancy and requires specialist advice on high-dose folic acid supplementation due to increased risk factors (e.g., previous neural tube defect, diabetes, or haematological conditions).
• There is failure to respond to folic acid supplementation or ongoing symptoms despite treatment, indicating the need for further diagnostic evaluation.

In general, folic acid supplementation is straightforward and well tolerated, and most cases can be managed in primary care with appropriate advice and support on adherence. Referral is warranted when there is diagnostic uncertainty, complex clinical context, or need for specialist input on management and monitoring.

For pregnant women or those planning pregnancy with increased risk of congenital malformations, referral to specialist services or advice from relevant specialists (e.g., bariatric surgery unit) is recommended for individualized management including folic acid dosing.

This approach aligns with NICE guidance on maternal and child nutrition and the management of folate supplementation in pregnancy.

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