Synopsis
Identify pathological slowing of linear growth, distinguish isolated growth-hormone deficiency from nutritional, systemic, thyroid, genetic and skeletal causes, then confirm the axis safely and monitor specialist somatropin for benefit and uncommon serious adverse effects.
- The key signal is reduced height velocity or downward crossing of height centiles, not a single short measurement; verify technique and plot serial values on the correct UK chart.
- Compare height with parental target range, gestation and previous trajectory, and assess weight pattern, body proportions, head circumference, puberty and dysmorphic or chronic-disease features.
- Congenital hypopituitarism may present with neonatal hypoglycaemia, prolonged jaundice, micropenis, undescended testes, midline facial abnormality or optic-nerve hypoplasia before short stature becomes apparent.
- First-line assessment excludes common causes with nutritional and systemic history, examination and targeted blood tests including full blood count, inflammation, renal, liver, coeliac and thyroid studies.
- IGF-1 and IGFBP-3 are screening markers influenced by age, puberty, nutrition, liver disease and chronic illness; a low result is not diagnostic and a normal result does not exclude every case.
- Random growth-hormone measurement is uninterpretable because secretion is pulsatile. Confirmatory stimulation testing belongs with paediatric endocrinology after adequate clinical screening and sex-steroid consideration.
- Pituitary MRI follows a supported biochemical or multi-axis concern and assesses hypothalamic, stalk and sellar anatomy; urgent imaging is needed for headache, vomiting, visual change or focal neurology.
- Somatropin is recommended by NICE for defined indications including confirmed growth-hormone deficiency; give subcutaneously daily using the licensed product and specialist weight-based plan.
- Monitor height velocity, IGF-1, thyroid and glucose, adherence and injection sites; severe headache or visual symptoms can indicate intracranial hypertension, and hip or knee pain with limp can indicate slipped upper femoral epiphysis.
- Growth response is greatest before epiphyseal closure, but treatment aims include body composition and metabolic health; review continuation at final height and during transition rather than stopping automatically at one age.
Key red flags
Growth deceleration with headache, morning vomiting, visual change or focal neurology requires urgent intracranial assessment.
Neonatal hypoglycaemia with micropenis, cholestatic jaundice or midline abnormality suggests combined pituitary deficiency including ACTH deficiency.
Polyuria and polydipsia after pituitary symptoms can indicate vasopressin deficiency and dangerous sodium disturbance.
Severe headache, vomiting or visual symptoms after somatropin initiation requires treatment pause and intracranial-pressure assessment.
New limp or hip or knee pain during rapid growth requires urgent evaluation for slipped upper femoral epiphysis.
Markedly disproportionate stature, skeletal pain or deformity should not be channelled into growth-hormone testing alone.
Poor growth with weight loss, chronic diarrhoea, inflammation or organ symptoms requires systemic-disease investigation before endocrine labelling.
Headache, vomiting, visual change, polyuria or neurological signs accompanying growth deceleration suggests a sellar or intracranial lesion.
Investigation priorities
Confirm true height deceleration using calibrated technique, correct chart, growth velocity and parental target range.
Management branches
A child is short, crosses height centiles or appears to be growing more slowly than peers.
- Repeat accurate measurement, calculate velocity and parental target and review birth, weight, nutrition, chronic symptoms and puberty.
- Examine body proportions, dysmorphism, thyroid, abdomen, neurological system and Tanner stage and retrieve historic measurements.
- Refer according to severity and red flags, using urgent imaging pathways for neurological or multi-axis features.