Referral criteria for growth issues

select(all_of(nor_check)) %>% pivot_longer(cols = everything(), names_to = "variable", values_to = "value")## Concerns

Referral is done to specialist like pediatric endocrinologist, nutritionist and gastroenterologist

Short stature

• short stature of less than 3rd percentile or < -2 SD
• SD < -3 (severe short stature) need urgent referral as most cases are likely to be pathological
• height velocity below cutoffs
  • <5.5 cm for 2-4 yrs
  • <5 cm for 4-6 yrs
  • <4 cm for 6 yrs to puberty
  • height disproportionate for mid-parental height (± 8.5 cm from the MPH) i.e., less than 1.6 SD for target height
  • failure of SGA to catch-up growth by 2 years

Tall stature

• tall stature more than 97th percentile or > + 2 SD
• height crossing more than 2 SD upwards - accelerated growth
• signs of precocious puberty

Faltering growth

• weight for age less than -2 SD
• weight for height/length less than -3 SD
• failure to respond to initial outpatient nutritional treatment
• weight curve crosses two or more than 2 major percentiles downward

Red flag signs

• disproportionate growth - either short limbs/short trunk
• dysmorphic facies - genetic syndromes like down's and turner
• neurological symptoms - severe headache, vomiting, visual changes suggestive of mass affecting pituitary gland
• signs of chronic disease - persistent diarrhea, bloody stools, signs of hypothyroidism
• delayed puberty (after 13 for girls and after 14 for boys) and precocious puberty (before 8 for girls and 9 for boys)