Impaired growth

1. Growth assessments

   Assess height every 6 months until completion of puberty and attainment of final height

2. Impaired growth signs

   Any of the following:

   • Downward crossing of height percentile
   • Height velocity of <4 cm/year
   • Height <3^rd percentile

3. Refer to endocrinologist

4. Recommended

   • Assessment of bone age with left-hand X-ray
   • Thyroid function tests
   • Coeliac panel
   • Growth factors
   • Comprehensive metabolic panel
   • Complete blood count

   To be considered

   • Growth hormone stimulation testing

Delayed puberty

1. Puberty assessments

   Physical assessment of pubertal status by Tanner staging every 6 months, starting by 9 years of age

2. Delayed puberty signs

   Testicular volume <4 cm ^{Footnote 3} at age 14 years or older

3. Refer to endocrinologist

4. Recommended

   Laboratory assays:

   • Luteinising hormone
   • Follicle-stimulating hormone
   • Testosterone

   To be considered

   • Assessment of bone age with left-hand X-ray

Adrenal insufficiency

• Endocrinologists should be involved in managing glucocorticoid use, to prevent adrenal insufficiency via appropriate steroid tapering and patient education
• Endocrinologists should assist with the initiation of steroids using the PJ Nicholoff Steroid Protocol