Reasoning GP · Algorithm · 1-page summary

Short stature in children

For: children and young people with short stature or a concern about height, in UK primary care. Not for: weight faltering or poor weight gain (use the faltered growth algorithm) or a child already under specialist growth care, except the GH safety rows in block 0.

Reviewed October 2026 · next review April 2027

BSPED 2022NICE TA188NG20NG18RCPCH charts

Core rule: growth velocity matters more than a single height. A child tracking a low centile with normal velocity and no red flags is usually a normal variant; a fall of more than about one centile space, or reduced velocity, needs investigation.

0Act today — same-day actions in this pathway

Polyuria or polydipsia → capillary glucose Same-day; raised → Same-day paediatric diabetes team. Do not wait for HbA1c.
Headache + visual symptoms + polyuria/polydipsia (craniopharyngioma) → discuss with paediatrics Same-day, seen ≤48 h
On GH: severe headache, visual symptoms, papilloedema → endocrine team + Same-day assessment. Limp or hip/knee pain (SCFE) → endocrine team + Same-day orthopaedics. Do not stop GH without them.

1Refer or monitor? — serial plots, UK-WHO 0–4 y, UK90 4–18 y (BSPED)

Finding	Action
Height ≤0.4th centile	Paediatric referral, any age
<2nd centile, age ≥3 y	Refer if reduced velocity, well below mid-parental height (MPH) or red flags
Falling centiles	>about 1 centile space or reduced velocity → paediatrics ≤4 weeks
Any height	Dysmorphism, disproportion, systemic illness, delayed or precocious puberty → refer
Within MPH range	Normal velocity, no red flags → likely familial; monitor

2Screen — one row is enough

Neurological symptoms, suspected brain/pituitary tumour, malignancy, severe systemic disease, severe hypertension → Same-day paediatric discussion, seen ≤48 h
Weight gain + hypertension + proximal weakness, bruising or violaceous striae (Cushing; ask about glucocorticoids) → paediatric endocrinology ≤4 weeks
Girl with unexplained short stature (Turner; may have few features) → karyotype/genomic testing via paediatric endocrinology/genetics ≤4 weeks
Delayed (anosmia: Kallmann) or precocious puberty → paediatric endocrinology ≤4 weeks
Psychosocial deprivation or neglect → consider safeguarding; follow local safeguarding procedures

3Assess — measure well, then target tests

☐ Stadiometer, shoes off, ≥2 readings ☐ Plot height, weight, BMI; velocity over an adequate interval ☐ MPH range ☐ Proportions, puberty, dysmorphism

Targeted tests: FBC, ESR/CRP, U&E, LFTs, TSH + free T4, urinalysis, anti-tTG IgA + total IgA while eating gluten. Not in primary care: GH stimulation tests, IGF-1, bone age, karyotype — via specialist pathways. Repeat a single short reading unless red flags.

4Classify — only if the screen is negative

Familial — within MPH range, normal velocity, no red flags, normal tests → reassure.
Constitutional delay — late puberty and bone age, family history, normal velocity → reassure; annual monitoring.
Coeliac — anti-tTG positive → paediatric gastroenterology; no gluten-free diet before assessment.
Hypothyroidism — TSH high, free T4 low → discuss with paediatrics; treat per local paediatric formulary.
GH deficiency, Turner, skeletal dysplasia (short limbs, macrocephaly) → specialist; GH only specialist-initiated (TA188).
Uncertain — e.g. well below MPH range: investigate further and discuss with paediatrics.

5Treat today — only these

Positive anti-tTG: continue gluten until assessed.
Nutrition: paediatric dietitian if undernutrition or malabsorption suspected.
Wellbeing: Child Growth Foundation; advise against non-prescribed growth supplements and anabolic steroids.
GH shared care: agreed local protocol only; dose changes specialist-led. Doses per BNFc and local formulary.

6Refer and review routinely

Paediatric endocrinology ≤4 weeks: suspected GH deficiency; hypothyroidism with marked growth failure.
Genetics: dysmorphism, skeletal dysplasia. Metabolic team: hepatosplenomegaly + abnormal LFTs.
Constitutional delay with severe distress → specialist decision on a short course of sex steroids.
Re-measure every 6 months (3-monthly after starting treatment); record velocity.

7Never reassure by

Short parents alone — familial needs normal velocity and no red flags.
One height, or a reading taken without correct technique.
A girl with few Turner features — mosaicism can hide them.
No gut symptoms — coeliac is often silent in short children.
Negative coeliac serology without gluten in the diet or total IgA.
Delayed bone age — also seen in hypothyroidism, GH deficiency, chronic disease and malnutrition.

8Safety-net — say it, then document it

Same day “Contact us today if your child becomes very thirsty or passes much more urine, or has headaches with changes in vision.” Same day “On growth hormone: severe headache, vision problems, a limp or hip or knee pain — call the endocrine team and be seen today.”

Document: plotted heights, growth velocity and MPH in the record; the next measurement date and who reviews it — not "return if worse".

✓Safe to manage in primary care only if — all five, documented

No block 0–2 row applies Accurate height plotted with velocity and MPH Puberty, proportions, dysmorphism checked; safeguarding considered Targeted tests done; 6-monthly re-measure booked Safety-net given and documented

Summary of the full Reasoning GP short stature algorithm, which holds measurement technique, MPH formula, bone age interpretation, treatment by cause, GH monitoring and evidence. Sources: BSPED growth failure/short stature recommendations (2022); NICE TA188, NG20, NG18, NG12 (updated April 2026), NG76, CG89; RCPCH UK growth charts; International Turner syndrome guidelines (2024). Clinical reference — follow local paediatric and safeguarding pathways and check doses in the current BNF for Children.