Changes in growth velocity warrant a workup. If the height falls off I’ll order a bone age, CBC, TSH and ESR for a boy, and add a chromosome analysis if it’s a girl (to rule out Turner’s syndrome). I’ve picked up Crohn’s disease with the only symptom of growth decline and elevated ESR. If the weight velocity falters without affecting height, the history is usually sufficient to explain the symptom, for example a night-time nurser at 18 months who’s a picky eater by day.

An extremely delayed bone age with decreasing growth velocity will usually lead to an endocrinologic cause and will require growth hormone stimulation testing if hypothyroidism is ruled out. Concurrently, if the bone age is advanced and height is slowing, precocious puberty is suspected and the child should have a thorough endocrine workup.

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