Pharmacy Prior Authorization Growth Hormone - Clinical Guidelines

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1 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Gentrpin, Humatrpe, Nrditrpin, Nutrpin, Omnitrpe, Saizen, Serstim, smatrpin, Zrbtive, Zmactn I. Grwth Hrmne Deficiency in Children and Adlescents: Nte: Prvider must submit chart ntes that include the fllwing dcumentatin: weight, height, grwth velcity, and lab values (Grwth Hrmne (GH) levels, insulin-like grwth factr-1 (IGF-1) / insulin-like grwth factr-binding 3 (IGFBP-3)), stim test results, bne age Grwth Hrmne will be apprved fr members wh meet all f the fllwing criteria at initiatin f treatment: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist Infant is less than 4 mnths f age and has grwth hrmne deficiency; OR Histry f nenatal hypglycemia assciated with pituitary disease; OR Diagnsis f pan hyppituitarism; OR Histry f irradiatin, surgery r trauma t hypthalamic-pituitary area; OR A defined central nervus system (CNS) pathlgy cnfirmed by magnetic resnance imaging (MRI) r cmputed tmgraphy (CT); OR Nte: magnetic resnance imaging (MRI)/cmputed tmgraphy (CT) shuld be dne t exclude a brain tumr (fr example, cranipharyngima). Members with grwth hrmne deficiency (GHD) have an abnrmality f the pituitary gland (fr example: ectpic bright spt, empty r small sella) Diagnsis f Pediatric grwth hrmne (GH) deficiency cnfirmed by fllwing: Member must meet ne f the fllwing: Height: Height is greater than 2 standard deviatin (SD) belw mid parental height (prjected height); OR Height is greater than 2.25 standard deviatin (SD) belw ppulatin mean fr age and gender OR Grwth Velcity: Grwth Velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender OR Delayed skeletal maturatin (delayed bne age cnfirmed by X-ray): Bne age (BA) cmpared t chrnlgical age (CA) is equal t r greater than 2 standard deviatin (SD) belw mean fr age and gender (fr example: delayed mre than r equal t 2 years cmpared with chrnlgical age) Member must meet ONE f fllwing labratry results: Member has undergne tw prvcative grwth hrmne (GH) stimulatin test (fr example: Arginine, Clnidine, Glucagn, Insulin, Levdpa, grwth hrmne-releasing hrmne (GhRh)) grwth hrmne (GH) respnse values are less than 10 mcg/l; 1 P age

2 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines OR One abnrmal grwth hrmne (GH) test is sufficient fr children with defined central nervus system (CNS) pathlgy, multiple pituitary hrmne deficiency (MPHD), histry f irradiatin, r a genetic defect affecting the grwth hrmne (GH) axis; OR Member is less than 1 year f age IGF-1 (insulin-like grwth factr) r insulin-like grwth factr-binding 3 (IGFBP-3) is belw the age and gender adjusted nrmal range as prvided by the physician s lab Epiphyses are pen (cnfirmatin f pen grwth plates in members ver 12 years f age) Other pituitary hrmne deficiencies (fr example: hypthyridism, chrnic ischemic disease) have been ruled ut Prader-Willi Syndrme (PWS): Member must meet the fllwing fr initial apprval: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist; Diagnsis f Prader-Willi Syndrme (deletin in chrmsmal 15q11.2-q13 regin, maternal uniparental dismy in chrmsme 15, imprinting defects r translcatins invlving chrmsme 15) Grwth velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender Epiphyses are pen (cnfirmatin f pen grwth plates in members ver 12 years f age) Turner Syndrme (TS, gnadal Dysgenesis): Member must meet the fllwing fr initial apprval: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist Diagnsis f Turner Syndrme (karytype shwing a 45, XO gentype) Member is Female (greater than 2 years f age) and Bne age is less than 14 years Grwth velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender Epiphyses are pen (cnfirmatin f pen grwth plates in members ver 12 years f age) Nnan Syndrme (NS): (Nrditrpin nly) Member must meet the fllwing fr initial apprval: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist Diagnsis f Nnan Syndrme Epiphyses are pen (cnfirmatin f pen grwth plates in members ver 12 years f age) 2 P age

3 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Bne age (BA) cmpared t chrnlgical age (CA) is equal t r greater than 2 standard deviatin (SD) belw mean fr age and gender (fr example: delayed mre than r equal t 2 years cmpared with chrnlgical age); OR Grwth velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender Shrt stature with SHOX (shrt stature hmebx-cntaining gene) deficiency (SHOXD): (Humatrpe nly) Member must meet the fllwing fr initial apprval: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist Diagnsis f pediatric grwth failure with shrt-stature hmebx (SHOX) gene deficiency as cnfirmed by genetic testing Epiphyses are pen (cnfirmatin f pen grwth plates in members ver 12 years f age) Bne age (BA) cmpared t chrnlgical age (CA) is equal t r greater than 2 standard deviatin (SD) belw mean fr age and gender (fr example: delayed mre than r equal t 2 years cmpared with chrnlgical age); OR Grwth velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender Grwth failure assciated with Chrnic Renal Insufficiency (CRI) r Chrnic Kidney disease (CKD) (up t the time f renal transplantatin): (Nutrpin nly) Member must meet the fllwing fr initial apprval: Must be prescribed by r in cnsultatin with a Pediatric Endcrinlgist, Pediatric Nephrlgist r Endcrinlgist Diagnsis f pediatric grwth failure due t chrnic renal insufficiency (e.g., serum creatinine is less than 30 mg/dl, up t the time f renal transplant) Bne age (BA) cmpared t chrnlgical age (CA) is equal t r greater than 2 standard deviatin (SD) belw mean fr age and gender (fr example: delayed mre than r equal t 2 years cmpared with chrnlgical age); OR Grwth velcity (GV) is greater than 2 standard deviatin (SD) belw ppulatin mean fr age and gender Nte: Prir t initiatin f grwth hrmne (GH) treatment, existing metablic derangements such as malnutritin, zinc deficiency, and secndary hyperparathyridism shuld be crrected. Grwth failure in Children Small fr Gestatinal Age (SGA): Nte: Prvider must submit chart ntes with that include the fllwing dcumentatin: Gestatinal Age (GA), birth weight, height, and grwth chart Member must meet the fllwing fr initial apprval: Member is greater than 2 years f age Diagnsis f small fr gestatinal age (SGA) (fetal grwth retardatin), child wh failed t catch 3 P age

4 Initial Apprval duratin: 12 mnths Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines up grwth in first 24 mnths f life (by 2 years f age) r with n catch up grwth using a 0-36 mnth grwth chart and shwing: Member is belw the 3 rd percentile fr gestatinal age (mre than 2 standard deviatin (SD) belw ppulatin mean) fr birth weight and length; Member s height remains belw the 3 rd percentile (mre than 2 standard deviatin (SD) belw ppulatin age and gender) Renewal criteria fr grwth hrmne (GH) therapy in Children: Nte: Prvider must submit dcumentatin fr renewal: previus height, current height and expected adult height gal. Member must meet the fllwing fr renewal apprval: Dcumentatin supprting psitive respnse t therapy: Height increase f at least 2.5cm/year (pst-pubertal grwth rate) r 4.5cm/year (pre-pubertal grwth rate) Expected final height is nt achieved Bne age is less than16 years fr males; less than 14 years fr female; Grwth (epiphyseal) plates are still pen Fr children with Prader Willi Syndrme (PWS): Dcumentatin supprting psitive respnse t therapy (fr example: increase in ttal lean bdy mass, decrease in fat mass); OR abve renewal requirements. Renewal Apprval duratin: 12 mnths Discntinuatin criteria fr grwth hrmne (GH) therapy in Children: Expected final adult height has been reached; OR Member had pr respnse t treatment, generally defined as an increase in grwth velcity (GV) f less than 50% frm baseline in the 1 st year f therapy; OR Increase in height velcity is less than 2 cm ttal grwth in 1 year f therapy; OR Epiphyseal fusin has ccurred; r There are persistent and uncrrectable prblems with adherence t treatment II. Transitin Phase Adlescent members Member must meet the fllwing fr initial apprval: Member has attained expected adult height Clsed epiphyses n bne radigraph Member is at high risk f grwth hrmne (GH) deficiency due t childhd-nset grwth hrmne deficiency (COGHD) frm ne f fllwing: Hypthalamic-pituitary structural defect r tumr; OR At least 3 deficiency f anterir pituitary hrmnes (fr example: fllicle-stimulating hrmne (FSH)/luteinizing hrmne (LH), thyrid-stimulating hrmne (TSH), adrencrtictrpic hrmne 4 P age

5 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines (ACTH), Prlactin), pan hyppituitarism; OR Genetic cause f grwth hrmne (GH) Insulin-like grwth factr (IGF-1) is belw the age and gender adjusted nrmal range as prvided by the physician s lab OR Member has stpped grwth hrmne (GH) therapy fr at least ne mnth diagnsis f grwth hrmne deficiency (GHD) has been recnfirmed by ONE f the fllwing: One lw insulin-like grwth factr-1 (IGF-1)/ insulin-like grwth factr-binding 3 (IGFBP-3) and ne grwth hrmne (GH) stim test with grwth hrmne (GH) peak value f greater than 10 mcg/ml; OR Tw grwth hrmne (GH) stim tests with grwth hrmne (GH) peak value f greater than 10 mcg/ml Nte: Transitin Phase: Defined as perid f life starting in late puberty and ending with full adult maturatin (frm mid t late teenage years until 6-7 years after achievement f final height) Adlescent: is a persn between ages f 10 and 19 as defined by the Wrld Health Organizatin (WHO) There is n prven benefit t cntinuing grwth hrmne (GH) treatment in adulthd fr childhd grwth hrmne (GH) treatment f cnditins ther than grwth hrmne deficiency (fr example: Turner s syndrme) Initial Apprval duratin: 12 mnths Renewal criteria fr Transitin Phase Adlescent members: Nte: Prvider must submit dcumentatin fr renewal: chart ntes, insulin-like grwth factr-1 (IGF-1) levels Member must meet the fllwing fr renewal apprval: Dcumentatin supprting psitive respnse t therapy (fr example: increased in ttal lean bdy mass, increased exercise capacity r increased insulin-like grwth factr-1 (IGF-1) levels) Renewal Apprval duratin: 12 mnths III. Adult Grwth Hrmne Deficiency: Nte: Prvider must submit dcumentatin supprting diagnsis, stim test results, insulin-like grwth factr-1 (IGF- 1) levels. Member must meet the fllwing fr initial apprval: Diagnsis f childhd-nset grwth hrmne deficiency (COGHD); OR Diagnsis f adult-nset grwth hrmne deficiency (AOGHD); Dcumentatin supprting hrmne deficiency is due t hypthalamic-pituitary disease frm rganic r knwn causes (fr example: damage frm surgery, cranial irradiatin, head trauma, r subarachnid hemrrhage); 5 P age

6 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Member has undergne ONE prvcative grwth hrmne (GH) stimulatin tests (fr example: insulin tlerance test (ITT), Arginine+ grwth hrmne-releasing hrmne (GHRH), glucagn, Arginine) cnfirming adult grwth hrmne (GH) deficiency ne f fllwing peak values: Insulin tlerance test (ITT) is less than r equal t 5 ng/ml Arginine+ grwth hrmne-releasing hrmne (GHRH): less than r equal t 11 ng/ml if bdy mass index (BMI) less than 25 kg/m2;less than r equal t 8 ng/ml if bdy mass index (BMI) greater than r equal t 25 and less than30 kg/m2; less than r equal t 4 ng/ml if bdy mass index (BMI) greater than r equal t 30 kg/m2 Glucagn: less than r equal t 3 ng/ml Arginine: less than r equal t 0.4 ng/ml Nte: Insulin tlerance test (ITT) is gld standard stimulatin test agent. Insulin tlerance test (ITT) is cntraindicated with crnary artery disease, seizures, abnrmal electrcardigram (EKG) with histry f Ischemic heart disease r cardivascular disease, and nt apprpriate fr thse greater than age 60 years. Others shuld be used when Insulin tlerance test (ITT) is cntraindicated. Glucagn has mre diagnstic accuracy. Arginine alne is rarely used. If arginine is used alne, a secnd stimulatin test may be required depending n insulin-like grwth factr-1 (IGF-1) levels. If the insulin-like grwth factr-1 (IGF-1) is subnrmal with presentatin f a hypthalamic disrder then ne stim test is required. If the insulin-like grwth factr-1 (IGF-1) is nrmal with hypthalamic disrder then tw stim tests are required. OR; Member has at least 3 deficiency f anterir pituitary hrmnes (fr example: fllicle-stimulating hrmne (FSH)/luteinizing hrmne (LH), thyrid-stimulating hrmne (TSH), adrencrtictrpic hrmne (ACTH), Prlactin), pan hyppituitarism; IGF-1 (insulin-like Grwth factr) is belw the age and gender adjusted nrmal range as prvided by the physician s lab Initial Apprval duratin: 12 mnths Renewal criteria fr Adult Grwth Hrmne deficiency: Nte: Prvider must submit dcumentatin fr renewal: chart ntes, insulin-like grwth factr-1 (IGF-1) levels Member must meet the fllwing criteria fr renewal apprval: Dcumentatin supprting psitive respnse t therapy (fr example: increased in ttal lean bdy mass, increased exercise capacity r increased insulin-like grwth factr-1 (IGF-1) levels) Renewal Apprval duratin: 12 mnths 6 P age

7 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines HIV-assciated Cachexia r Wasting: (Serstim nly) Nte: Prvider must submit dcumentatin f bdy mass index (BMI), weight, and ideal bdy weight (IBW) (prir t initiatin and after initiatin f Serstim fr renewals) Member must meet the fllwing fr initial apprval: Prescribed by r in cnsultatin with an infectius Disease r Human Immundeficiency Virus (HIV) Specialist; Currently n antiretrviral therapy; Inadequate respnse, intlerable side effects r cntraindicatin t megestrl acetate r drnabinl; Member has nt had weight lss due t ther causes (fr example: depressin, mycbacterium avium cmplex (MAC), chrnic infectius diarrhea, r malignancy with exceptin f Kapsi s sarcma limited t skin r mucus membranes); Bdy mass index (BMI) less than 20 kg/m2 prir t initiating therapy with Serstim; OR Unintentinal weight lss f mre than 10% ver last 12 mnths r mre than 5% ver the last 6 mnths; OR Member weights less than 90% f the lwer limit f ideal bdy weight (IBW) Initial apprval duratin: 3 mnths Renewal criteria Member must meet the fllwing fr renewal apprval: Dcumentatin supprting psitive respnse t therapy (bdy mass index (BMI) has imprved r stabilized) Currently n antiretrviral therapy Renewal Apprval duratin: 9 mnths (Maximum ttal: 48 weeks) Shrt Bwel Syndrme: (Zrbtive nly) Member must meet the fllwing fr apprval: Diagnsis f Shrt Bwel syndrme; Member is 18 years r lder Member is currently receiving specialized nutritin supprt (e.g., intravenus (IV) parenteral nutritin, fluid, and micrnutrient supplements) ; Member has nt previusly received 4 weeks f treatment with Zrbtive Initial Apprval: 4 weeks. Nte that treatment with Zrbtive will nt be apprved beynd 4 weeks as administratin fr mre than 4 weeks has nt been adequately studied. Cverage criteria fr a Nn-preferred grwth hrmne (GH) prduct: Member must meet ONE f fllwing criteria: Inadequate respnse, an intlerable side effect r has cntraindicatin t preferred agent; OR Inability t use vial frmulatin due t disability (fr example: visual/physical impairment); OR 7 P age

8 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines There is n preferred prduct apprpriate fr the cnditin being treated Pharmacy Prir Authrizatin Grwth Hrmne- Clinical Guidelines Nn Cverage Criteria: Use nt apprved by the Fd and Drugs Administratin (FDA) and the use is unapprved and nt supprted by the literature r evidence as an accepted ff-label use Amytrphic lateral sclersis Anablic therapy t enhance bdy mass r strength fr prfessinal, recreatinal r scial reasns Idipathic Shrt Stature (ISS)* Anti-aging Burn injuries Chrnic catablic states, including inflammatry bwel disease, pharmaclgic gluccrticid administratin, and respiratry failure Cnstitutinal delay f grwth and develpment Insulin-like grwth factr-i (insulin-like grwth factr-1 (IGF-1)) deficiency (als knwn as neursecretry defect) Russell-Silver syndrme (that des nt result in small fr gestatinal age) Stem Cell mbilizatin Traumatic brain injury Wund healing *Aetna des nt cnsider Idipathic shrt stature (ISS) an illness, disease r injury therefre it is nt a cvered plan benefit. 8 P age

9 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Additinal Infrmatin: Examples f Hypthalamic/Pituitary/CNS disrders: Cngenital structural abnrmalities: 1. Optic nerve hypplasia/septic-ptic dysplasia 2. Agenesis f crpus callsum 3. Empty sella syndrme 4. Ectpic psterir pituitary 5. Pituitary aplasia/hypplasia 6. Pituitary stalk defect 7. Vascular malfrmatins Cngenital genetic abnrmalities: Mutatins in grwth hrmne-releasing hrmne (GHRH) receptr, grwth hrmne (GH) gene, grwth hrmne (GH) receptr r pituitary transcriptin factrs Acquired structural abnrmalities (r causes f hypthalamic/pituitary damage): 1. Central Nervus System (CNS) tumrs/neplasms (fr example: cranipharyngima, glima, pituitary adenma) 2. Cysts (Rathke cleft cyst r arachnid cleft cyst) 3. Surgery 4. Radiatin 5. Chemtherapy 6. Central Nervus System (CNS) infectins 7. Centra Nervus System (CNS) infractin (e.g., Sheehan s syndrme) 8. Inflammatry lesins (e.g., autimmune hypphysitis) 9. Infiltrative lesins (e.g., sarcidsis, histicytsis) 10. Head trauma/traumatic brain injury 11. Aneurysmal subarachnid hemrrhage Pituitary Hrmnes (ther than grwth hrmnes) 1. ACTH (adrencrtictrpic hrmne) 2. ADH (Antidiuretic hrmne) 3. FSH (fllicle stimulating hrmne) 4. LH (luteinizing hrmne) 5. Oxytcin 6. Prlactin 7. TSH (thyrid stimulating hrmne) Appendix Grwth Charts: Grwth charts fr infants, children and adlescents are psted at the fllwing internet sites: Centers fr Disease Cntrl and Preventin: (This link includes grwth charts with curves dwn t 2 standard deviatins (apprximately 3rd percentile)). 9 Page

10 Height Velcity Tables: Figure 1: Height Velcity (cm/year) -- Girls Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Age 3rd Percentile 10th Percentile 25th Percentile P a g e

11 Figure 2: Height Velcity (cm/year) -- Bys Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Age 3rd Percentile 10th Percentile 25th Percentile P a g e

12 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines Surce: Interplated frm data frm Tanner and Davies (1995). Cnversin Factr: 1 centimeter (cm) = inches (in). 1 in = 2.54 cm. Nte: Assuming a nrmal distributin, 1 standard deviatin belw the mean is apprximately equal t the 16th percentile, 2 standard deviatins belw the mean is equal t the 2nd percentile, and 3 standard deviatins belw the mean is equal t the 1/10th (0.1) percentile. Weight fr Gestatinal Age Table: Small fr gestatinal age is generally defined as weight fr gestatinal age belw the 10th percentile at birth. A chart indicating the 10th and 90th percentiles f weight fr gestatinal age at birth is presented in Pediatrics 2014;133;844 (Talge et al 2014) Table-1 and Table-2 and is available at the fllwing website: Nrmal Results f a grwth hrmne (GH) Stimulatin Test (using arginine, glucagn r insulin):available at: Nrmal peak value -- at least 10 ng/ml Indeterminate -- 5 t 10 ng/ml Subnrmal -- 5 ng/ml References: 1. Ck D, Yuen K, Biller B et al. American Assciatin f Clinical Endcrinlgist Medical Guidelines fr Clinical Practice fr Grwth Hrmne use in Grwth Hrmne Deficient Adults and Transitin Patients-2009 Update. Endcrine Practice, 2009; 15(Suppl 2): Accessed nline Aug Gharib H, Ck DM, et.al. American assciatin f clinical endcrinlgists medical guidelines fr clinical practice fr grwth hrmne use in adults and children update. Endcrine Practice, 2003; 9(1): Richmnd EJ, Rgl AD. Diagnsis f grwth hrmne deficiency in children. UpTDate www. uptdate.cm. Accessed n 08/ Snyder, P. Grwth hrmne deficiency in adults. UpTDate. Accessed n 08/ Mandy, G. Small fr gestatinal age infant. UpTDate. Accessed n 08/ Gld Standard, Inc. Nrditrpin. Clinical pharmaclgy [database nline] Available at Accessed April Nrditrpin [Prescribing Infrmatin]. Bagsvaerd, Denmar: Nv Nrdisk; Feb Accesses April 8, P a g e

13 Pharmacy Prir Authrizatin Grwth Hrmne - Clinical Guidelines 8. Nutrpin [Prescribing Infrmatin]. San Francisc, CA: Genentech; Dec Accessed April 8, Saizen [Prescribing Infrmatin]. Rckland, MA: EMD Sern Inc.; Dec Accessed April 8, Serstim [Prescribing Infrmatin]. Rckland, MA: EMD Sern Inc.;Dec Accessed April 8, Zrbtive[Prescribing Infrmatin]. Rckland, MA: EMD Sern Inc.; May Accessed April 8, Omnitrpe [Prescribing Infrmatin]. Princetn, NJ: Sandz, Inc.; Dec Accessed April 8, Humatrpe [Prescribing Infrmatin]. Indianaplis, IN: Lilly USA, LLC;Dec Accessed April 8, Gentrpin [Prescribing Infrmatin]. Belgium N.V., Puurs, Belgium: Pfizer Manufacturing; Dec Accessed April 8, Zmactn [Prescribing Infrmatin]. Parsippany, NJ: Ferring Pharmaceuticals; Jan Accessed April 8, Mlitch M, Clemmns DR, Malzwski S et al.; The Endcrine Sciety s Guideline. Evaluatin and Treatment f Adult Grwth Hrmne Deficiency: An Endcrine Sciety Clinical Practice Guideline. Clin Endcrinl Metab. 2006; 91(5): Wilsn T, Rse S, Chenp et al.; Update f Guidelines fr the use f Grwth Hrmne in Children: The Lawsn Wilkins Pediatric Endcrinlgy Sciety Drug and Therapeutics Cmmittee. Jurnal f Pediatrics, Accessed nline Aug Gld Standard, Inc. Zmactn. Clinical pharmaclgy [database nline] Available at Accessed Sep, Rse SR, Ck DM, Fine MJ. Grwth Hhmne therapy guidelines: Clinical and managed care perspectives. Am J Pharm Benefits. 2014;6(5):e134-e146. Accessed nline April Talge NM, Mudd LM, Sikrskii A, Bass O. United States birtb weight reference crrected fr implausible gestatinal age estimates. Pediatrics 2014; 133; DOI: /peds Barstw C, Rerucha C. Evaluatin f shrt and tall stature in children. Am Fam Physician Jul 1;92(1): P a g e