Growth and Short Stature

The goal of a medical evaluation in a child with growth concerns is to figure out whether the growth is the result of a treatable medical condition or a normal variation, such as familial short stature or constitutional delay.  

Children with familial short stature have parents with short stature as well. Their growth is stable, does not cross downwards over percentiles, and is appropriate for the parents’ heights. Constitutional delay is where children are “late bloomers.”  They usually are shorter than most of the other children during childhood, enter puberty later than their peers, and then catch up to a height consistent with their parents during puberty. There is often a family history of late puberty.  

Medical providers track the child’s growth by plotting his/her height and weight on ethnicity-specific growth charts according to age (in years and months) and sex. Growth charts show how a child is growing compared to other children. Study of the growth chart determines the child’s pattern of growth and whether he/she needs additional evaluation. Short stature is diagnosed when height is below the normal ranges for age and sex (less than 23rd percentile)   

• A normal growth rate is when height consistently plots on the same percentile on the growth chart, a rate of at least 2 inches per year during childhood.  
• An abnormal slowing in height growth—dropping down percentiles—may trigger a full growth evaluation.   
• A slowing of height growth rate during adolescence may indicate delayed puberty or lack of puberty.  
• An inappropriate increase in weight while the height gain has slowed down may indicate cortisol excess.  
• An inappropriate drop in weight may indicate poor nutrition or other systemic illness.   

A medical evaluation is done to identify a possible underlying medical cause that may affect growth. An evaluation of a child with growth concerns or short stature begins with a child’s medical history and a detailed family history, including parents’ heights and ages of puberty. Based on the results, the doctor can decide if additional labs or x-rays are needed. These medical examinations may include:  

Blood Test: screen for kidney abnormalities, anemia, sensitivity to gluten (celiac disease), hypothyroidism, or abnormalities in growth hormone markers or puberty hormones.   

Urine Analysis: This will be done if kidney abnormalities or urine infections are suspected.   

Chromosome Assessment: This blood work may be recommended in girls to screen for Turner syndrome.   

Bone Age: This is an x-ray of the left hand and wrist to determine the maturity of the bony growth plates to assess whether they are consistent with the child’s age and to see how much more time the child has to grow. 

Additional endocrine testing may be needed to confirm diagnosis of growth hormone deficiency, including giving medications through an IV and testing growth hormone production over the next several hours. An MRI of the pituitary may be done in children with growth hormone deficiency to determine possible abnormalities of the pituitary gland. 

Children with short stature may have no specific symptom beyond poor growth. Children with short stature because of familial short stature or constitutional delay are usually healthy.  Children with growth hormone deficiency and no other hormonal abnormalities may have no specific symptoms.  

If short stature is the result of an underlying systemic illness or syndrome, the child may present symptoms that relate to this specific condition. For example, children with inflammatory bowel disease may have frequent or bloody stools or poor weight gain. A child with a hypothyroidism may present with fatigue, feeling cold, constipation, dry skin and hair, and an enlarged thyroid (goiter) on physical examination.

The treatment of short stature depends on the underlying cause. For example, if a child is found to have short stature because of hypothyroidism, thyroid hormone replacement will improve growth.  For adolescents with growth slowing because of delayed or lack of puberty, treatment with sex hormones (estrogen or testosterone) will improve growth. Increasing calories can help a child with short statute because of undernutrition. For the rest of the cases, unfortunately, there is no specific food, diet, or exercise that can improve growth.   

Growth hormone therapy is prescribed when: 

• There is a growth hormone deficiency (i.e., have inadequate growth hormone secretion). 
• Children possess genetic syndromes such as Turner or Noonan syndrome. 
• Children are born with low birth weight or length (SGA) and have failed to demonstrate improved growth.  
• There is a need to improve adult height in children with end-stage renal disease. 
• Children have short stature for unknown reasons (idiopathic short stature), with a predicted adult height at or below 5’3” in a boy and 4’10” in a girl. Its use in such cases may be considered cosmetic, and is therefore controversial.   

Growth hormone therapy is generally considered safe for use in children. Possible short-term side effects are rare, but include a surgical condition causing hip pain (slipped capital femoral epiphyses [SCFE]), progression of scoliosis, fluid retention or edema (causing carpal tunnel syndrome or joint pain), increased growth of skin moles, or growth of adenoids and tonsils. Rarely, it can also cause persistent severe headaches (pseudotumor cerebrii), which resolves with discontinuation or lowering of growth hormone dose. Because it helps to promote growth, endocrinologists are cautious not to give too much growth hormone due to concern for possibly stimulating growth of any unknown cancers.

However, long term data to-date are very reassuring and do not suggest an increased risk of early death or malignancy, even in brain tumor survivors with growth hormone deficiency. The potential adverse effects in children are different from those in adults and should be discussed in detail before starting treatment. Not all children grow as hoped on growth hormone, so unmet expectations after use of a costly medication can be a negative outcome of treatment. 

The outcome of children with short stature depends on the underlying causes.

• Children with constitutional growth delay demonstrate catch up growth and reach a normal adult height, usually without any medical intervention. 
• Children with lack of puberty respond to sex hormone therapy and reach a normal adult height. 
• Children with growth hormone deficiency respond well to treatment, and their adult height is usually in the normal range.   
• Children who are treated with growth hormone for other indications (i.e., Turner, end- stage renal disease, SGA, idiopathic) usually experience an improvement in adult height but may not reach their parents’ heights. 

• My child has always been growing at the low part of the growth chart for height. Can he/she have a medical problem affecting their growth?  
• My child has dropped height percentiles over the last couple of years but their height still plots within the growth chart? Do they need a growth evaluation? 
• Is my child a candidate for growth hormone therapy? Is it likely to help? What are the risks?