Childhood Growth and Height Issues

What is the difference between short stature and growth failure?

Short stature compares an individual’s height to a reference group, while growth failure refers to abnormally slow growth that will not reach the genetically expected adult height. They often, but not always, occur together. For example, a child may have short stature (e.g., height 5th percentile of other children his/her age and gender) without growth failure (i.e., if his/her parents are also 5th percentile). Likewise, a child may have growth failure without short stature (e.g., height percentile for age falling from 90th percentile to 50th percentile).

Are there any medical issues associated with children who are very short but otherwise healthy?

Short stature is not a disease.

Are there any underlying diseases associated with children who are unusually tall?

Yes. Children who are inappropriately tall for their families should also be evaluated.

What is constitutional growth delay?

Constitutional growth delay is the medical term for late bloomers. These individuals are healthy and reach normal adult heights, but grow later than other children.

What is idiopathic short stature?

Idiopathic short stature refers to short stature without an identifiable cause. The FDA approved growth hormone therapy for children with idiopathic short stature; the height cut-off is the bottom 1 percentile for age.

Should we expect a child to reach a final height between the heights of both parents?

Because the average man in the United States is 5 inches taller than the average woman, we cannot just take the parents’ heights without correcting for gender. Children usually reach a height that is within +/- 4 inches of the average of their parents’ height percentiles. This assumes that the environmental effects on growth, including nutrition and disease, remain similar in both generations.

How often should my child be measured?

According to the March 2000 “Recommendations for Preventative Pediatric Health Care” by the American Academy of Pediatrics, a child’s height and weight should be measured at least at birth, age 2-4 days, 1, 2, 4, 6, 9, 12, 15, 18 and 24 months, and every year thereafter through age 21. (Pediatrics 2000;105:645).

What are possible consequences of overlooking or delaying the detection of an underlying disease that causes short stature or poor growth?

Many diseases (including infectious, gastrointestinal, kidney, heart and hormonal) can present with growth failure months or years before other symptoms develop, so overlooking growth failure as a clinical clue can lead to delayed diagnosis and treatment. This may adversely affect outcome not only for height, but also for the underlying disease and the child’s overall health. For example, long-standing unrecognized and untreated celiac disease, an intolerance to proteins found in wheat, predisposes development of other autoimmune conditions. Delayed treatment adversely affects height outcome because growth cannot be further improved once the growth plates fuse at the end of puberty. Sometimes doctors will try to medically delay puberty to allow more time for growth, but there are psychosocial and bone health costs to delaying puberty for years beyond normal. Thus, whether it’s a disease whose improvement leads to catch-up growth or a condition requiring growth hormone therapy, the final height outcome is better when the treatment is started younger.

My son is the shortest boy in his class, and has been ever since he started school. Should I have him evaluated by a physician? If so, should I go straight to a specialist?

Growth evaluations begin with accurate height measurements and careful plotting of a growth curve. Most pediatricians or family practitioners keep growth curves as part of pediatric primary care. Thus, the best place to start is with your child’s primary doctor. Thorough history and physical examination are needed to evaluate factors that can impact growth, such as family history, birth history, diseases and medications. Should any concerns be raised, then referral for further evaluation by a specialist is warranted.

My daughter is shorter than most of the other girls in her class, but people call her by adorable nicknames and think she’s so cute. Should I be concerned?

There’s nothing cute about missing an underlying disease. The same parameters that raise concern about growth in boys also apply to girls.

Are girls more likely than boys to have underlying diseases that cause growth disparities?

No. Our study found underlying disease in a higher percentage of the abnormally short girls than boys, but our study was looking at children referred to a specialty clinic and not at the general population. Turner syndrome, a genetic condition that causes short stature, occurs only in girls. Turner syndrome cases were not enough to account for the difference found in our study.

What information should I seek from my child’s pediatrician and what information should I have available so that they can make an accurate diagnosis?

It is very reasonable to look at your child’s growth curve together with your pediatrician. A few pediatricians feel that, based on experience, they can see which children are growing less than normal without the growth curve. While severe growth failure may be apparent, they are likely missing more subtle deficits.

It’s helpful to gather the following information to your best ability:

  • Heights of both genetic parents (without shoes)
  • Whether both parents went through puberty at average, early or late ages
  • Family history of short stature, late puberty or any diseases
  • Birth length and weight of the child

It is also helpful to prepare your child for the visit by avoiding any hairdos that can interfere with accurate height measurements (i.e., styles that bunch up hair or use pins/bobs on top of the head).

If I am referred to a specialist, what materials should I bring along to the appointment?

You should bring a copy of your child’s growth curve as well as the results of any laboratory or X-ray studies your pediatrician has already done to evaluate your child’s growth.

Likewise, you should bring a copy of your child’s prior growth curve whenever you switch primary doctors or have a specialist evaluation for problems other than growth.

Are there any risks to treating a short child with human growth hormone?

Growth hormone treatment is generally safer than many medications, but it is not without risk. These should be discussed in detail with your child’s doctor before pursuing treatment.

Aren't there legitimate social or psychological reasons for treating a short but healthy child with human growth hormone?

Most people agree that being very short can cause some social stress, just like being different from any other cause (eg. too tall, too fat, too skinny, too brainy, not smart enough, not athletic enough, etc.). However, whether that warrants growth hormone treatment is controversial. In any case, attention should be paid to promoting the child’s self-esteem and coping mechanisms.

What is the most important finding in your study?

Our study found that significantly fewer girls than boys are referred for specialist evaluation of short stature or growth failure. Of the referred children, the girls were shorter than the boys (relative to both the general population and their parents) and were more likely to have an underlying disease. This does not mean that short girls are sicker than short boys, but that the girls tend to be more severely affected than boys before they seek specialist care. This is likely due to social pressures that imply that short stature is a more significant problem in boys than girls.

Grimberg A, Katz JL, Kutikov, A, Cucchiara J. Sex differences in patients referred for evaluation of poor growth. J Pediatr 2005; 146(2): 212-16. In press.