Short Stature in Children

Hand measuring growing girl

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Parents and children, especially tweens and teenagers, often worry when they notice that they are shorter than many of their peers and classmates of the same age. While many medical conditions can cause children to have short stature, for some children, being short is expected and perfectly healthy.

This is one time when kids can blame their parents—or at least their genes—for something. Most children are short because they have short parents. Genetics plays a very big role in how tall a person will be.

Typical Growth Patterns

Before puberty, boys and girls will grow at more or less similar rates. On average, that's about 10 inches by their first birthday and about an additional 4 inches by their second. After that, children will grow at a decreasing rate (as low as about 2 inches a year) until puberty begins.

Children hit their peak growth spurt in puberty. For girls, puberty usually begins when they're between the ages of 8 and 13, while for boys, it usually starts between the ages of 9 and 14. Girls grow about 3 to 3 1/2 inches per year during their growth spurt. Boys grow about 4 inches per year during this time.

After their peak growth spurt, teenagers will see their height growth slow down steadily until they reach their full adult height—about four to five years after their peak growth spurt occurs. Most teenagers will reach their adult height somewhere between the ages of 14 and 16, depending on when they started puberty.

Average Growth Per Year
  Girls (inches per year) Boys (inches per year) 
 Ages 0-1  10 10 
 Ages 1-2  4  4
 Age 2 to Puberty  >2  >2
Peak Growth Spurt  3–3.5  4

Height Velocity

When evaluating short children, more important than where they are on a growth chart is how they have been growing. To look at this pattern of growth, or a child's height velocity, you usually have to look at several years of growth.

Typical growth in children should follow the growth curve fairly closely, so even if they are in a very low percentile, if that is where they have always been, then they are probably growing normally. If your child is crossing percentiles or lines on the growth curve, then there may be a medical problem causing their short stature.

For example, if a girl starts puberty at the age of 8, then she might hit her growth spurt at age 9 and be done growing by the time she is 13 years old. On the other hand, if a girl doesn't start puberty until she is 12 years old, then she might continue growing until she is 17 years old.

Causes of Short Stature

There are several different diagnoses your child could receive, including:

Familial Short Stature

Girls usually reach their pubertal growth spurt about two years earlier than boys, so many girls are taller than boys in early adolescence.

The most common reason why a kid might be short is because of familial short stature, or a family history of being short. In other words, if both parents are short, their child will likely be short too.

That's why one of the most accurate prediction methods of a child's height is called the Tanner method, which averages both parents' heights, then adds 2 1/2 inches if you're estimating a boy's height, or subtracts 2 1/2 inches if you're estimating a girl's.

These children usually grow at a typical rate. They follow a growth curve that is below but parallel to the normal growth curves. Testing is not routinely required for familial short stature, but if a bone age is done, the result would be normal and not delayed.

Constitutional Growth Delay

Constitutional growth delay is a condition where children do not grow as much as their peers. It can appear at different developmental stages. These kids are often called "late bloomers," and it is about twice as common in boys. Often, it occurs when puberty (and the associated growth) spurt is delayed.

Children with constitutional growth delay tend to grow at or below the third percentile for their height. Their rate of growth tends to be 2 to 2 1/2 inches per year. They will often continue to grow when other children have stopped growing, and they should reach a final adult height that is near their target height.

Growth Hormone Deficiency

Growth hormone is required for normal growth. If a child's pituitary gland makes too little, they will likely be short and often look younger than their chronological age. Growth hormone deficiency may be congenital (meaning it's present at birth), or it may be acquired later in life from a head injury, brain tumor, mass, or pituitary gland abnormality. Other times, doctors do not know the cause.

Other endocrine diseases can also cause short stature, including hypothyroidism (an under-active thyroid) and Cushing's syndrome (a disorder that results from too much cortisol in the blood).

Chronic Diseases

Celiac disease, inflammatory bowel disease (IBD), kidney disease, and diabetes can all affect how much your child grows, as can chronic symptoms, such as vomiting, diarrhea, fever, weight loss, poor appetite, poor nutrition, headaches, and delayed puberty.

Genetic Conditions

Prader-Willi syndrome, Turner syndrome, Noonan syndrome, achondroplastic dwarfism, and skeletal abnormalities are all genetic causes of short stature. Most of these would be diagnosed early in life.

Idiopathic Short Stature

Idiopathic Short Stature (ISS) is when children are short—shorter than 1.2% of those the same age and sex—and doctors don't know why. It means they've ruled out hormonal, endocrine, genetic, or organ disorders.

Because healthcare professionals have to rule out other causes first, it usually takes a while to get this diagnosis—which might be frustrating to some parents. However, even though there is no known cause, there are successful treatment options, notably the use of growth hormone during puberty to help children grow.

Diagnosis and Testing

If your child is short, but following their respective growth curve, further testing may not be required. But sometimes, your child's pediatrician may want to rule out a medical condition, which will require some testing.

One test commonly done determines bone age: A doctor will order x-rays of your child's hand, then the x-ray is compared to a series of standard hand x-rays from typically growing children of different ages to determine bone age. For instance, if your child's hand x-ray looks most like the standard 8-year-old's, then your child is said to have a bone age of 8 years old.

If your child's bone age is much less than their chronological age, then there is probably still room for their bones to grow after the age that you would expect them to stop growing. Girls usually continue to grow until a bone age of about 14 years, and boys stop growing after a bone age of 16 years (with a peak growth rate at a bone age of 14 years).

Having a bone age that is much less than the child's chronological age can be an indication that the child may not be growing properly, possibly due to a growth hormone deficiency or another issue that requires medical evaluation and intervention.

An advanced bone age can also be a sign of a problem that needs further evaluation. Sometimes a karyotype is used to look for chromosomal abnormalities.

If your pediatrician suspects that your child has a growth hormone deficiency, they can check your child's levels of IGF-1 and IGF BP3, which will be low in a child with a deficiency. A growth hormone stimulation test may also be done by a pediatric endocrinologist.

Other tests may include:

  • Blood chemistries (which can include an SMA 20 to check for kidney and liver disease)
  • Blood tests to check for hypothyroidism (T4 and TSH)
  • Complete blood counts (to check for anemia)
  • Urinalysis

Treatment

Treatment will depend on the diagnosis. If your child is diagnosed with growth hormone deficiency, for example, treatment includes growth hormone replacement. Growth hormone therapy might also be used as the treatment for other conditions as well, including Turner syndrome, chronic renal failure, and Prader-Willi syndrome. It may also be used to treat idiopathic short stature if the child is more than 2.25 standard deviations below the mean for age and sex, or among the shortest 1.2% of children.

It is important to note that growth hormone shots are expensive, are usually given to short children for six out of seven days of the week until they complete puberty, and will usually only get a child an extra 2 to 3 inches of growth. Growth hormone can also be used for children who were born small for gestational age and do not catch up in their growth by the time they are 2 years old.

If your child has a treatable medical condition causing their short stature, such as celiac disease or hypothyroidism, then the underlying cause will be treated. For example, a child with celiac disease will be prescribed a gluten-free diet, while a kid with hypothyroidism might be treated with thyroid hormone replacement.

A Word From Verywell

Keeping good records of your child's height and weight can make it a lot easier to evaluate a child with short stature. Be sure to go to your regular well-child visits with your pediatrician, and even at a sick visit, ask them to measure your child's height if it hasn't been done recently.

While most pediatricians can begin the initial evaluation of a short child, if additional testing is required or you need reassurance, then a visit to a pediatric endocrinologist can be helpful.

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Article Sources
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  1. Centers for Disease Control and Prevention. Clinical growth charts. Updated June 16, 2017.

  2. American Academy of Pediatrics. Physical changes during puberty. Updated December 19, 2014.

  3. Tanner JM, Goldstein H, Whitehouse RH. Standards for children’s height at ages 2-9 years allowing for height of parentsArchives of Disease in Childhood. 1970;45(244):755-762.

  4. American Academy of Pediatrics. When a child is unusually short. Updated June 21, 2016.

  5. Aguilar D, Castano G. Constitutional growth delay. In: StatPearls. StatPearls Publishing; 2021.

  6. Pedicelli S, Peschiaroli E, Violi E, Cianfarani S. Controversies in the definition and treatment of idiopathic short stature(Iss)J Clin Res Pediatr Endocrinol. 2009;1(3):105-115.

  7. Creo AL, Schwenk WF. Bone age: A handy tool for pediatric providers. Pediatrics. 2017;140(6) doi:10.1542/peds.2017-1486

  8. Topor LS, Feldman HA, Bauchner H, Cohen LE. Variation in methods of predicting adult height for children with idiopathic short stature. Pediatrics. 2010;126(5):938-44. doi:10.1542/peds.2009-3649

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