Growth disorders

Physical growth refers to bodily changes that happen as a child matures including weight, length or height and head circumference increases. Growth failure is by far one of the most common reasons for referrals to the pediatric endocrine office.

Linear growth is most rapid in prenatal life when it is mainly regulated by maternal and placental factors. Postnatal growth is progressively slower and predominantly reflective of childs own genetic potential (see growth velocity figure). Another growth acceleration occurs at puberty.

What is normal linear growth?

0-1 years

25 cm

1-2 years

10 cm/yr

3-5 years

7 cm/yr

4-7 years

6 cm/yr

7 years - puberty

5 cm/yr

Table 1. Linea growth by age


Accurate measurement can not be overemphasized in the evaluation of the short child.

Height and Length:

Growth Velocity: Growth velocity (cm/yr) = (Height2-Height1) / (#months between times) x 12. It determines normal or abnormal growth by comparing height change over a period of time to gender-appropriate norms.

Body Proportions:

Figure 6: Measuring Upper to Lower segment ratio
Figure 6. Measuring Upper to Lower segment ratio

Mid-parental height (MPH): measure of child's genetic height potential, using parents adult heights.

Mid parental height calculation:

Bone Age x-ray: tool for assessment of skeletal maturation as it compares to the chronological age and for the prediction of child's final adult height (for films older than age 6 years). Bone age x-ray is typically delayed in thyroid hormone and growth hormone deficiency or constitutional delay of growth, normal in familial short stature and advanced in precocious puberty.


Figure 7. Example of bone age x-ray.

Children < the 3rd %ile on the growth chart or > 2 standard deviations below MPH deserve a short stature evaluation. 

Short stature etiology

Common parental concerns about height tend to be gender biased (e.g. boys that are the shortest in their class or girls that are "too tall" or "taller than even her male classmates"). Referral for a short stature evaluation is also commonly prompted by concerns over bullying/ teasing at school for child's size/stature. 

Normal variants

Pathological causes

Diagnosis: Bone age x-ray (to assess skeletal maturation), CBC, CMP, ESR, UA to screen for systemic disease, free T4, TSH, IGF-1, and IGFBP-3 to screen for endocrinopathy. Celiac screen optional, Pituitary/brain MRI as needed. Karyotype/microarray or specialized genetic testing as clinically indicated.


Typically, growth hormone replacement is reserved for true growth hormone deficiency. Many causes of short stature are due to an underlying disease and by treating this disease, you are simultaneously able to treat the short stature. For example, levothyroxine treatment for hypothyroidism and growth hormone for growth hormone deficiency typically restores linear growth. However, growth hormone treatment is also FDA approved for Turner Syndrome, small-for-gestational age with failure to catch up, Prader-Willi Syndrome, idiopathic short stature, SHOX gene haploinsufficiency, Noonan Syndrome and chronic kidney disease.

Tall stature is defined as predicted adult stature greater than two standard deviations above the mean height for age and gender. Tall stature can represent a normal variant of growth such as familial tall stature or it may be pathological.





  • Short Stature Homeobox (SHOX) excess


  • growth hormone excess
  • Disorders of pubertal development
  • familial glucocorticoid deficiency
  • Hyperthyroidism
  • Hyperinsulinism


  • Pituitary (i.e. MEN type 1, McCune-Albright
  • Ectopic growth hormone
  • Growth hormone releasing hormones tumors
  • precocious puberty
  • Obesity
  • T1DM
  • IDM
  • Persistent hyperinsulinemic hypoglycemia of infancy
  • Lipodystrophy
  • Beckwith-Wiedemann


Syndromic Overgrowth

  • Sotots Syndrome
  • Weaver Syndrome
  • Beckwith-Widemann
  • Perlman Syndrome
  • Simpson-Golabi-Behemel Type1
  • Proteus
  • Nevo
  • Marfan
  • Homcystinuria
  • Fragile X


Table 2. Common causes of pahological tall stature

Diagnosis: Bone age x-ray, thyroid function tests, fasting insulin level