Short Stature
Short stature is when a child’s height falls well below what is typical for their age and sex. While most children with short stature are healthy and have no medical problems, understanding growth patterns can help families know when to seek medical advice.
Table of contents
- What is short stature?
- Causes of short stature
- Signs and symptoms
- How short stature is diagnosed
- Treatment options
- When to be concerned
What is short stature?
Short stature refers to a height that is more than two standard deviations (a measure used in statistics to show how far something is from the average) below the average for a child’s age and sex. In practical terms, this means a height below the 3rd percentile on growth charts. If you imagine 100 children of the same age and sex, a child with short stature would be among the shortest three.[1][2]
Short stature is one of the most common reasons children are referred to pediatric endocrinologists (doctors who specialize in children’s hormones and growth). Children with growth concerns account for up to 50% of new visits to these specialists.[2]
It’s important to understand that being short is not the same as having a growth problem. Short stature can mean a child is simply smaller than average but is still growing at a normal rate. A growth problem, on the other hand, means the child is growing at an abnormally slow rate over time.[3]
Causes of short stature
Most children who have short stature do not have a medical condition. They are healthy and grow at a normal rate. The most common reasons for short stature are normal variations that run in families or relate to timing of development.[5]
Familial short stature occurs when parents are shorter than average, and the child inherits this trait. In these cases, the child’s growth rate is normal, their bone age (determined by an X-ray of the hand) matches their actual age, and they will likely grow to a height similar to their parents.[3][4]
Constitutional delay of growth and puberty is another common cause. This is what many people call being a “late bloomer.” Children with constitutional delay are often shorter than their peers during childhood, but they enter puberty later than average and eventually reach a normal adult height. These children typically have a family history of late development, and their bone age is slightly delayed compared to their actual age.[5][7]
Both familial short stature and constitutional delay are considered normal variations and generally do not require medical treatment.[5]
Less commonly, short stature can be caused by medical conditions. Endocrine (hormone-related) causes include growth hormone deficiency, hypothyroidism (underactive thyroid), and Cushing disease. Chronic medical conditions such as heart disease, celiac disease, inflammatory bowel disease, and kidney or blood disorders can also affect growth.[5][7]
Genetic conditions can also lead to short stature. These include Turner syndrome, Noonan syndrome, Down syndrome, and Prader-Willi syndrome. Children with these conditions often have other physical features that suggest an underlying genetic cause.[5][7]
Poor nutrition can result in poor growth, which typically improves when nutrition improves. Additionally, being born small for gestational age (smaller than expected based on the number of weeks of pregnancy) without catching up on growth can result in short stature in childhood.[5]
Signs and symptoms
The main sign of short stature is being smaller than most other children of the same age and sex. More specifically, children with short stature are abnormally small for their age and grow less than two inches per year after their second birthday.[4]
A simple way to watch for growth concerns is to observe whether your child consistently outgrows clothes and shoes. If a child is growing normally, pants should get shorter from spring to fall, and new shoes should be needed at the beginning of each school year. If a child wears the same size clothing for several years and wears out clothes and shoes before outgrowing them, this can be a sign of poor growth.[9][18]
Short stature can be noticed when a baby is born, or it may become apparent later as the child grows. It’s most commonly noticed as puberty begins, around age 10 for girls and 11 for boys.[7]
How short stature is diagnosed
Diagnosing short stature involves looking at several pieces of information together. Regular wellness checks with accurate measurements over time are essential for tracking growth patterns.[9]
Doctors use four key indicators to determine if a child’s growth is normal:
Current height percentile: This shows where the child’s height falls compared to other children of the same age and sex. While a low percentile indicates the child is shorter than average, it doesn’t automatically mean there’s a problem. A child measuring at the 3rd percentile is still taller than 3% of the population, and by statistics alone, some children will naturally fall in this range.[9][18]
Growth velocity: This is the rate of growth over time and is one of the most important measures. If a child who has been growing at the 90th percentile suddenly drops to the 50th percentile, this could indicate a problem. Conversely, a child who has always been growing at the 3rd percentile and continues to grow at that rate is more reassuring. To accurately determine growth velocity, two measurements at least three to six months apart are needed.[6][9]
Mid-parental height: This calculation uses both parents’ heights to estimate what the child’s adult height might be. For boys, add the father’s height to the mother’s height plus 13 centimeters, then divide by 2. For girls, add the father’s height minus 13 centimeters to the mother’s height, then divide by 2. This helps doctors understand the child’s genetic potential for height.[5][9]
Bone age: An X-ray of the left hand can show the maturity of the bones. Sometimes a child’s bones may be less mature than their actual age would suggest, indicating delayed growth. This can help narrow down the possible causes of short stature.[3][7]
If a doctor suspects an underlying medical cause, they may recommend blood tests to check for growth hormone deficiency, thyroid disease, celiac disease, kidney disease, or blood disorders. Other tests might include genetic testing if a genetic syndrome is suspected.[5]
Treatment options
Treatment for short stature depends on the underlying cause. If short stature is due to familial short stature or constitutional delay, no treatment is typically needed because these are normal variations.[5]
If a medical condition is causing the growth problem, treating that condition may help improve growth. For example, children with hypothyroidism would receive thyroid hormone replacement, and children with celiac disease would follow a gluten-free diet.[4]
Growth hormone therapy is available for certain conditions. This treatment involves daily injections of recombinant human growth hormone (laboratory-made growth hormone). It is most effective for children with documented growth hormone deficiency. The U.S. Food and Drug Administration has also approved growth hormone for children with certain genetic conditions like Turner syndrome, as well as for idiopathic short stature (short stature with no identifiable cause) when a child’s height is below the 1st percentile.[11][13]
Growth hormone treatment can increase adult height by 3 to 7 centimeters in children with idiopathic short stature, though results vary widely among individuals. Treatment typically continues through the end of puberty, which may mean daily injections for several years. The cost can be substantial, ranging from $10,000 to $60,000 per patient per year.[11]
The decision to use growth hormone therapy is complex. Families need to weigh the potential benefits against the burden of daily injections, frequent doctor visits, and costs. There are also questions about long-term effects, as data beyond 30 years is not yet available.[11][24]
For children experiencing emotional distress due to short stature, counseling can help support emotional well-being and develop coping skills.[2]
When to be concerned
Parents should talk to their child’s doctor if they notice the child is not growing as expected for their age. Regular well-child visits are important for tracking growth over time.[9]
Specific situations that warrant medical evaluation include when a child’s height falls below the 3rd percentile (especially if parents are of normal height), when growth velocity is slow (less than 4 centimeters per year), or when the child’s height is three or more standard deviations below what would be expected based on the parents’ heights.[5]
Evaluation is also important if a child’s growth pattern changes significantly. For example, if a child who has been growing along one percentile line suddenly starts falling to lower percentiles, this deviation from their previous growth pattern often signals a new medical problem.[3]
If parents are concerned, the ideal time to seek evaluation is around age 8 to 10, before puberty begins. Once puberty ends and the growth plates in the bones close (typically around age 16 for boys and 14 for girls), there is little that can be done to increase height.[7][15]
It’s important to remember that children who are more than three standard deviations from the average height are more likely to have an underlying medical condition that needs evaluation.[6]
