When Your Child is Short: A Parent’s Guide to Short Stature
Dr. Kavitha Dileepan, Pediatric Endocrinology
A person with short stature simply means he or she has not grown as tall as other people their age and sex. While short stature is somewhat subjective, it’s typically defined as a person growing below the third percentile.
The reality is we come in a wide-variety of shapes and sizes and there are going to be short kids. Just because a child is significantly shorter than their classmates, doesn’t mean the child isn’t healthy.
Some parents tend to think their child is short and not growing at all. Most times, that’s not the case. One of the first things I ask parents is if their child is consistently outgrowing clothes and shoes. Is the child’s pants getting shorter from spring to fall? Do you need to buy new shoes at the beginning of each school year?
If the answer is yes, then most likely the child is growing normally. If a child is wearing the same clothes year-after-year and new clothes are only needed to replace old worn out clothes, then that’s a different scenario.
Reasons for Short Stature
There are a multitude of reasons why a child may be short. A common reason is familial short stature, which means the parents are short.
Constitutional delay in growth and puberty is another cause, which means the child is a late bloomer. It’s not unusual for someone who has been small all their life to suddenly have a growth spurt late in high school. Both constitutional delay and familial short stature are considered variants of normal.
Sometimes, there are underlying medical conditions that lead to poor growth development, and short stature may be the first sign something else is going on. It takes a lot of energy for a kid to grow, so if the body is under any other type of stress, such as a thyroid issue, inflammatory bowel disease or celiac disease the child may not grow properly.
Growth hormone deficiency is another cause, but it's not as common. Our job is to figure out the healthy kids versus the kid who is growing but has a medical or organic reason for being short.
Determining if a Child’s Growth is Normal
There are four things we look at to determine if a child’s growth is normal.
#1. Current Height Percentile
Both pediatricians and parents tend to obsess about the child’s current height percentile, but it’s just one piece of the puzzle. If a child is measuring at the third percentile, yes, the kid is small, but the child is also taller than three percent of the population. Just by statistics alone, there has to be three percent of the population in this percentile, so it doesn’t automatically mean there’s a problem. We must take into account other factors to assess if the percentile suggests a problem.
#2 Growth Velocity
What we take a closer look at is growth velocity and what’s happening over time. Growth charts are critical when determining short stature and it’s important for children to have routine wellness checks to have their growth measured accurately year-after-year.
If a child measures at the 50 percentile that child is not necessarily short. However, if that child had been growing at the 90 percentile and dropped to the 50 percentile that could indicate a problem.
On the contrary, a child in the third percentile is short, but if they’ve always been growing at the third percentile that's more reassuring because they've had normal growth.
#3 Genetic Potential
The third thing we look at is the family’s genetic potential. To calculate a boy’s mid-parental height, start with the mother’s height and add five inches. Average that number with the dad’s height, which equals the child’s mid-parental height. For girls, take the father’s height minus five inches and average it with mom’s height. Ninety percent of kids will fall in plus or minus two inches of their mid-parental height.
So, if the parents are both short, it may be normal for the child to be short. It’s more concerning if the parents are tall, but the child is growing short. (That's not to say a child can’t have abnormal growth if the parents are short.)
#4 How Much Time the Child Has Left to Grow
Puberty plays a big role in growth. With puberty, you get a large growth spurt, but once puberty is over, growth is complete. We assess how much time a child has left to grow through a bone age, which is determined by taking an x-ray of the child’s wrist and comparing the maturation of the bones in the hand and wrist to standards in a book. A child with delayed bone age has additional time to grow.
Treatment for Growth Hormone Deficiency
If it’s determined that growth hormone deficiency is the cause of a child’s short stature than the child can be treated with growth hormone therapy, which is given by injections 6-7 days a week. A big misconception is that growth hormones can make any child taller. The fact is, growth hormones will not make the child genetically taller than that child is supposed to be.
Kids who take growth hormones typically stay on hormone therapy until their growth plates are fused. However, if a child has an underlying reason for growth hormone deficiency, such as a pituitary abnormality or multiple others hormonal deficiencies, that child may need to be on hormone therapy for life.
Benefits and Risks of Growth Hormone
There are other benefits of growth hormone other than just growth (if a child is truly growth hormone deficient). Growth hormone helps protect bone density and maintain positive muscle mass to lean tissue ratio. It also affects cholesterol and helps prevent cardiovascular disease.
As far as risks are concerned, growth hormone is very safe. Common side effects include scoliosis, headaches, muscle aches, or joint aches. However, it can be associated with increased pressure in the spinal fluid in the brain, slipped capital femoral epiphysis in the hip joint, and type 2 diabetes, which are more concerning.
Treatment for Late Bloomers
Another treatment available is an aromatase inhibitor, which blocks the enzyme that converts testosterone into estrogen. Estrogen is what causes growth plates to close in both females and males.
We typically use this treatment in male adolescents who developed quickly and their growth plates are going to close quickly or are late bloomers who may run out of time. Again, this treatment won’t make a boy taller than he should be, but it’ll buy more time so he can grow to his full potential.
Treatment for Delayed Puberty
If a child has delayed puberty (a girl doesn't have any sign of breast development by age 12-13 and a boy hasn’t had any sign of testicular enlargement by age 13-14) we can give the child a short (4-6 month) burst of estrogen or testosterone, which stimulates puberty and growth. A child who is simply a late bloomer will typically develop and grow in response to this treatment alone. If they respond well, then the treatment will be discontinued, and they will be followed to see how they grow.
Growth Takes Time
Short stature can be an emotional issue, especially if there are different expectations about a person’s height vs. reality. People may place significance on their child’s height, while others do not want to treat height as long as their child is healthy. Decisions about how aggressively to treat short stature can be difficult. These are conversations kids and parents need to have together. Sometimes, a teenager may say “I’m fine with my height,” but they may not understand that when growth is done, there is nothing that can be done. The reality is I’m not dealing with typically a life-threatening issue, but it can be very important to some people. I’m dealing with growth, and growth is a longitudinal thing. My job is to make sure my patients are healthy and to offer options if they are available and appropriate, and to offer realistic expectations of how those options will help to obtain a height consistent with their genetic potential, not to determine what height is acceptable or not. The reality is that height is just one element of a person, and it does not define them.
The most important thing I can tell families is children need to attend regular follow-ups with their primary care pediatrician and make sure the child’s height is plotted on a growth chart yearly. If parents are concerned about a child’s growth they should see a specialist. Sometimes, treatment needs to be started sooner rather than later, but other times patience is the name of the game.
Learn more about the Division of Pediatric Endocrinology and Diabetes at Children’s Mercy.