About the Authors
Patricia Rieser is
a Certified Family
Nurse Practitioner,
formerly in the
Division of
Endocrinology,
Department of
Pediatrics, University
of North Carolina at
Chapel Hill (USA).
Louis E. Underwood,
M.D., is a Professor
of Pediatrics, Division
of Endocrinology,
Department of
Pediatrics, University
of North Carolina at
Chapel Hill (USA).
Introduction
4
The Normal Pattern of Growth
6
Growth Before Birth
7
From Birth to Puberty
7
Pubertal Growth
8
Growth Charts
10
Recognition of Growth Problems
14
Evaluation of Growth Problems
16
Variations in the Normal Pattern of Growth
22
Shifting Channels in Infancy
23
Familial Short Stature
24
Constitutional Growth Delay
26
Abnormal Growth
28
Systemic Diseases
30
Endocrine Diseases
32
Congenital Conditions
34
Idiopathic Short Stature
36
Tall Stature
38
Psychological and Emotional Aspects of Short Stature
42
The Short School-Aged Child
44
The Short Child and Sports
46
Making Life Easier for the Short Child
47
The Human Growth Foundation
52
The Magic Foundation for Children’s Growth
53
Glossary
54
Additional Reading
back cover
Introduction
Growth begins when a baby is conceived and continues
throughout life. It is a complex process, influenced by a
variety of factors that are only beginning to be understood.
There is a wide range of
“normal” for both height
and weight.
Not all short children
have abnormal growth.
As parents, we keep track of our children’s growth in many
ways: We are reassured when the doctor says our baby is
growing well; we notice how quickly new clothes are
outgrown; we observe our child’s size in relation to that of
classmates and playmates. If a child is not growing as expected
or is lagging far behind classmates in size, most parents
become concerned and seek the advice of their pediatrician
or family physician. The first thing a concerned parent is
likely to learn is that there is a wide range of “normal” for
both height and weight, and the smallest child in the class
may or may not have a medical problem relating to size.
Not all short children have abnormal growth.
There are about 1.27 million children in the United States
who are shorter than 98% of children their age. Most of
these boys and girls are normal in every way, but a few have
problems that can have long-lasting effects on their health
and growth if they are not diagnosed and treated.
4
Short stature is not the only cause for concern: A tall boy
who stops growing deserves attention long before he stands
out as the shortest child in his class. A girl who “shoots up”
to stand inches taller than her classmates usually is perfectly
normal, but she also may have a problem affecting growth.
How can a parent tell whether to be concerned about a
child’s size and growth? If there is a wide range of normal
for height and weight, how does a parent know what is
abnormal? This booklet answers these and other questions
that parents often ask about growth and provides basic
information about:
•
normal and abnormal patterns of growth (what
to expect from infancy through adolescence);
•
recognition and evaluation of growth problems (how
to tell if your child has a growth problem and what
to do about it);
•
psychological and emotional aspects of short stature
(how to understand and make life easier for the short
child); and
•
information resources for parents of short
children and for those interested in growth and
growth problems.
There are about
1.27 million children in
the United States who are
shorter than 98% of
children their age.
The Glossary on page 54 lists some of the new words used in
this booklet, along with their definitions. These words will be
highlighted the first time they appear.
5
The Normal
Pattern
of Growth
Growth Before Birth
A 2¹⁄₂-month-old fetus (a baby before it is born) weighs
about one-tenth of an ounce (3 grams) and is 1¹⁄₄ inches
(3 cm*) long. All of its body organs are present and are
almost completely formed. At this point, the process of
growth begins to speed up. By 5 months, the fetus may be
growing as fast as 1 inch (2.5 cm) per week. If this incredible
rate of growth were to continue, it would translate into a rate
of more than 4 feet (1.3 meters) per year. Growth slows
toward the end of pregnancy as the baby fills the uterus. At
birth, full-term babies are usually 19 to 21 inches (48 to
53 cm) long and weigh from 6 to 8¹⁄₂ pounds (2.7 to 3.8 kg).
From Birth to Puberty
Average children grow
about 5 inches (13 cm)
between their first and
second birthdays.
As you can see by looking at Table I and Figure 1, growth is
also rapid during the first year of life. Many infants grow as
much as 10 inches (25 cm) and triple their birth weight by
their first birthday. Growth slows between 1 and 2 years of
age: Average children grow about 5 inches (13 cm) between
their first and second birthdays. After 2 years of age, growth
continues at a slower but steady rate of 2¹⁄₂ inches (6 cm)
per year until about the age of 11 in girls and 13 in boys,
when the growth spurt that goes along with adolescence
usually begins.
* Terms that appear in boldface are defined in the Glossary on page 54.
7
Table I: Normal Growth Rates During Childhood
The pubertal growth spurt
lasts about 2 years.
Age
Growth Rate (per year)
birth to 1 year
1 to 2 years
2 years to puberty
pubertal growth spurt
girls
boys
7 to 10 inches (18 to 25 cm)
4 to 5 inches (10 to 13 cm)
2 to 2¹⁄₂ inches (5 to 6 cm)
2¹⁄₂ to 4¹⁄₂ inches (6 to 11 cm)
3 to 5 inches (7 to 13 cm)
Pubertal Growth
The pubertal growth spurt lasts about 2 years and is
accompanied by sexual development (growth of pubic hair,
development of sex organs, and beginning of menstruation
in girls). Normal growth stops when the growing ends of the
bones fuse. This usually occurs between the ages of 13 to
15 years for girls and 14 to 17 years for boys.
8
Figure 1: Typical Pattern of Growth Rate From Birth
Through Adolescence
The typical pattern of growth for boys and girls from
birth through adolescence. The growth rate (how
fast the child is growing) is shown on the left side
of the chart; the child’s age in years is shown along
the bottom.
Normal growth stops
when the growing ends
of the bones fuse. This
usually occurs between
the ages of 13 to
15 years for girls and
14 to 17 years for boys.
9
Growth
Charts
The most valuable tool for assessing a child’s growth is a
well-kept growth chart made up of accurate height and
weight measurements. A child’s height and weight should
be measured and marked on his or her growth chart during
visits to the doctor or healthcare provider. Children under
the age of 3 years should be measured at least every
6 months; children over 3, every year. If there is any concern
about growth, measurements should be made as often as
every 3 months until a growth pattern becomes clear.
The most widely used growth charts are constructed by
measuring many boys and girls of all ages and breaking the
range of their heights and weights into centiles, or percents.
These centiles are represented on the growth charts (Figures
2 and 3) by the curved lines marked 5, 10, 25, 50, 75, 90, and
95. The spaces between the centile lines are called channels.
Age in years is marked along the bottom of the chart. Height
in inches and centimeters is marked along the sides. The
50th centile line is the average height for any given age.
If there is any concern
about growth, measurements should be made as
often as every 3 months
until a growth pattern
becomes clear.
11
Figure 2: Boys’ Growth Chart
Figure 3: Girls’ Growth Chart
To use the chart, we find the child’s age along the bottom and draw a line going up, parallel to
the two sides of the chart. Then we find the child’s height along the side and draw a line across,
marking the point where the child’s age line and height line cross. By looking at the boys’ growth
chart (Figure 2), for example, we can tell that a 5-year-old boy who is 43 inches (109.2 cm) tall is
average-sized (50th centile) for his age (point A on the growth chart). A 5-year-old boy who is only
12
40 inches (101.6 cm) tall, however, falls at about the 5th centile
line (point B on the growth chart). This means that if you
measured 99 other boys who were exactly 5 years old,
chances are that 95 of them would be taller than this 40-inch
boy and 4 would be shorter.
A growth chart shows us how a child’s height compares to
that of other children of the same age. It also shows us a
child’s growth pattern over time. After 2 years of age, most
children maintain steady growth throughout childhood along
one of the centile lines or channels. Children over 2 years
of age who move away from their established growth curve
deserve a thorough evaluation by a doctor, no matter how
tall they are. Look at the girls’ growth chart (Figure 3,
page 12). The child whose growth is shown on curve A is
more likely to have a serious problem than the child whose
growth is shown on curve B. The reason is that although
Child B is shorter, she continues to grow as expected—in
this case, along the 5th centile line. While Child A is still
taller than 25% of children her age, the growth chart shows
that her rate of growth has slowed seriously over the past
2 years. She needs to see her doctor promptly so the cause
of her growth failure can be investigated.
Children over 2 years of
age who move away from
their established growth
curve deserve a thorough
evaluation by a doctor, no
matter how tall they are.
13
Recognition
of Growth
Problems
Many parents are concerned about their children’s growth and
want to learn more about growth and growth problems. They
want to know when to worry and when not to worry about their
children’s growth.
The questions listed on the right can serve as guidelines for
parents who are worried about their children’s growth.* While
not necessarily indicating a problem, a “yes” answer to any of
these questions signals a need to discuss the question with your
child’s healthcare provider.
Remember that one of the most important things parents can
do to protect a child’s health and growth is to have their child
examined regularly by a pediatrician or qualified healthcare
provider. A child’s height and weight should be measured and
marked on the child’s growth chart as part of every visit to the
doctor. Researchers have found that girls are less likely than
boys to be referred for evaluation of growth problems, perhaps
because short stature is less of a social concern for girls. Poor
growth can be a symptom of a serious medical condition, so
any child whose height is below the 5th centile line on the
growth chart or who moves away from a previously normal
growth curve should be checked by a doctor.
* This list is based in part on Human Growth Foundation (HGF) guidelines.
For more information about HGF, please see page 52.
• Is my child the shortest or
tallest in the class?
• Is my child unable to keep
up with other children of
the same age in play?
• Is my child growing less
than 2 inches or more than
3 inches a year?
• Is my child showing signs
of early sexual development (before age 7 in girls
and before age 9 in boys)?
• Has my 13-year-old girl
or 15-year-old boy failed
to show signs of sexual
development?
15
Evaluation
of Growth
Problems
The first thing parents should do if they are worried about
their child’s growth is take the child to a pediatrician or
healthcare provider. First, the doctor will decide whether
the child’s size or growth curve is really a cause for concern.
If it is, a long list of possible causes of short stature and
growth failure must be considered. Table II lists some of the
problems and diseases that can cause poor growth. An
important thing to realize in looking at this long and complex
list is that there are many possibilities that need to be
considered, and it is helpful to approach the problem in an
organized way. The pediatrician or healthcare provider may
consult with a pediatric endocrinologist (a specialist in
children’s hormone and growth problems) about the best
way to assess a particular child.
The doctor may need to measure your child’s height over
a period of 6 to 12 months to evaluate the child’s present
growth rate. These measurements should be plotted on a
growth chart along with as many earlier measurements as
possible. Your child’s doctor or school often will have records
of yearly height and weight measurements.
The doctor may ask many
questions about your
child’s health, diet,
appetite, habits, and past
illnesses and injuries.
The doctor may ask many questions about your child’s
health, diet, appetite, habits, and past illnesses and injuries.
The doctor will also ask for information about the mother’s
pregnancy, labor, and delivery because these may provide a
clue to the cause of the child’s short stature. Questions about
17
your child’s progress in school, general mood, and home life
are important in getting to know your child as a person, but
also may shed light on your child’s growth problem. The doctor will ask about the health of other family members and
will want to know the heights of parents, grandparents, close
relatives, and brothers and sisters. Be sure to tell the doctor
about any diseases or problems that run in the family, as well
as any history of early or late puberty (growth spurt and sexual development) in family members.
The doctor will perform
a thorough physical
examination to look for
signs of the causes of
short stature.
18
The doctor will perform a thorough physical examination to
look for signs of many of the causes of short stature listed in
Table II. X-rays or scans may be done to check on the condition
of the pituitary gland (a small gland attached to the base of
the brain). Blood tests can tell the doctor about the condition
of the kidneys, bones, and thyroid gland. The amount of
insulin-like growth factor I (IGF-I/somatomedin-c) in
the blood may be checked. This is a substance that provides
an indirect measure of the amount of growth hormone in
the body.
Table II: Possible Causes of Short Stature and
Growth Failure
Familial short stature —“heredity” (short parents are more likely to
have short children)
Constitutional growth delay — delayed puberty, delayed growth
spurt, normal adult height
Illnesses and diseases that affect the whole body (systemic diseases)
• Nutritional deficiencies — undernutrition or malnutrition
• Digestive tract disease — bowel disease
• Kidney disease
• Heart disease
• Lung disease
• Diabetes mellitus — high sugar
• Severe stress or deprived environment
Endocrine (hormone) diseases
• Lack of thyroid hormone — hypothyroidism
• Too much cortisol (stress hormone) — Cushing’s syndrome
• Lack of growth hormone (GH) — GH deficiency
Problems in the tissues where growth occurs (congenital conditions)
• Intrauterine growth retardation — slow growth before birth
caused by infections, smoking, alcohol use during
pregnancy, or unknown factors
• Chromosome abnormalities — Turner syndrome, other
genetic syndromes
• Skeletal abnormalities (bone diseases) — defects in size,
shape, growth of bones
Idiopathic — no cause can be found
19
Figure 4: X-ray Changes
as Bones Develop
2¹⁄₂ yrs
8 yrs
14 yrs
20
An X-ray of the child’s hand and wrist may be made to check
the child’s bone age. In some short children, the maturity of
the bones lags behind the child’s actual age, and we say that
the child has a delayed bone age. The bone age may be
delayed for a variety of reasons, so it is not very helpful in
finding the cause of short stature. It is, however, useful for
determining the growth potential of the short child, and this
is one time that delayed maturity is a good sign. A 9-year-old
boy who has a bone age of 7 years, for example, has about
2 years more growth potential, or room to grow, than the
average 9-year-old. This is because the development of his
bones is more like a 7-year-old than like a 9-year-old. This
child’s delayed bone age can “catch up” to his chronological
age in less than 2 calendar years, however, especially after
he enters puberty. Some of the changes that occur with the
development of bones throughout childhood are shown in
X-rays (Figure 4).
By referring to special tables, the doctor can predict adult
height based on the child’s present bone age and height. It
is important to remember that these predictions are only
educated guesses, and that the child’s adult height will be
the result of many factors, including heights of parents, the
child’s general health and state of nutrition, the age at which
puberty begins, and the length and vigor of the pubertal
growth spurt. In general, height predictions are more
reliable as the child becomes older.
Tests for growth hormone secretion should be performed
after other causes of growth failure have been considered
and ruled out. Growth hormone is secreted by the pituitary
gland in quick bursts and does not last long in the blood, so
checking a single blood sample for growth hormone is not
likely to be helpful. Deep sleep, vigorous exercise, and
certain drugs are known to stimulate the secretion of growth
hormone. The amount of growth hormone in the bloodstream is measured by taking several small blood samples
over a period of time. This may be done in the doctor’s
office or during a brief hospital stay. The results of this test
will show if the child’s growth problem is caused by a
deficiency (lack) of growth hormone.
The amount of testing
that a child needs
depends on what the
doctor finds at each step
of the evaluation.
The amount of testing that a child needs depends on what
the doctor finds at each step of the evaluation. A short child
who is healthy and growing at a normal rate may be
observed throughout childhood, while a child whose growth
has stopped will need more involved testing. The evaluation
process may make more sense if we take a closer look at
some of the variations of the normal growth pattern and
some of the causes of abnormal growth.
21
Variations in
the Normal
Pattern
of Growth
Although most children follow the usual pattern of growth
described earlier, a small but significant number of children
have growth patterns that differ from this typical model.
Some of these less common but normal patterns of growth
include shifting channels in infancy, familial short stature,
constitutional growth delay, and familial tall stature (see
pages 39-41 for a discussion of familial tall stature).
Shifting Channels in Infancy
It is not unusual for normal children under 2 years of age to
cross centile lines in either direction. This happens because the
factors that affect growth before birth are different from those
that govern growth after birth.
Babies who are small at birth often shift to a higher growth
channel during the first few months of life, as they “catch
up” to their own growth potential. On the other hand, large
or average-sized babies who have short parents may have
slower-than-expected growth during the first months of life
as they settle into their own growth channel. A downward
shift in growth during the first 1¹⁄₂ to 2 years of life may not
be a cause for concern if the baby is healthy, thriving and has
a good diet, and if height and weight are shifting together.
It is not unusual for
normal children under
2 years of age to
cross centile lines in
either direction.
23
At some point between
the child’s first and
second birthdays,
the child should begin
to maintain steady
growth along the “new”
centile channel.
24
The doctor who sees a baby like this may ask many questions
about the baby’s habits and behavior and will perform a careful examination to make sure there are no physical problems.
The baby’s height and weight should be measured carefully
and marked on his or her growth chart every 3 months. At
some point between the child’s first and second birthdays,
the child should begin to maintain steady growth along the
“new” centile channel. After this “new” growth curve is
established, height and weight should be checked and plotted
on the growth chart every 3 to 6 months until age 3 and
every 6 to 12 months after that. As long as the child is
healthy and growing at a normal rate, no special treatment
is needed.
Familial Short Stature
Short parents tend to have short children. This is the result
of genes that are passed from one generation to the next.
The doctor evaluating a short child will need to know the
heights of the child’s parents and other relatives. By taking
the midpoint of the parents’ heights, the doctor can figure
out a child’s expected range of height. The height of a short
child with short parents often will fall within a normal range
of height when this midpoint is taken into account.
The term familial short stature applies to
children who:
•
are small for their age (growth is at or below the
5th centile line on the growth chart);
•
come from short families;
•
are growing at a normal rate; and
•
do not have any signs or symptoms of diseases
or conditions that affect growth.
Children with familial short stature are likely to enter puberty
and have a growth spurt at a normal age; their bone age will
be the same as their chronological age (age in years), meaning
that there is no delay in bone maturity. They can expect to
reach an adult height about the same as that of their parents.
Sometimes the diagnosis of familial short stature can be
made only by excluding other causes of short stature. This is
why the doctor may order some laboratory tests before making
this diagnosis.
Laboratory tests may
be ordered before
your physician makes
a diagnosis.
25
Constitutional Growth Delay
This type of growth pattern is one of the most frequent causes
of parental concern about growth.
Constitutional growth delay is the term used to
describe children who:
Constitutional growth
delay is more common
in boys than in girls.
•
are small for their age (growth is at or below the
5th centile line on the growth chart);
•
are growing at a normal or near normal rate;
•
have a delayed bone age (usually 1 to 4 years behind
their chronological age);
•
are late entering puberty; and
•
do not have any signs or symptoms of diseases
or conditions that affect growth.
Constitutional growth delay is more common in boys than in
girls. These children often are shorter than other children
their age before they start school. If good growth records are
available, one or more periods of slow growth during early
childhood may be seen. These children do not catch up in
their growth until after the pubertal growth spurt. They
continue to grow at the slow, steady rate of childhood for
longer than most of their friends. When they finally enter
puberty at about age 15 for boys and about 14 for girls, they
have a normal growth spurt and normal sexual development.
26
Their adult height usually is similar to that of their parents.
Constitutional growth delay tends to run in families. Often
there is a history of delayed growth and adolescence in the
child’s parents and in other relatives. As with familial short
stature, the diagnosis of constitutional growth delay may
depend upon excluding other causes of short stature. To do
that, the doctor may order some laboratory tests before
making the diagnosis.
The social problems faced by some children with constitutional
growth delay result from their short stature and delayed
sexual development. A 14-year-old boy with severe growth
delay may look like a 9- or 10-year-old—a real disadvantage
when it comes to making the football team or getting a date
for the school dance. In many cases, support from parents
and reassurance from the doctor that he is normal, that he
can expect to mature sexually, and that he will reach a
normal adult height is all that is needed to help an affected
boy adjust. In some cases, where the teenage boy’s emotional
pain is extreme, the doctor may consider using male
hormones (androgens) to speed up the delayed timetable
of puberty. These hormones cause a growth spurt and hasten
the onset of sexual development, but they may speed up
bone maturation. This means that the growing ends of the
bones may fuse and growth may stop at an earlier age than
if no treatment were given.
The social problems
faced by some children
with constitutional growth
delay result from their
short stature and delayed
sexual development.
27
Abnormal
Growth
Although most children who are short or tall are healthy and
normal, there are children who have diseases or conditions
that affect their growth. Remember that a child’s growth rate
over time is a more important clue to the presence of a
growth problem than his or her size. For this reason, regular,
accurate measurements plotted on a growth chart are very
important: A change in the child’s growth rate may provide
the first hint of an underlying problem.
The known causes of growth failure and short stature
fall into 3 major groups:
• systemic diseases (diseases that have effects on
the whole body)
• endocrine diseases (deficiencies or excesses
A change in the child’s
growth rate may provide
the first hint of an
underlying problem.
of hormones)
• congenital conditions (conditions present at birth).
Sometimes no cause can be found; this is called idiopathic
short stature. The purpose of this section is to provide an
overview of the causes of growth failure. Sources of more
specific information will be found on the back cover.
Abnormal tall stature is most often caused by an endocrine
disease or a genetic condition; these will be discussed on
pages 32–36.
29
Systemic Diseases
Systemic diseases are those which have effects on the whole
body. They impair growth by affecting the child’s overall health
and well-being. Any disease that is severe or poorly controlled
can have a negative effect on a child’s growth.
Any disease that is
severe or poorly
controlled can have
a negative effect on
a child’s growth.
Nutritional problems are the most common cause of growth
failure worldwide. Good nutrition is the cornerstone of normal
growth. A balanced diet with the right number of calories and
the right amount of protein is necessary to meet the needs of
growing children. Several diseases of the digestive tract
(gastrointestinal diseases) can cause food to be poorly
absorbed, so that the body cannot use food properly. Failure
to absorb nutrients and energy from food often leads to
growth failure.
Some of the symptoms of nutritional or bowel
diseases include:
•
poor weight gain;
•
low weight for height;
•
frequent nausea, vomiting, diarrhea, or constipation;
•
abnormal bowel movements; and
• severe bloating or gas when dairy products or other
foods are eaten.
30
Treatment of digestive tract problems often involves a
special diet. Children with nutritional problems usually grow
normally after the problem is diagnosed and treated correctly.
Diseases of the kidneys, heart, and lungs may lead to growth
failure by causing the buildup of undesirable substances in
the body and by interfering with the body’s use of nutrients
and energy.
Poor growth may be the first sign of chronic renal insufficiency
(CRI), which is a permanent decline in kidney function.
Children with CRI produce a normal amount of growth
hormone, but do not use properly the growth hormone
they make. The growth of many children with CRI can be
improved by treating them with growth hormone.
Other metabolic conditions can affect growth as well;
for example, children with diabetes, or “high sugar,” sometimes
grow poorly even when their blood sugar is fairly
well controlled.
Nutritional problems are
the most common cause
of growth failure worldwide. Good nutrition is
the cornerstone of
normal growth.
Severe stress can cause growth failure. Children who are
neglected or abused may stop growing for a while, then start
growing again when their home life improves or when they
are removed from the home.
31
Endocrine Diseases
Endocrine diseases are those that involve deficiencies or
excesses of hormones. A deficiency exists when there is not
enough of a hormone in the body; excess means there is too
much of a hormone in the body.
Hypothyroidism, or deficiency of thyroid hormone, can halt
growth completely and can occur at any time. Growth failure
may be the first sign of this disease in childhood.
Every child who is
growing at a slower
than normal rate should
have a simple blood
test to check for
thyroid deficiency.
Other symptoms that may appear later include:
•
lack of energy and concentration;
•
constipation;
•
dry, rough skin and hair;
• hoarseness;
•
feeling cold when others are warm; and
•
coarsening (“thickening”) of facial features.
Every child who is growing at a slower than normal rate
should have a simple blood test to check for thyroid deficiency.
This disease is treated easily by taking a thyroid pill every
day. The child with growth arrest from hypothyroidism
usually “catches up” and returns to his or her previous
growth channel after treatment begins.
32
Cortisol (stress hormone) excess, or Cushing’s syndrome, is
a less common cause of growth failure in children. In this
disorder, weight often increases while growth in height
slows. Too much cortisol also causes thinning of the skin,
easy bruising, softening of the bones, and muscle wasting
and weakness. It may be caused by overactivity of the
pituitary gland, the presence of a tumor in the adrenal
glands (where cortisol is made), or over-medication with
cortisol pills used to treat asthma and other diseases. A blood
test is used to check the amount of cortisol in the blood. If
there is too much cortisol, additional tests are needed to find
out what is causing the excess. The treatment depends on
the cause. Early diagnosis of this problem is important
because the longer it lasts, the less chance the child has of
returning to a normal growth channel.
Although growth hormone
(GH) deficiency is
uncommon, it may occur
at any time from infancy
through childhood.
Although growth hormone (GH) deficiency is uncommon,
it may occur at any time from infancy through childhood.
There are many causes of GH deficiency. Most involve
damage to the pituitary gland or a specialized part of the
brain that controls the pituitary. In childhood, a common
sign of GH deficiency is a marked slowing of growth, usually
to less than 2 inches (5 cm) a year. Many children with GH
deficiency have normal body proportions and normal intelligence; some may be overweight for height or have problems
with low blood sugar. GH deficiency is diagnosed by doing
special tests to look for GH in the blood. It is treated by
33
giving the affected child injections of GH until the child
reaches his or her adult height or until the growing ends of
the bones fuse.
Childhood GH deficiency
may continue into
adulthood.
Childhood GH deficiency may continue into adulthood.
Because GH affects body metabolism after growth has
stopped, physicians should inform their teen-aged and adult
patients that they may benefit from continued GH therapy
throughout adulthood. Adults with GH deficiency may have
more fat and less muscle (lean body) mass than unaffected
adults. Lipid (fat and cholesterol) metabolism may be
affected, and there is an increased risk of diseases affecting
the heart and blood vessels. Some adults with GH deficiency
may have low energy and other psychological and social
problems that can affect their quality of life.
Congenital Conditions
Congenital conditions are present at birth and result from
problems that occur before the baby is born. A number of
factors can affect the mother, the fetus, or the placenta
(the organ in the uterus that links mother and fetus) to cause
intrauterine growth retardation, or slow growth within
the uterus.
Babies who are born prematurely (early) but who are normal
size for their age usually “catch up” and fall within the
34
normal range for height and weight by 2 to 3 years of age if
they are in good health. Some full-term babies are smaller
than expected at birth. If a full-term baby weighs over
4¹⁄₂ pounds (2 kg) and does not have any other problems,
there is a good chance that he or she will “catch up” and be
of normal size by 2 to 3 years of age. Full-term babies who
are very small at birth (under 4 pounds or 1.8 kg) are more
likely to remain small throughout life.
Many genetic syndromes (groups of signs and symptoms of
an abnormality) are associated with short stature and growth
problems. One of the most common is Turner syndrome,
which occurs only in girls. Girls with Turner syndrome have
a missing or misshapen sex chromosome (“package” of
genes) in many of their cells. These girls have underdeveloped
ovaries (female sex glands where eggs and female hormones
normally are produced), they are short as adults, and their
intelligence is usually normal. Turner syndrome is diagnosed
by doing a special blood test (karyotype) to look for damaged
or missing sex chromosomes. Growth failure may be the only
sign of this condition. The results of many studies show that
GH injections increase the growth rate of girls with Turner
syndrome and improve their adult height. Female hormones
(estrogens) must be given to bring about full sexual
Because GH affects
body metabolism after
growth has stopped,
physicians should
inform their teen-aged
and adult patients that
they may benefit from
continued GH therapy
throughout adulthood.
35
development at the time of puberty because the girl’s underdeveloped ovaries will not usually produce these hormones.
There are more than
100 bone diseases
that can affect height
and growth.
There are more than 100 bone diseases that can affect height
and growth. Children with one of these skeletal dysplasias, or
chondrodystrophies, are very short and have abnormal body
proportions; intelligence is usually normal. One of the most
common genetic bone disorders is achondroplasia, a disease in
which a child’s arms and legs are short in proportion to body
length; the head is often large and the trunk is normal size.
Skeletal dysplasias involve abnormal formation and growth of
cartilage and bone. Although no hormonal treatment is proven
to be effective in increasing adult height, a surgical method for
lengthening of the legs has been applied with some success. It
is important to try to identify the type of disorder present
because this information is useful in anticipating related medical problems and in providing genetic counseling.
Idiopathic Short Stature
The term idiopathic short stature is used to describe short
children who do not fit into any of the categories described
above and in whom results of lab tests are normal. Most will
be below the normal range for height as adults, and below
what would be expected given their parents' heights.
The diagnosis of idiopathic short stature is applied to the
36
child who has had a comprehensive evaluation for his/her
growth disorder and no cause has been found.
Not all causes of short stature and growth failure can be
treated, but parents and doctors should be alert for changes
that may signal the onset of a treatable growth problem.
Whether medical treatment is recommended or parents are
reassured that their short child is healthy and normal,
emotional problems related to size may exist. It is just as
important to recognize and treat these problems as it is
to recognize and treat the child’s physical problems;
increased height does not automatically make a child’s
challenges disappear.
Attention to a child’s
psychological well-being
should be part of every
medical evaluation and
treatment plan.
37
Tall Stature
By definition, there are as many children above the
95th centile in height as there are below the 5th centile.
Most tall children have tall parents, and few have reason
to worry about their height.
The term familial tall stature applies to children who:
•
are tall for their age (growth is at or above the
95th centile line on the growth chart);
•
come from tall families;
•
are growing at a normal rate; and
•
do not have any signs or symptoms of diseases
or conditions that affect growth.
Tall boys rarely complain about their size, but tall girls may
feel ill at ease or out of place towering over their friends.
Support and reassurance that many of the boys will catch up
later may be all that is needed to help the tall girl feel more
comfortable with her size. Adult height can be predicted on
the basis of bone maturity (bone age determined by X-ray)
and present height. If predicted adult height is over 6 feet
and the preteen girl is suffering a great deal because of her
size, some doctors would consider using female hormones
(estrogens) to hasten the onset of puberty and decrease
adult height. These female hormones may have undesirable
side effects, however, so this treatment should be considered
By definition, there are
as many children above
the 95th centile in height
as there are below the
5th centile.
39
only in extreme cases, after all known and potential side
effects are evaluated and thoroughly discussed with the girl
and her family. Children who are above the 95th centile in
height or who are growing at an abnormally rapid rate
should be checked by a doctor. Abnormal tall stature is most
often caused by an endocrine disease or a genetic condition.
Abnormal tall stature is
most often caused by an
endocrine disease or a
genetic condition.
40
There are several endocrine causes of abnormal tall stature
and rapid growth. Growth hormone excess may be caused by
a small tumor in the pituitary gland. It is treated by removing
the tumor and watching carefully for signs of recurrence.
Children with GH excess usually are tall as adults.
Sexual precocity, or early puberty, is a more common cause
of unusually fast growth. In this condition, rapid growth is
accompanied by early sexual development and advanced
bone maturation. True sexual precocity is not the same as
early development of pubic hair or breasts (in girls), which
may be normal. However, any girl under 7 years or any boy
under 9 years who shows signs of sexual development (growth
of pubic hair; enlargement of breasts, penis, or scrotum;
deepening of voice) should be checked by a doctor. These
children may be tall at first, but early puberty causes early
closure of the growth plates of the bones, so the children
will stop growing at a younger age and be short as adults.
It is important to find and treat the cause of early sexual
development. Certain drugs may be used to try to halt early
puberty and increase growth potential.
Genetic conditions that cause abnormal tall stature are rare.
These conditions usually are associated with a set of distinctive
physical traits, which often includes abnormal body proportions.
Although our society is more accepting of tall stature than of
short stature, children who are tall for their age may have
emotional problems related to their size. Like short children,
they stand out as different from their classmates and may be
the victims of teasing and name-calling. Family, teachers,
and friends may have a difficult time treating the tall child
according to age rather than size; they may expect more of
the child because he or she looks older. Some of the
comments in the following section on psychological and
emotional aspects of short stature apply just as well to
children who are very tall.
Although our society is
more accepting of tall
stature than of short
stature, children who are
tall for their age may
have emotional problems
related to their size.
41
Psychological
and Emotional
Aspects of
Short Stature
Since children who are short often face teasing and other
forms of emotional stress, they may have problems coping
and adjusting. The following story highlights some of the
problems any short children may face, regardless of their
diagnosis. Although we sometimes refer to boys and use
male pronouns (he, his) in this section, the discussion applies
to both girls and boys.
Josh is a 12-year-old boy with constitutional growth delay.
Although he has grown at a normal rate throughout
childhood, his height is below the 5th centile line on the
growth chart. His bone age is delayed by 2 to 3 years, so he
is likely to reach a normal adult height. He has always been
the smallest child in his class, and the size difference is getting
more noticeable as some of his classmates begin their growth
spurts: Josh looks more like a 4th grader than a 7th grader.
He is having school problems this year, after moving into a
new school. His teachers report that “he’s either a clown or
a bully in class, and he just does not pay attention.” He likes
sports and is good at soccer, but the coach does not want to
let him try out for the team—he is afraid Josh will get hurt.
The older boys at school sometimes pick him up and carry
him around, calling him “Peewee” and “Squirt.” He has
started spending a lot of time alone in his room and does not
seem interested in anything. After his last visit to the doctor,
he said, “I’m sick of hearing how tall I’ll be in 10 years. I’m
a shrimp now, and that is all that matters.”
43
Our society places
positive emphasis on
height. Children or adults
who are short may be the
victims of teasing,
name-calling, cruelty,
and prejudice.
Family, teachers, and
other children have a
difficult time treating a
short child according to
age rather than size.
44
Although most short children adapt well to their size and do
not have severe psychological problems because of being
short, Josh’s story is not unusual. Our society places positive
emphasis on height. Children or adults who are short may be
the victims of teasing, name-calling, cruelty, and prejudice.
Different-aged children will have different concerns and
problems depending on their level of development and
maturity. For instance, preschoolers may worry that it is
their fault that they are not growing. Regression (acting like
a younger child) may be seen in school-aged children, while
teenagers are likely to be concerned about dating, driving,
and discrimination in school, sports, and the job market. Any
child may deal with these frustrations by becoming
depressed (withdrawn and unhappy) or by “acting out”
(behaving in an angry, aggressive, hurtful way). Whatever the
behavior, it is important for parents to try to understand the
feelings behind the child’s actions. If you feel things are
getting out of control or are more than you can handle, talk
to your child’s doctor or nurse. They can give you some
suggestions or direct you to someone who can help.
The Short School-Aged Child
Josh is experiencing some of the common and predictable
problems faced by school-aged children who are short.
Family, teachers, and other children have a difficult time
treating a short child according to age rather than size.
Sometimes discussing this tendency with teachers and
friends (young and old) may be helpful in overcoming it.
Although Josh looks like a 9-year-old, he is 12. Being treated
as if he were 9 makes it easy for Josh to act younger than he
really is—and perhaps he feels safer and more secure in a
dependent, immature role. Acting younger does not make
him happier, but it is safer because less is expected of him.
Facing challenges is an important part of growing up and,
like any child, the short child needs to have chances to
succeed as well as to fail.
There is a natural tendency for parents to shelter their short
child from the outside world, but children need not be
shielded completely from reality. A healthy approach is to
provide love, encouragement, support, and skills that will
help the child deal with the “big” world and develop
self-confidence and a sense of responsibility. Focus on your
child’s strengths: Look for things the child does well and give
him the chance to do his best. Be excited about her
achievements, whatever they are.
Focus on your child’s
strengths: Look for things
the child does well and
give him the chance to
do his best. Be excited
about her achievements,
whatever they are.
One of the reasons Josh is having school problems this year
is that he has just transferred to a different school and has to
face new teachers and new classmates who are not sure how
to act around him. If a child is in the same school for several
45
Sports are an important
part of life for many
children, and there
is no reason why short
children cannot
participate and excel
in athletic activities.
Short children, like
other children, should
be encouraged to find
a sport they enjoy,
work hard at it, and
do their best.
46
years, he often will develop a special role in the class and the
other children will get to know him and stop thinking of him
as different. In other words, he becomes accepted. A change
(moving, transferring to another school) is like starting all over
again with teasing and name-calling. Some children subjected
to this kind of treatment just give up, withdraw, and do not
make new friends. Sometimes an older or bigger child serves
as “protector” or “bodyguard” for the small child. This may
be helpful for the short child, as long as he does not depend
on his “bodyguard” to fight all his battles.
The Short Child and Sports
Another issue facing Josh and his family involves sports.
Sports are an important part of life for many children, and
there is no reason why short children cannot participate and
excel in athletic activities. Many sports require intelligence,
strength, and endurance more than tall stature. Soccer,
tennis, karate, judo, gymnastics, wrestling, skiing, skating,
squash, handball, racquetball, horseback riding, horse racing,
bowling, golf, track, swimming—there is a long list of activities
that give short children and adults a chance to compete
successfully. Short children, like other children, should be
encouraged to find a sport they enjoy, work hard at it, and
do their best.
Making Life Easier for the Short Child
The most important step in making life easier for a short
child is also the hardest, and that is recognizing and accepting
the child’s size. Children need to feel loved and valued just
as they are, whether short or tall, thin or heavy. Parents who
constantly focus on a child’s height (or lack of it) may make
the child feel that it is not okay to be the way he or she is.
Once parents come to terms with their child’s size, they can
talk about it with the child in an open and realistic way.
Children may have a hard time putting their feelings into
words, but that does not mean they don’t have feelings about
being small. Short children know they are short by the time
they reach school age, if not before. The short child may be
relieved to have parents who can help him to identify and
express his feelings about being different.
In addition to conveying a basic feeling of acceptance, there
are some very practical ways a parent can help to make life
easier for a short child. The following ideas, based in part
on a section in Kate Phifer’s book, Growing Up Small,* may
be helpful.
The most important step
in making life easier for
a short child is also the
hardest, and that is
recognizing and accepting
the child’s size.
• Make the physical environment at home as comfortable
as possible for the child. Walk through the child’s daily
routine and see how things look from a lower eye level.
This is something parents and child can do together.
* You will find this book listed on the back cover.
47
Teach your child ways
of coping with the
physical environment
away from home.
48
It is hard, for example, to hang up your coat if you can’t
reach the hanger. Lowering rods and hooks in closets
solves this problem. Children may do a better job of
combing their hair if there is a mirror placed so they can
see more than the top of their head. Steady footstools or
stepladders throughout the house can make a big
difference in how easily a child can take care of himself.
Whatever changes you make around the house, make
them as simply and quickly as you can. Don’t make a “big
deal” out of what you are doing or make the child feel
that he is causing trouble by being small.
• Teach your child ways of coping with the physical
environment away from home. This may include practice
in “speaking up” when he is stuck behind a high counter
or needs help reaching a doorknob. Help your child think
about situations in public that cause awkwardness or
embarrassment and then help the child to come up with
ideas for handling those situations. Help your child
rehearse a response (“role-play”) until he feels ready to
try it out in the real world to see how it works. It may
take a few tries, but it should be worth the effort.
• Help your child learn some of the social skills that may be
taken for granted. Take your child with you when you go
out and teach him how to order food in a restaurant, pay
the cashier at the store, or ask for the right size in the
shoe department. Have your child’s friends over often
and help your child make them feel welcome. Encourage
your child to join in group activities if he would like to.
It may be hard at first, but it often gets easier as the
children get to know each other.
• Discuss your child’s size with teachers and friends (young
and old). Explain that it is important that your child be
treated according to age, not size. It is hard to resist the
urge to carry around a cute and cuddly 5-year-old who
looks like a 3-year-old, but it is important to treat that
child like any other 5-year-old. This is true at home
as well.
• Helping with chores and jobs around the house is part of
growing up for many children. It helps children develop
a sense of responsibility and gain a feeling of pride and
satisfaction. Short children don’t need to be excused from
sharing in household chores. With a little creativity, a
short child should be able to do almost anything around
the house, the yard, or the school, comfortably and safely.
Help your child learn
some of the social skills
that may be taken for
granted.
• Dress your child according to age, not size, even if it
sometimes means having clothes altered. A 6-year-old
who is dressed in toddler clothes, complete with snap
seams on the legs, most likely is going to be treated like a
toddler. Going along with fads is part of being a teenager.
Learning to sew may be one answer for the teen who
can’t find the right style in the right size.
49
• Encourage your child to learn skills that allow for competition, no matter what his size. Music, drama, dancing
lessons, 4-H clubs, sport—there are many activities that
give children a chance to develop special skills and learn
to work and play with others. Local schools and recreation
departments are good sources of information about
activities for children.
To Sum Up:
Local schools and
recreation departments
are good sources of
information about
activities for children.
•
Recognize and accept your child’s size.
•
Show respect for your child by treating him according
to age, not size.
•
Teach your child useful skills for dealing with the
“big” world.
Show respect for your
child by treating him
according to age,
not size, and talk to
your child openly
and realistically.
•
Talk to your child openly and realistically.
•
Focus on your child’s strengths.
•
Give your child chances to succeed and fail, and give
support in failures as well as in successes.
•
Seek professional help if you or your child need it
(from your physician, a psychologist, or the local
mental health center).
50
•
Even if the child’s short stature is due to a treatable
medical problem, do not rely on catch-up growth
to solve problems of psychological adjustment, if
these exist. Even catch-up growth is a gradual
process. Support your child in actively coping with
the challenges that he or she is facing.
Raising a happy, healthy, well-adjusted child is a challenge to
every parent. The challenge is even greater if the child stands
out as “different” because of size, but greater challenges can
lead to greater rewards.
Seek professional help if
you or your child need it
by contacting your
physician, a psychologist,
or the local mental
health center.
51
The Human Growth Foundation
Families with short children or children with growth problems
should be aware of the services of the Human Growth
Foundation (HGF). HGF is a nonprofit national organization
of families of short children and others who are interested in
growth problems. Its goals include support of research into
normal and abnormal growth, parent education and service,
education of healthcare professionals and the public, and
advocacy on behalf of affected children and families.
Chapters are located in major cities across the country. More
information about the services of HGF and local chapter
addresses can be obtained by writing to this address:
Human Growth Foundation
997 Glen Cove Avenue
Glen Head, New York 11545
Toll-free: (800) 451-6434
www.hgfound.org
52
The Magic Foundation for
Children’s Growth
MAGIC provides educational support to families of children
with growth-related disorders. A quarterly newsletter,
national networking, annual national convention, educational
brochures, and videos are some of the programs available.
Specialty divisions are available for a variety of growth
disorders. For additional information and a copy of our
brochure, newsletter, and upcoming convention details,
please contact MAGIC at:
The MAGIC Foundation
1327 N. Harlem Avenue
Oak Park, IL 60302
Toll-free: (800) 3-MAGIC 3
Tel: (708) 383-0808
Fax: (708) 383-0899
www.magicfoundation.org
53
Glossary
• adolescence — The teenage years, when the child is
becoming an adult physically and mentally (see puberty).
• bone age — Refers to the stage of development or
maturity of the bones. In most children, bone age will
be about the same as chronological (actual) age, but in
some children it may be advanced (ahead) or delayed
(behind). It is measured by taking an X-ray, usually of the
hand and wrist, to look at the bones and compare them
to standards for boys and girls of various ages.
• centile or percentile — A number based on dividing
something into 100 parts, in this case, a group of
children of the same age. The centile number tells what
percent of children of that age are taller or shorter than
the child being measured.
• chondrodystrophies — Conditions involving abnormal
development of the cartilage (tissue that develops into
bone); sometimes called skeletal dysplasias (conditions
involving abnormal development of bones).
• cm (centimeter) — A unit to measure length in the metric
system. 1 cm = 0.4 inches; 2.54 cm = 1 inch.
• deficiency — Not enough of something, in this case,
a hormone.
• genes — Chemical units inherited from parents. Genes
determine the specific characteristics of offspring.
• growth hormone — A hormone secreted by the pituitary
gland which causes physical growth.
54
• hormones — Chemicals secreted into the bloodstream in
small amounts by glands throughout the body. Hormones
“set in motion” many life processes—growth, puberty,
reproduction, metabolism, self-preservation.
• idiopathic — Occurring without a known cause.
• insulin-like growth factor I (IGF-I/somatomedin-c) — A
chemical produced by the liver and other tissues in
response to growth hormone (GH). It is the “middleman”
between GH and the changes in cells that lead to growth.
• kg (kilogram) — A unit to measure weight in the metric
system. 1 kg = 2.2 pounds; 0.45 kg = 1 pound.
• pituitary gland — A small gland attached by a stalk to the
base of the brain; it secretes hormones that control other
glands and regulate growth. It is sometimes called the
“master gland.”
• puberty — Often used to mean the same thing as
adolescence, but it can be used to describe the time
when the physical changes of adolescence occur.
• syndrome — A set of features or symptoms often occurring
together and believed to stem from the same cause.
55
Additional Reading
If you are interested in learning more about normal growth, growth problems, or the
psychological effects of being “different,” these are some books you may find helpful.
Briggs, Dorothy. Your Child’s Self-Esteem. NY: Doubleday, 1975.
Available in paperback and at public libraries. For parents interested
in finding ways to help their children feel good about themselves.
Fraiberg, Selma. The Magic Years. NY: Charles Scribner’s Sons,
1959. Available in paperback and at public libraries. A classic book
on “understanding and handling the problems of early childhood.”
Although it does not deal with short stature specifically, it is useful in
gaining understanding of how young children think, and may help you
deal with the problems of having a young short child.
Human Growth Foundation. Series of booklets designed for parents
on the following topics: Short & OK: A Guide For Parents of Short
Children; Patterns of Growth; Growth Hormone Deficiency; Growth
Hormone Treatment: What To Expect; Turner Syndrome;
Achondroplasia; Intrauterine Growth Retardation. Available from
HGF by writing to them at: 997 Glen Cove Avenue, Glen Head,
NY, 11545
Phifer, Kate. Growing Up Small: A Handbook for Short People.
Middlebury, VT: Paul Eriksson, 1979. Available in hardback. “How
parents and others can help children understand it, cope with it, take
advantage of it, and maybe even cure it.”
Phifer, Kate. Tall and Small: A Book About Height. NY: Walker and
Company, 1987. Available in hardback. A book about normal growth
and puberty and variations from the normal pattern of development.
Aimed at the middle and high school audience; contains tips for
handling school and peer problems related to height.
Silverstein, Shel. The Missing Piece. NY: Harper and Row,
Publishers, 1976. Available in paperback and at public libraries. This
children’s book (for all ages) is about a wheel that is missing a piece
and how it learns to feel good about itself even though (or because)
it is different from other wheels.
Spier, Peter. People. NY: Doubleday Publishing, 1980. Available in
paperback and at public libraries. This book for 4- to 8-year-olds helps
them learn about differences and similarities among people.
Tanner, James. Fetus Into Man: Physical Growth from Conception to
Maturity. Cambridge, MA: Harvard University Press, 1978. Available
in hardback. A brief and understandable account of human physical
growth; highly recommended for the interested parent.
Tanner, James and Taylor, Gordon. Growth. Alexandria, VA: TimeLife Publishers, 1981. Available in hardback; may be available in
public libraries. One volume in the Time-Life Science Library;
very readable.
The contents of this book and related websites are not intended for the purpose of disease diagnosis or a substitute for information that is provided to you by
your physician. You should always discuss your individual symptoms and any questions you have with your physician. Genentech, Inc. is not responsible for the
accuracy of the information contained on third-party websites and does not recommend or endorse the content provided on these websites.
Provided as an educational service by
Human Growth Foundation
www.hgfound.org
.O.
F.P
The MAGIC Foundation
www.magicfoundation.org
©2014 Genentech USA, Inc., So. San Francisco, CA NTR/093014/0040 11/14