My child is short … is that OK?
A pediatric endocrinologist gives an in-depth look at evaluating a child’s height
I think that human beings are drawn to see uniqueness in our surroundings. We make note of differences and often form quick impressions about what we see. Difference in height from person to person, for instance, is one feature that easily stands out.
Extremes in height- short stature or tall stature - further call attention to a person’s uniqueness and may represent challenges for some in everyday life. The judgment of what is normal height can be distorted in a variety of ways including media images, peer groups, and family/cultural backgrounds.
Being short seems to be negatively viewed in the range of height difference. Men and boys, in particular, seem more impacted by short stature with research reports from several decades ago reporting negative psychological and social effects in males with short stature. And while, more recent research calls into question whether or not there is a negative impact, it’s still difficult for many to forget old impressions and stereotypes.
Short stature referrals are one of the main types of referrals seen by most pediatric endocrinologists. While the medical evaluation of short stature is a fairly straightforward process (at least for a pediatric endocrinologist), navigating the family and emotional dynamics can sometimes be tricky. I think offering education to child and family about normal expectations is an essential part early in the first referral visit.
The first and perhaps most important part in short stature evaluation is understanding that a child’s growth and height are strongly connected to genetics of his or her family. In other words, short children typically have short parents.
It is also important before moving further for a reminder of average height for women and men in the U.S.
Average women’s height is 5’4”
Average man’s height is 5’10”
A handy formula used to help estimate a child’s genetic height target (the range of their adult height) is as follows:
Let’s look at two examples to illustrate,
Short Parent Family: Mom 5’0” Dad 5’7”
Height range for son: Middle of target: 5’6”Range: 5’2’ to 5’10”
Height range for daughter: Middle of target: 5’1”
Range: 4’9” to 5’5”
Tall Parent Family: Mom 5’6” Dad 6’1”
Height range for son: Middle of target: 6’0”Range: 5’8” to 6’4”
Height range for daughter: Middle of target: 5’7”
Range: 5’3” to 5’11”
The formula gives a target estimated height with a range of 4 inches above or below the target that will cover almost all children. Still, it’s a wide range when you consider the difference between being a 5’3” woman compared to a 5’11” woman.Knowing a child’s genetic height target range is important in determining the location on the growth chart like the one shown below where most of a child’s growth points should be located.
A child growing below their expected height range needs a closer check. A child progressively falling lower on the growth chart likely needs an in-depth investigation to determine if a problem exists.
Causes of short stature in children are numerous, ranging from normal variations in growth to serious underlying health problems. My first priority when a child is referred to me is to further investigate short stature is answering the following question:
Is the child's short stature OK or not OK?
What I mean by OK is that there is no apparent underlying negative reason for a child’s short stature. There are really only two reasons that fall in the OK category.
- Familial (genetic) short stature
- Constitutional delay of growth
Children with constitutional delay of growth will start off slower in growth compared to other children. They will fall to the lower part of the growth chart in early life which can concern parents and pediatricians. A child with constitutional delay grows at a slower, but normal pace during childhood and early adolescent years and gets the growth spurt of puberty later than average. These “late-blooming children with constitutional delay will eventually reach a height within their family height range.
Answering that initial question of OK or NOT OK can sometimes be difficult. Return visits to monitor growth are almost always a necessity to reassure that “growth and health are OK.”
Key steps in the process of monitoring a child’s growth include a medical history and an examination. The first two steps help me and other pediatric endocrinologists decide both if further special testing is necessary and what kinds of special tests may be needed. Different kinds of special testing include
- Radiology tests such as a bone age X-ray or MRI scan of the brain
- Growth hormone stimulation testing
The bone age X-ray is an important tool used by me in the early stage of short stature evaluation. The test looks at the appearance of growth plates in the hand. The growth plates start out in early life with lots of room to grow. The size of growth plates becomes progressively smaller as a child ages. By the time an average child reaches the end of puberty…...
- Girl around age 14 years
- Boy around age 16 years
…….the growth plates are nearly closed, and there will be very little increase in height.
A bone age is a very useful tool in helping me figure out quickly my level of concern and the types of testing which might be done in a child’s investigation.
For instance, look at the two bone age images of a boy’s hand below. The white arrow shows a growth plate located on tip of the finger. A 10-year old boy's hand is on the left and a 15-year-old boy's hand is on the right:
10-year-old boy's hand: 15-year-old boy's hand:
When To Worry
- Falling below the lowest percentile (line) on a growth chart
- Progressively falling lower on the growth chart
- This can be detected by parents when new clothes or shoe sizes are not needed for a year or more.
- Short stature in a child with signs of puberty
What to do
Collecting good records on your child including his or her birth weight and length is important. Bringing these records and discussing your concerns first will your primary care doctor is the first step in addressing your concerns.
Read Dr. Steelman's previous blog on this issue:
Dr. Steelman is an endocrinologist at Cook Children's. He trained in endocrinology at the University of Colorado Children’s Hospital in Denver, where the magnificent setting turned Dr. Steelman into a lifelong outdoor sport enthusiast, with a strong desire to lead a healthy life. On his rare days off, he could be found skiing, mountain biking and trail running. He loves to go back to the Rockies as often as possible, and just a few years ago, he ran the Pike’s Peak ascent half marathon. He continues to run for exercise regularly.
During his tenure in Colorado, where he met his future wife, Dr. Steelman trained at the internationally renowned Barbara Davis Diabetes Center, one of the world’s largest and most esteemed diabetes medical facilities for adults and children, specializing in type 1 diabetes research. Along the way, he discovered another strong research interest in the area of bone disorders, and Dr. Steelman began to treat children with osteogenesis imperfecta, or brittle bone disease-- a rare, crippling malady. After completing his training, Dr. Steelman left the West to enter academic medicine at Vanderbilt Children’s hospital in Nashville, Tennessee. Over the next seven years he focused on research projects and medical education.
As a self-described ‘techie,’ Dr. Steelman has a keen interest in the wise use of technology to improve medical care. Since 2001, he has helped implement electronic medical recordkeeping in two endocrine practices. He still loves to write, and he is a regular contributor to Checkup Newsroom.