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PAEDIATRICS · OUTPATIENT CLINIC
A calm, structured way to work up the short child in clinic - sort the common normal variants from the few who need treating, and know what to organise before you refer.
IS IT ACTUALLY SHORT?
Short stature is a height below the 2nd centile (about -2 SD) for age and sex, but the single point matters less than the pattern. Plot serially, correct for prematurity, and always compare to the parents.
Height under the 2nd centile (roughly -2 SD) on the right chart for age and sex. Use the WHO chart 0-2y, then your local growth chart.
A fall through the centile lines over time is more concerning than a stable low line. A child who was on the 50th and is now on the 3rd needs explaining.
Compare the child to their mid-parental (genetic) height. A child tracking well below the family target range needs a reason.
Check body proportions. Short limbs or a short back (disproportion) points to a skeletal cause and changes the workup.
GET THE NUMBERS RIGHT
Most 'abnormal' growth turns out to be a measurement or plotting error. Nail the basics before investigating.
Wall-mounted stadiometer, shoes off, heels together, eyes in the Frankfort plane. Under 2y measure length lying down. Plot on the same chart each visit.
Boys = (mother + father + 13 cm) / 2. Girls = (mother + father - 13 cm) / 2. The target range is roughly +/- 8.5 cm around that.
Two accurate heights at least 6 months apart. A slow velocity (crossing centiles) is the single strongest pointer to a pathological cause.
Plot weight and head circumference and calculate BMI. Weight faltering before height suggests a nutritional or gut cause; height faltering first suggests endocrine.
WHAT THE CURVE TELLS YOU
The growth pattern, the proportions and the bone age separate the common normal variants from the few children who need treatment.
Short, healthy child of short parents. Normal velocity, tracks a low centile, on target for the family, bone age equal to chronological age. The commonest cause.
The late bloomer. Delayed bone age and delayed puberty, often a family history. Short now, but normal adult height. Commoner in boys.
The pattern that needs investigating: endocrine (growth hormone deficiency, hypothyroidism, Cushing), chronic disease (coeliac, IBD, renal), Turner syndrome, or SGA without catch-up.
Short limbs or a short back. Points to a skeletal dysplasia or rickets. Measure sitting height and arm span.
| Pattern | Velocity | Bone age | Puberty | Adult height |
|---|---|---|---|---|
| Familial short stature | Normal | Equal to age | Normal timing | Short, on target |
| Constitutional delay | Normal or slightly low | Delayed | Delayed | Normal |
| GH deficiency / hypothyroid | Reduced | Delayed | Delayed | Reduced if untreated |
| Turner syndrome | Reduced | Variable | Absent or incomplete | Reduced without treatment |
DO NOT MISS
These features move a child from 'watch and reassure' to 'investigate and refer'.
Clearly crossing centiles downward, or a height well below the mid-parental target. This is growth failure until proven otherwise.
Height below -3 SD, or a large gap from the family target, needs investigating regardless of how well the child looks.
Dysmorphic features, or any girl with unexplained short stature (webbed neck, widely spaced nipples; oedema may be absent). Check a karyotype.
Headache, visual field loss or vomiting (intracranial cause of GH deficiency); or GI symptoms, pallor and fatigue (coeliac, IBD, chronic disease).
FROM THE CLINIC
What you can organise from an outpatient clinic before, or alongside, referral. Tailor it to the history and examination.
| Test | Why |
|---|---|
| Bone age (left wrist X-ray) | Delayed in constitutional delay and endocrine causes; equal to age in familial short stature |
| FBC, ESR / CRP | Chronic disease, inflammation, anaemia |
| U&E, creatinine, LFTs | Renal or hepatic chronic disease |
| Calcium, phosphate, ALP | Rickets and metabolic bone disease |
| TFTs (TSH, free T4) | Hypothyroidism |
| Coeliac serology (tTG-IgA + total IgA) | Coeliac disease is common and treatable |
| IGF-1 (with or without IGFBP-3) | A screening pointer to growth hormone status; interpret for age |
| Karyotype | Turner syndrome in every girl |
A random growth hormone level is unhelpful - GH is secreted in pulses. GH status needs formal stimulation testing, arranged by endocrinology.
GH stimulation testing, a pituitary MRI and targeted genetics are organised by paediatric endocrinology, not from general clinic.
ESCALATE
Two clean pathways cover most children.
The short but well child, likely a normal variant, when the family want review or the diagnosis is unclear - for assessment and serial growth.
Growth failure (falling velocity), height below -3 SD, disproportion, Turner features, abnormal first-line bloods, or any red flag above.
More from the paediatric clinic, and the charts and tools you will need: