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The Slowly Growing Child and Short Stature

Altered or abnormal linear growth is a common and highly significant sign that requires evaluation. Early detection of poor growth is crucial because effective intervention is distinctly time-limited. Evaluation includes a thorough history, physical


Provided that the biologic parents had adequate nutrition and no untreated condition that compromised final height, a child's final height can be estimated with a fair degree of accuracy. First, mean parental height is calculated. The mean height of the parents is adjusted on the basis that men are, on average, 5 in (13 cm) taller than women.~ Therefore, for a boy, the mean parental height is modified by adding 5 in (13 cm) to

Next, the time of onset of growth failure is determined. That is, did the growth failure begin in utero or in the postnatal period? Intrauterine growth failure may be due not only to genetic or chromosomal abnormalities in the infant, but may also be due to transplacental infections, malnutrition, hypoxia and exposure to toxins (e.g., ethanol, midget

Physical Examination


Measurement of infants and children must not be taken casually or relegated to untrained personnel. Assessment of recumbent length requires two trained staff members; the child is gently stretched with one person at the child's head and one at the child's feet. A reliable device that guarantees a


In all children, a careful physical examination to evaluate for signs of systemic disease is required. Two additional physical findings in the neonate are relevant: micropenis (less than 2.8 cm [1.1 in] in stretched length in a term infant) and

Selected testing

Anti-gliadin or anti-endomysial antibody levels to rule out gluten sensitive enteropathy Sweat chloride analysis (in children younger than two years of age) to rule out cystic fibrosis T4 and TSH concentrations to rule out hypothyroidism

IGF-1 and IGF-binding protein to rule out growth hormone deficiency

T4 = serum thyroxine; TSH = thyroid-stimulating hormone; IGF-1 = insulin growth factor-1.

Radiographic Assessment

Although difficult to assess, radiographic studies to determine bone age permit a clinically relevant estimate of final height when interpreted in the context of the patient's age and current height (Table 1). Preferred views include the left knee (anteroposterior and lateral) when the child is younger than two years of age and the left hand (anteroposterior view only) when the child is older than two years. Films should be interpreted by a pediatric endocrinologist or a pediatric radiologist with appropriate expertise. If the bone age is "younger" than the

Differential Diagnosis

The diagnosis of abnormal growth is defined by (1) abnormal growth velocity, (2) an attained height that is lower than the range of percentiles calculated from the mid-parental height, and (3) the variance between bone age and chronologic age. Two normal variations are familial short stature and constitutional delay of growth.

Treatment with growth hormone (Somatotropin, humatrope) is