Short stature is a common reason for referral to the paediatric clinic and can be of considerable concern to parents and young people. The most common definition of short stature is a height which is two or more standard deviations below the mean (<2nd centile) for age and gender; the further away from the population mean the child’s height lies the more likely it is that they will have an underlying pathology. It is important not just to look at a single height measurement but to consider whether a child is growing slowly or if they are inappropriately small compared to their family.
Most truly short children do not have an underlying organic cause but a combination of familial short stature and constitutional delay of growth and development. However, in some children, short stature is a manifestation of an underlying chronic medical condition or a primary growth disorder. Boys tend to come to medical attention more frequently than girls but the chances of finding an underlying cause are similar in both.
It is useful to plot height on an age and sex appropriate centile chart.
For children up to 4 years these are available in the Personal Child Health Record (‘red book’). For premature infants (earlier than 32 weeks) it is important to plot their growth on specific charts designed to account for their gestational age. Growth charts for older children (2-18 years) can be downloaded from the RCPCH website https://www.rcpch.ac.uk/resources/uk-who-growth-charts-2-18-years.
The UK-WHO growth charts include instructions for predicting adult height based on the child’s current height, and guidance on mid-parental height centile. Demonstrating a predicted adult height which is similar to parental height may be sufficient reassurance for parents and children. However further assessment may be required if growth velocity has slowed or height is lower than expected.
History
Short stature in itself is not an emergency; however it may be symptomatic of an underlying medical problem requiring urgent treatment and a thorough history is therefore important.
Examination
A well child with a normal examination and a height that lies within the parental target can often be reassured without any investigations. If there any concerns about the growth pattern or the history, then baseline bloods and wrist x-ray to assess bone age can be carried out. Please consider x ray of left hand and wrist for bone age – this can be requested as ‘x ray hand and bone age’.
Assessment of short stature often requires serial measurements over a period of several months or even years.
The vast majority of children referred with short stature will not require any treatment. Chronic illness will be diagnosed and managed appropriately with specialist input as required. Growth hormone treatment or medication to progress puberty will only be started for clearly defined reasons as per national guidelines. Any hormone treatment will be initiated by a paediatric endocrinologist or a paediatrician with a special interest in growth and puberty disorders.
The most useful investigation in the assessment of short stature is serial measurements plotted on a growth chart (see above) so parents should be encouraged to fill in the red book if possible. It is also helpful if both parents have had their heights measured in centimetres, and that of any other children in the family, and they bring these measurements to their first clinic appointment.
Initial referrals should be made to general paediatric outpatients via ERS. If you are uncertain about referring please contact the paediatric team via Advice & Guidance on ERS for advice.
