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Evaluation of Short and Tall Stature in Children

Rebecca Caro, DO
Paul Savel, MD
Paul Isaiah Moss, MD

American Family Physician. 2025;111(6):532-542.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Short stature is defined as height that is more than 2 standard deviations below the mean height for age; tall stature is defined as height that is more than 2 standard deviations above the mean height for age. The initial evaluation of short and tall stature should include obtaining a comprehensive history, performing a physical examination, plotting serial height measurements on the Centers for Disease Control and Prevention or World Health Organization growth charts, calculating estimated adult height and comparing it with midparental height, determining bone age, and laboratory testing in select patients. The most common causes of short stature are constitutional delay of growth and puberty, familial short stature, and idiopathic short stature. Pathologic etiologies are less common and include nutritional deficiencies, systemic disease, growth hormone deficiencies, and genetic abnormalities. Common causes of tall stature include constitutional advancement of growth, familial tall stature, and obesity. Uncommon etiologies of tall stature include precocious puberty, Marfan syndrome, and Klinefelter syndrome. Referral to pediatric endocrinology is indicated in patients with idiopathic short stature for management of select genetic and metabolic conditions and for interventions to correct growth.

Normal childhood longitudinal growth varies with age and is dependent on endocrine, paracrine, cytokine, and nutritional factors, and physical mechanisms acting on the growth plate.1–4 A newborn's size is based on the complex nature of the intrauterine environment and influenced by genetic, maternal, and fetal factors.2 Starting at approximately 6 months of age, children undergo catch-up or catch-down growth from their birth weight until they reach their genetically determined growth velocity.2 This continues until 18 to 24 months of age; during this time, growth hormone (GH) and insulin-like growth factor 1 play an increasing role in development.5,6 During adolescence, the sex hormones that drive puberty are exerting increasing influence on longitudinal growth.2,4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments
To plot anthropometrics, the World Health Organization growth chart should be used for children younger than 2 years; the Centers for Disease Control and Prevention growth charts should be used for children 2 years and older.5,9–13 CExpert opinion and consensus in usual practice
Sex-adjusted, midparental height calculations should be performed to evaluate growth velocity and compare predicted adult height (estimated by projecting the current growth curve height percentile into adulthood) with midparental height to establish normal vs pathologic stature.2,5,6,9,11–13 CExpert opinion and consensus in usual practice
Bone age should be compared with chronologic age to help narrow the differential diagnosis in those with short and tall stature. Bone age that is less than chronologic age by more than 2 SD is delayed, and bone age that is greater than chronologic age by more than 2 SD is advanced.2,5,6,11,13 CExpert opinion and consensus in usual practice
Recombinant GH therapy is recommended for the treatment of GH deficiency in children with short stature, Turner syndrome, Prader-Willi syndrome, Noonan syndrome, chronic kidney failure, children who were born small for gestational age without catch-up growth, short stature homeobox-containing gene deficiencies, and idiopathic short stature.3,13,25,30,33–36 BLimited-quality, patient-oriented evidence

GH = growth hormone; SD = standard deviations.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

REBECCA CARO, DO, FAAFP, is director of education, training, and research at Alexander T. Augusta Military Medical Center, Fort Belvoir, Virginia, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Maryland.

PAUL SAVEL, MD, is a family physician and an active American Red Cross clinical volunteer in the Department of Family Medicine at Alexander T. Augusta Military Medical Center.

PAUL ISAIAH MOSS, MD, is a family medicine resident in the National Capital Consortium Family Medicine Residency Program at Alexander T. Augusta Military Medical Center.

Address correspondence to Rebecca Caro, DO, FAAFP, at r.jeanblack@gmail.com.

Author disclosure: No relevant financial relationships.

  1. 1.Beker L. Principles of growth assessment. Pediatr Rev. 2006;27(5):196-197.
  2. 2.Bamba A, Kelly A. Assessment of growth. In: Kliegman P, St. Geme JW, Nelson WE, eds. Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2024.
  3. 3.Mastromauro C, Giannini C, Chiarelli F. Short stature related to growth hormone insensitivity (GHI) in childhood. Front Endocrinol (Lausanne). 2023;14:1141039.
  4. 4.Baron J, Sävendahl L, De Luca F, et al. Short and tall stature: a new paradigm emerges. Nat Rev Endocrinol. 2015;11(12):735-746.
  5. 5.Barstow C, Rerucha C. Evaluation of short and tall stature in children. Am Fam Physician. 2015;92(1):43-50.
  6. 6.Braun LR, Marino R. Disorders of growth and stature. Pediatr Rev. 2017;38(7):293-304.
  7. 7.Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Bright Futures/American Academy of Pediatrics; 2017.
  8. 8.Turner K. Well-child visits for infants and young children. Am Fam Physician. 2018;98(6):347-353.
  9. 9.Rogol AD, Hayden GF. Etiologies and early diagnosis of short stature and growth failure in children and adolescents. J Pediatr. 2014;164(5 suppl):S1-S14.e6.
  10. 10.Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0–59 months in the United States. MMWR Recomm Rep. 2010;59(RR-9):1-15.
  11. 11.Nwosu BU, Lee MM. Evaluation of short and tall stature in children. Am Fam Physician. 2008;78(5):597-604.
  12. 12.Cohen LE. Idiopathic short stature: a clinical review. JAMA. 2014;311(17):1787-1796.
  13. 13.Deplewski D; Pediatric Endocrine Society Education Committee. Child with suspected short stature. 2020. Accessed April 29, 2024. https://pedsendo.org/wp-content/uploads/2020/09/Child-with-suspected-short-stature-final.pdf
  14. 14.Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.
  15. 15.Zemel BS, Pipan M, Stallings VA, et al. Growth charts for children with Down syndrome in the United States. Pediatrics. 2015;136(5):e1204-e1211.
  16. 16.Bertapelli F, de Azevedo Barros-Filho A, de Góes Monteiro Antonio MÂR, et al. Growth curves for girls with Turner syndrome. BioMed Res Int. 2014:687978.
  17. 17.Neumeyer L, Merker A, Hagenäs L. Clinical charts for surveillance of growth and body proportion development in achondroplasia and examples of their use. Am J Med Genet A. 2021;185(2):401-412.
  18. 18.Davies JH, Cheetham T. Investigation and management of tall stature. Arch Dis Child. 2014;99(8):772-777.
  19. 19.Meazza C, Gertosio C, Giacchero R, et al. Tall stature: a difficult diagnosis? Ital J Pediatr. 2017;43(1):66.
  20. 20.Hannema SE, Sävendahl L. The evaluation and management of tall stature. Horm Res Paediatr. 2016;85(5):347-352.
  21. 21.Papadimitriou A, Nicolaidou P, Fretzayas A, et al. Clinical review: constitutional advancement of growth, a.k.a. early growth acceleration, predicts early puberty and childhood obesity. J Clin Endocrinol Metab. 2010;95(10):4535-4541.
  22. 22.Zhou E, Hauser BR, Jee YH. Genetic evaluation in children with short stature. Curr Opin Pediatr. 2021;33(4):458-463.
  23. 23.Creo AL, Schwenk WF. Bone age: a handy tool for pediatric providers. Pediatrics. 2017;140(6):e20171486.
  24. 24.Polidori N, Castorani V, Mohn A, et al. Deciphering short stature in children. Ann Pediatr Endocrinol Metab. 2020;25(2):69-79.
  25. 25.Danowitz M, Grimberg A. Clinical indications for growth hormone therapy. Adv Pediatr. 2022;69(1):203-217.
  26. 26.Wozniak-Mielczarek L, Osowicka M, Radtke-Lysek A, et al. How to distinguish Marfan syndrome from marfanoid habitus in a physical examination—comparison of external features in patients with Marfan syndrome and marfanoid habitus. Int J Environ Res Public Health. 2022;19(2):772.
  27. 27.Cheetham T, Davies JH. Investigation and management of short stature. Arch Dis Child. 2014;99(8):767-771.
  28. 28.Schwartz J, Angle C, Pitcher H. Relationship between childhood blood lead levels and stature. Pediatrics. 1986;77(3):281-288.
  29. 29.Rapaport R, Wit JM, Savage MO. Growth failure: ‘idiopathic’ only after a detailed diagnostic evaluation. Endocr Connect. 2021;10(3):R125-R138.
  30. 30.Mameli C, Orso M, Calcaterra V, et al. Efficacy, safety, quality of life, adherence and cost-effectiveness of long-acting growth hormone replacement therapy compared to daily growth hormone in children with growth hormone deficiency: a systematic review and meta-analysis. Pharmacol Res. 2023;193:106805.
  31. 31.Jee YH, Baron J, Nilsson O. New developments in the genetic diagnosis of short stature. Curr Opin Pediatr. 2018;30(4):541-547.
  32. 32.Netchine I, van der Steen M, López-Bermejo A, et al. New horizons in short children born small for gestational age. Front Pediatr. 2021;9:655931.
  33. 33.Grunauer M, Jorge AAL. Genetic short stature. Growth Horm IGF Res. 2018;38:29-33.
  34. 34.Grimberg A, DiVall SA, Polychronakos C, et al.; Drug and Therapeutics Committee and Ethics Committee of the Pediatric Endocrine Society. Guidelines for growth hormone and insulin-like growth factor-I treatment in children and adolescents: growth hormone deficiency, idiopathic short stature, and primary insulin-like growth factor-I deficiency. Horm Res Paediatr. 2016;86(6):361-397.
  35. 35.Henry RK, Miller BS. Approach to the patient: case studies in pediatric growth hormone deficiency and their management. J Clin Endocrinol Metab. 2023;108(11):3009-3021.
  36. 36.Woelfle J, Schnabel D, Binder G. The treatment of growth disorders in childhood and adolescence. Dtsch Arztebl Int. 2024;121(3):96-106.
  37. 37.Drube J, Wan M, Bonthuis M, et al.; European Society for Paediatric Nephrology Chronic Kidney Disease Mineral and Bone Disorders, Dialysis, and Transplantation Working Groups. Clinical practice recommendations for growth hormone treatment in children with chronic kidney disease. Nat Rev Nephrol. 2019;15(9):577-589.
  38. 38.Murray PG, Clayton PE. Disorders of growth hormone in childhood. March 9, 2022. Accessed December 31, 2024. https://www.ncbi.nlm.nih.gov/books/NBK278971/
  39. 39.Rogol AD, Reiter EO. Growth and growth hormone through the ages: art and science. Horm Res Paediatr. 2022;95(6):515-528.
  40. 40.Allen DB, Cuttler L. Clinical practice. Short stature in childhood— challenges and choices. N Engl J Med. 2013;368(13):1220-1228.
  41. 41.Corredor B, Dattani M, Gertosio C, et al. Tall stature: a challenge for clinicians. Curr Pediatr Rev. 2019;15(1):10-21.
  42. 42.Upners EN, Juul A. Evaluation and phenotypic characteristics of 293 Danish girls with tall stature: effects of oral administration of natural 17β-estradiol. Pediatr Res. 2016;80(5):693-701.
  43. 43.Hendriks AEJ, Drop SLS, Laven JSE, et al. Fertility of tall girls treated with high-dose estrogen, a dose-response relationship. J Clin Endocrinol Metab. 2012;97(9):3107-3114.
  44. 44.Benyi E, Kieler H, Linder M, et al. Risks of malignant and non-malignant tumours in tall women treated with high-dose oestrogen during adolescence. Horm Res Paediatr. 2014;82(2):89-96.
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