Growth Delay

Constitutional Delay of Growth and Puberty

What is constitutional delay of growth and puberty?

Constitutional delay refers to a variation of the tempo of the growth process rather than a disorder of growth. The child experiences normal growth and maturation, but at a slower than average pace. Such children are often the smallest in their school class. The physical changes of puberty and the pubertal growth spurt occur later in these children with constitutional delay. They are often referred to as “late bloomers”.

What causes constitutional delay?

The cause is unknown. In many cases there may be a history of a similar growth pattern in one or more family members. It occurs more frequently in males than in females.

What are the possible effects of constitutional delay?

Being short and delayed in sexual maturation may cause some emotional stress for the child. Late development and short stature can cause anxiety for both males and females at a time when coping with the social pressure of adolescence is already a source of stress. They may experience teasing, which can be traumatic for some or may be passed over for selection on sports teams, etc… It is important to talk to your child about how he/she is feeling and encourage him/her to discuss any concerns or worries they may be having.

How is constitutional delay diagnosed?

Initially, the doctor will complete a thorough physical exam and will ask many questions. He/she will review the growth chart to determine your child’s rate of growth. An X-ray of the left hand and wrist will often be performed to determine the child’s bone age, which shows the growth plate development, which is a measure of his/her biological maturity. In selected cases, some blood tests may be performed to seek other causes of the short stature and pubertal delay, such as infections, poor nutrition, Celiac disease, kidney disease, congenital condition, and growth hormone deficiency. Growth hormone stimulation tests may be necessary – in some cases – to confirm or exclude the diagnosis of growth hormone deficiency. It is important to differentiate the diagnoses, because the causes and treatment are different.

For patients who have been referred to our clinic for further evaluation of their growth and/or pubertal development who have had a bone age x-ray (x-ray of the left hand/wrist) performed prior to their visit, it will be important that a hard copy (computer disk) of the x-ray be obtained by the parent(s) and brought to the appointment so that we may interpret it personally.

What is the treatment for constitutional delay?

Because constitutional delay is a variation of the growth process, your child will eventually enter puberty, followed by a growth spurt. To “jump start” this process, monthly testosterone injections may be given to boys over 6 to 12 months. These injections can be given at our office or through your primary care physician. The growth and development in the child will be carefully monitored at our office.

When should the doctor see my child?

If testosterone injections are given, you will meet with the doctor every 3 months, and the nurse will give the shot every month. Remember to continue to see your primary care physician for routine medical care. If you have any additional questions or concerns, please call us at (303)783-3883.

Normal Growth in Children

What is normal growth?

Growth in children is as unique as each individual child. Many factors influence how much and how rapidly a child grows, and how tall he or she will be as an adult, including heredity, nutrition, hormones, and underlying illness. Some of these factors can be controlled and others cannot. In addition to that, there are certain times of the year and periods of development, such as puberty, when children have growth spurts.

Heredity (the genes we inherit from our parents) is one of the most important factors influencing a child’s growth. Height varies widely among different ethnic groups, among different families within the same ethnic group, and even among members of the same family. Overall there is a strong association between the height of a child’s parents and the height of the child. Those kids with tall parents will probably end up tall, whereas those kids with short parents will likely end up short. The expected adult height of a child can be estimated based on the height of the parents.

Nutrition is another important factor in a child’s growth. A well-balanced, age-appropriate diet that includes carbohydrates, proteins, fats, and vitamins and minerals can have a positive affect on how well a child grows. Children who receive an inadequate amount of calories or nutrients may grow poorly; improving the diet of children can improve growth. However, there really is no “average” diet that is best for all children. A child’s specific dietary requirement varies with age, physical activity level, and other factors.

Hormones are chemical messengers of the body. They are released from glands and circulate in the blood, affecting everything from growth and metabolism to blood pressure and mood. Almost all hormones affect growth to some extent, but some have particularly important roles in your child’s growth, including growth hormone and thyroid hormone, and cortisol.

Growth hormone is essential for normal growth. It is made by the pituitary gland (located at the base of the brain), then released into the bloodstream, where it travels to the body’s tissues. Here it stimulates production of a growth factor, called insulin-like growth factor 1 or IGF-1. Growth hormone works to stimulate growth in large part due to the effect in releasing IGF-1.

How is normal growth assessed?

The best measure of the general health of a child is the child’s height and weight. It is helpful to have past height and weight measurements from the primary care physician or school records available. It is also important to know the parental heights. One of the most important things to do is to ensure that your child is measured without shoes and plotted on a growth chart at least once every year.

What are normal growth rates for children?

Infancy (0-12 months) 9-11 inches/year or 23-28 cm/year
Toddler (12-24 months) 3-5 inches/year or 7.5-13 cm/year
Childhood (3 years to puberty) 2-2.5 inches/year or 5-6.5 cm/year

How will I know if my child’s growth is normal?

The doctor will review your child’s records and determine his/her growth pattern by plotting the measurement on a growth chart. Growth charts provide standards for children at various ages. The doctor will view the growth of your child over the years, as well as, how your child compares to other children who are the same age and sex. A medical history and physical exam may be done. This information will help determine whether your child is growing at a normal rate and/or a normal pattern for his age and genetic potential. Occasionally an X-ray of the left hand and wrist may be obtained, to measure the bone age in comparison to the chronological (actual) age, if there are concerns about height.

Short Stature Tips

What is short stature?

Short stature is defined as having a height that is shorter than expected for a given age and gender. Growth is measured with a special device called a stadiometer (standing measurement) or an infantometer (length measurement used for infants and children who are unable to stand). These measurements are recorded on a special form called a growth chart. If a child’s measurements are below the normal range for his or her age group, they are considered to have short stature. Additional testing may need to be done to determine whether this condition is a normal variant or caused by a medical problem.

What kinds of problems can occur if my child has short stature?

Psychological impact: Children who are shorter than expected for their age may be seen as “different” and may not be accepted by people at a normal height. It is important for parents and family members to help the child with a growth disorder develop positive self-esteem and self-image.

Physical impact: Since most buildings are designed for people of “normal” stature, children with short stature may be at a disadvantage when performing everyday tasks. It may be difficult to reach kitchen cupboards, light switches and doorknobs. This may exclude the child from participating in normal activities such as setting the family table, turning off lights prior to going to bed and closing the door behind them. Age appropriate children’s clothing and shoes may be difficult to find in smaller sizes.

How can I help my child with short stature build positive self-esteem?

Parents can help build their child’s self-esteem by treating their child age appropriately; in other words, they should be treated their chronological, “birthday age” rather than their “height age”. Allowing the child to behave or engage in play that is inappropriately young can be destructive to normal social and psychological development. Make sure to buy age appropriate clothing for your child, being sensitive to the peer pressure to wear trendy clothes in order to fit in with his or her peers. This may be more important to the child who has a physical difference than to his or her peers.

In situations in which it is age appropriate for the child to be assertive and speak up for him or herself, encourage the child to do so. It may be helpful 2 to role-play different situations such as being handed a kiddy menu in a restaurant, or responding to an adult who makes a comment about how short the child is in a tone of voice usually reserved for a much younger child or an infant.

Have your child emphasize his success, especially those that don’t involve height, and have them make a list of things that they enjoy doing or do well. Help your child see that small size is not a disadvantage in some activities (soccer, baseball, softball, swimming), and may even be an advantage in others (gymnastics, ballet, and long-distance running) Also pay attention to your own attitude about your child’s size. Your child depends on you to be supportive.

How can I help my child with short stature get along with other children?

Earning peer respect at school is a major achievement for children with short stature. One of the goals of a helpful adult should be to help the child earn this respect. This may be academic excellence, public speaking, drama, music, or art.

How can I help my child handle the “BULLY”?

Teasing may be a major challenge throughout your child’s school years. You might have your child brainstorm with you a list of ways to “handle the bully”. Some of these include: ignoring the bully, befriending the bully, agreeing with the bully and moving on or returning the bully’s comment with a snappy comeback. Role playing and practicing the seemingly spontaneous comebacks is very helpful in giving the child confidence to actually perform if they are teased.

Ask your child why they think the bully might be teasing and lead them to giving you the answer that the bully is feeling very insecure and needs to be picking on someone else to make himself feel better inside. Make a rule that absolutely no fighting is allowed since it is quite possible for a shorter child to be physically injured by a larger bully. When all fails, the child should be encouraged to call an adult and report the bully’s behavior. This is not seen as tattling or running to the teacher but a method of self-protection when other methods of dealing with the bully have not been successful. Reinforce that the child is using his brain when seeking adult help in situations that are out of his control. Asking for help when needed should be viewed as a positive act and one that takes courage.

How can I help my child with short stature become more independent?

Often, the home and school environment are designed for taller individuals. Setting up step stools, doorknob turners, light switch pullers or anything else that helps the child function independently is a plus. Household rules may need to be adjusted. For example, if there is a rule that there is no standing on counters perhaps that is not the best rule for a child who cannot reach the dishes or glassware, when he needs a glass of water or is assigned the task of setting the family table. Another approach may be to switch the placement of the glassware and the dishes to a place below the sink while items used less frequently by a young child, such as pots and pans could be put in higher cabinets. The guiding principle in every effort is to enable the child to succeed and increase his sense of self-worth and self-confidence.

Always be supportive of your child’s difference. If there are family members or close friends who have experienced similar growth patterns, encourage that adult to share positive success stories. This will hopefully show your child that they can become a valued and contributing adult member of society no matter what their final height. Also answer questions as best as you can, and encourage your child to write down questions you can’t answer. Let your child ask the questions at the next visit – children feel less helpless if they understand what’s going on.

Finally, seek the help of a professional psychologist, counselor, or clinical social worker if your child is having problems and needs additional help from someone outside the family.

If you have any further question or concerns please call us at (303)783- 3883.

Resources available for children with short stature and their families:

Human Growth Foundation

Magic Foundation

Growth Hormone Deficiency

What is growth hormone deficiency (GHD)?

Growth hormone is made and released by the pituitary gland (located in the brain) then delivered to different parts of the body. It is important for bone growth and strength, muscle development, and sugar and fat metabolism. GHD is a condition in which the pituitary gland produces less than the normal amount of growth hormone, which may result in slow growth, short stature, and disturbance of metabolism.

What causes GHD?

GHD occurs when the pituitary gland does not make enough growth hormone. This problem may be present at birth and a failure of the pituitary gland to develop properly or by damage to the gland during the birth process. Most of the time, no specific cause for the GHD can be found.

Acquired growth hormone deficiency can be caused by damage to or disease of the pituitary during or after birth. Conditions responsible for this include: inflammation, infection, head injury, surgical damage to the gland, radiation, increased pressure in the chambers of the brain, and tumors.

How is GHD diagnosed?

After other causes of growth delay in your child have been excluded, your child may be evaluated for GHD. One frequently measures the concentration of a growth factor, stimulated by GH, called IGF-1 (insulin-like growth factor 1) and/or a protein that carries IGF-1 around in the blood, called IGFBP-3 (insulin-like growth factor binding protein 3)- these two substances help regulate how much growth hormone is released by the pituitary gland.

The pituitary gland releases growth hormone in intermittent spurts at night, during certain stages of sleep. Therefore, drawing a random growth hormone sample during the day is useless. We may also need to perform a stimulation test. This test involves taking multiple blood samples from an IV at specific intervals after a medication is given. This medication stimulates your child’s pituitary gland to secrete growth hormone. The stimulants used in this office are Glucagon (a hormone excreted by the pancreas, which controls the blood sugar levels in the body; it is the opponent of Insulin) and Arginine (an amino acid in the body). Your child needs to be fasting prior to the test. The test is performed at our office and is 4 hours long.

An X-ray of the left hand and wrist will measure your child’s bone age. The bone age will determine the maturity of your child’s bones, compared to your child’s chronological (actual or “birthday”) age. A child with GHD may have a bone age that is much less than his/her chronological age.

An MRI (magnetic resonance imaging) scan may be performed to determine the cause of GHD. This scan allows the doctor to look at your child’s brain and pituitary to check for the size, structure, or a possible lesion.

What is the treatment for GHD?

When short stature is caused by GHD, growth hormone replacement therapy is the treatment of choice. Our office will begin the process to obtain the medication for your child. This includes getting authorization from your insurance, so they will cover the cost of the treatment. A mail order pharmacy will then distribute the growth hormone to you. Human growth hormone is produced synthetically and given by an injection into the fatty tissue just below the skin. Parents or caregivers are taught to give the injection. If your child is old enough, he/she may be taught to give the injection him/herself. Growth hormone needs to be given according to the schedule suggested by your doctor. The best results of therapy are obtained when taken as directed by your doctor.

Side effects of growth hormone are infrequent. In some instances the treatment may unmask hypothyroidism. In this case the thyroid hormone will need to be replaced by a pill. We will check the thyroid levels in your child’s blood every other visit to make sure your child’s thyroid gland is working properly. In rare cases the growth plate at the hip may slip when children are growing rapidly. This can be treated surgically. Another very rare side effect is an increase in the fluid that surrounds the brain and the spine. This may happen about 2 weeks after treatment is initiated. Your child will complain of severe head aches, or nausea/vomiting. If this should occur we will lower the dose of GH and slowly taper your child to the correct dose. A skin rash may also occur as an effect of the medication. Growth hormone may increase the blood sugar in patients with diabetes. Your doctor will discuss the effects and side effect growth hormone in detail when treatment is considered.

When will my child need to be seen by the doctor?

Your child’s response to growth hormone therapy should be monitored closely by your physician. Frequency of visits is usually every 3 months. At 3 that time your child will be weighed and measured. The need for adjustment of growth hormone will also be considered. Periodic blood tests and X-rays will also be required for evaluation of treatment. Remember to continue to visit your primary care physician for routine medical care.

Support and resource groups:

Human Growth Foundation

Magic Foundation

PDF version of this document

Constitutional Growth Delay PDF

Normal Growth in Children PDF

Short Stature Tips PDF

Growth Hormone Deficiency PDF