Evaluation of Short and Tall Stature in Children
Benjamin?U.?nwosU,?mD,?and?mary?m.?Lee,?mD,?University of Massachusetts Medical School, Worcester, Massachusetts
performed? in? all? children? with? abnormal?
growth,? and? laboratory? studies? should? be?
rimary? care? physicians? play? an?
dren? with? abnormal? growth.? in?
Normal Growth Pattern
uterine? environment,? which? is? influenced?
and? social? habits? (e.g.,? smoking? status).?
The? average? weight? of? a? newborn? is? 7? lb,? ?
3? oz? (3.25? kg),? and? the? average? length? is? ?
becomes? more? dependent? on? the? infant’s?
percentiles.? Thereafter,? growth? typically?
by? sustained? growth? deceleration? start-
24? months? of? age,? children? with? constitu-
Approach to the Height Evaluation
Children and adolescents whose heights and growth velocities deviate from the normal percentiles on standard
growth charts present a special challenge to physicians. Height that is less than the 3rd percentile or greater than
the 97th percentile is deemed short or tall stature, respectively. A growth velocity outside the 25th to 75th percen-
tile range may be considered abnormal. Serial height measurements over time documented on a growth chart are
key in identifying abnormal growth. Short or tall stature is usually caused by variants of a normal growth pattern,
although some patients may have serious underlying pathologies. A comprehensive history and physical examination
can help differentiate abnormal growth patterns from normal variants and identify specific dysmorphic features of
genetic syndromes. History and physical examination findings should guide laboratory testing. (Am Fam Physician.
2008;78(5):597-604. Copyright © 2008 American Academy of Family Physicians.)
table 1. Normal Growth Velocity at Various Life stages
Life stageGrowth velocity per year
Pubertal growth spurt
60 to 100 cm (24 to 40 in)
23 to 27 cm (9 to 11 in)
10 to 14 cm (4 to 6 in)
6 to 7 cm (2 to 3 in)
5 to 5.5 cm (2 to 2.2 in)
Girls: 8 to 12 cm (3 to 5 in)
Boys: 10 to 14 cm (4 to 6 in)
Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial
use of one individual user of the Web site. All other rights reserved. Contact firstname.lastname@example.org for copyright questions and/or permission requests.
604 American Family Physician
Volume 78, Number 5 ◆ September 1, 2008
9. Drop SL, De Waal WJ, De Muinck Keizer-Schrama SM. Sex steroid treat-
ment of constitutionally tall stature. Endocr Rev. 1998;19(5):540-558.
10. Tanner JM, Goldstein H, Whitehouse RH. Standards for children’s
height at ages 2-9 years allowing for heights of parents. Arch Dis Child.
11. Moshang T Jr, Grimberg A. The effects of irradiation and chemotherapy
on growth. Endocrinol Metab Clin North Am. 1996;25(3):731-741.
12. Engstrom FM, Roche AF, Mukherjee D. Differences between arm span
and stature in white children. J Adolesc Health Care. 1981;2(1):19-22.
13. Zverev Y, Chisi J. Estimating height from arm span measurement in
Malawian children. Coll Antropol. 2005;29(2):469-473.
14. Boersma B, Houwen RH, Blum WF, et al. Catch-up growth and endo-
crine changes in childhood celiac disease. Endocrine changes during
catch-up growth. Horm Res. 2002;58(suppl 1):57-65.
15. Barberia Leache E, Marañes Pallardo JP, Mourelle Martinez MR, et al.
Tooth eruption in children with growth deficit. J Int Assoc Dent Child.
16. Kjellberg H, Beiring M, Albertsson Wikland K. Craniofacial morphol-
ogy, dental occlusion, tooth eruption, and dental maturity in boys of
short stature with or without growth hormone deficiency. Eur J Oral Sci.
17. Gaethofs M, Verdonck A, Carels C, et al. Delayed dental age in boys with
constitutionally delayed puberty. Eur J Orthod. 1999;21(6):711-715.
18. Loevy HT, Aduss H, Rosenthal IM. Tooth eruption and craniofacial devel-
opment in congenital hypothyroidism: report of case. J Am Dent Assoc.
19. Grimberg AD. Disorders of growth. In: Moshang T. Pediatric Endocrinol-
ogy: The Requisites in Pediatrics. St. Louis, Mo.: Mosby; 2004:127-167.
20. Lenko HL. Prediction of adult height with various methods in Finnish
children. Acta Paediatr Scand. 1979;68(1):85-92.
21. Cox LA. The biology of bone maturation and ageing. Acta Paediatr
22. Bayley N, Pinneau SR. Tables for predicting adult height from skeletal
age: revised for use with the Greulich-Pyle hand standards. J Pediatr.
23. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of
the Hands and Wrists. 2nd ed. Stanford, Calif.: Stanford University
24. Bierich JR. Constitutional delay of growth and adolescence. Baillieres
Clin Endocrinol Metab. 1992;6(3):573-588.
25. New MI. Extensive clinical experience: nonclassical 21-hydroxylase
deficiency [published correction appears in J Clin Endocrinol Metab.
2007;92(1):142]. J Clin Endocrinol Metab. 2006;91(11):4205-4214.
26. Bojesen A, Gravholt CH. Klinefelter syndrome in clinical practice. Nat
Clin Pract Urol. 2007;4(4):192-204.
27. Root AW, Diamond FB Jr. Overgrowth syndromes: evaluation and man-
agement of the child with excessive linear growth. In: Lifshitz F. Pediat-
ric Endocrinology. New York, NY: Informa Healthcare; 2007:163-194.
28. Parent AS, Teilmann G, Juul A, et al. The timing of normal puberty
and the age limits of sexual precocity: variations around the world,
secular trends, and changes after migration. Endocr Rev. 2003;24(5):
29. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sex-
ual characteristics and menses in young girls seen in office practice: a
study from the Pediatric Research in Office Settings network. Pediatrics.
Evaluation of Children with tall stature
History and physical examination
macroglossia, anterior abdominal
wall defects, pre- and postnatal
overgrowth, advanced bone age,
Weaver syndrome: advanced bone
age (evident at birth), unusual
Klinefelter syndrome: sparse facial,
body, or sexual hair; high-
pitched voice; female pattern fat
distribution, increased arm span,
Sotos syndrome: facial flushing;
abnormally prominent forehead
(frontal boss); downward-slanting
palpebral fissures; prominent,
narrow jaw; long, narrow face
and head, excessive physical
growth, advanced bone age
Estrogen deficiency and resistance
Precocious pubertyGrowth hormone excess
Assess bone age
Assess body mass index
Figure 3. Algorithm for the evaluation of children with tall stature.