Poor Growth in Children

How growth is measured

Pediatricians measure weight, length or height and, under age 2, head circumference at checkups and plot them on growth charts (the WHO charts under 2, and CDC charts from 2 to 20 years in the US).

A percentile compares a child with others of the same age and sex. A child on the 10th percentile is shorter than 90 of 100 children. That alone is not a problem. What matters is:

• the trend: most children follow roughly the same percentile line after age 2
• crossing lines: dropping across two or more major percentile lines suggests growth faltering
• growth velocity: how many inches or centimeters a child grows each year
• family height: a child's expected adult height is estimated from both parents' heights

Normal growth rates: about 10 inches (25 cm) in the first year, about 4 to 5 inches (10 to 12 cm) in the second, then about 2 to 2.5 inches (5 to 6 cm) a year until the pubertal growth spurt.

Poor weight gain vs poor height growth

Normal variants (most common)

Familial short stature

Children of short parents tend to be short. They grow at a normal rate along a low percentile, have a bone age that matches their age, and reach an adult height in line with their parents.

Constitutional delay of growth and puberty

These "late bloomers" grow slowly in early childhood, start puberty late and have a delayed bone age, then catch up as older teens. Often a parent was also a late developer. Adult height is usually normal.

Medical causes of poor growth

Nutrition and feeding

• In babies: breastfeeding difficulties, incorrect formula preparation, reflux, feeding problems from prematurity, or oral-motor difficulties. See failure to thrive.
• In older children: restrictive or very selective eating, eating disorders, food insecurity and malnutrition.

Gut conditions

• Celiac disease: an immune reaction to gluten that damages the small intestine. It can cause poor growth even without gut symptoms, so it is tested in almost every child with unexplained poor growth.
• Crohn's disease: growth failure can appear before tummy pain or diarrhea.
• Cystic fibrosis and other causes of malabsorption.

Hormone problems

• Hypothyroidism: slowed growth, weight gain, tiredness, constipation and dry skin.
• Growth hormone deficiency: slow growth with a normal or slightly chubby build and a young-looking face.
• Cushing's syndrome or long-term steroid use: weight gain with poor height growth.

Genetic conditions

• Turner syndrome: in girls, short stature, delayed puberty, and sometimes a webbed neck or heart and kidney problems. It should be considered in any girl with unexplained short stature.
• Noonan syndrome, Down syndrome, Prader-Willi syndrome, Russell-Silver syndrome and skeletal dysplasias (conditions affecting bone growth, with short limbs).

Chronic illness and medicines

Heart disease, chronic kidney disease, poorly controlled asthma, diabetes, chronic infections, and medicines such as high-dose steroids and some ADHD stimulants (usually a modest effect) can slow growth.

Born small

Babies born small for gestational age usually catch up by age 2 to 4. Those who do not may benefit from growth hormone treatment.

Emotional deprivation

Severe neglect or stress can suppress growth, which often recovers when the environment improves.

How doctors assess poor growth

1. Accurate measurements repeated over 4 to 6 months to calculate growth velocity, plotted against previous measurements.
2. History: pregnancy and birth, feeding and diet, bowel habits, development, medicines, puberty, and both parents' heights and timing of puberty.
3. Examination: body proportions, nutritional status, puberty stage and features of genetic syndromes.
4. Tests, guided by the pattern: - bone age X-ray of the left hand and wrist - blood count, kidney and liver function, inflammatory markers - celiac antibody test - thyroid function - IGF-1 as a screen for growth hormone problems - karyotype (chromosome test) for girls with short stature

Children with suspected growth hormone deficiency may need stimulation tests and a pituitary MRI.

Treatment

• Feeding support: help from a pediatrician, dietitian, lactation consultant or feeding therapist; calorie-dense foods and regular meal routines.
• Celiac disease: a strict gluten-free diet usually brings catch-up growth.
• Crohn's disease: nutritional therapy and medicines to control inflammation.
• Hypothyroidism: thyroid hormone replacement.
• Growth hormone: daily or weekly injections for growth hormone deficiency, Turner syndrome, small-for-gestational-age without catch-up, and some other conditions.
• Constitutional delay: usually reassurance; a short course of sex hormones can be offered to teens distressed by late puberty.

Frequently asked questions

What causes poor growth in children?

The most common reasons are normal variants: familial short stature and late development. Medical causes include feeding problems, celiac disease, Crohn's disease, hypothyroidism, growth hormone deficiency, genetic conditions such as Turner syndrome, and chronic illnesses. The growth pattern on the chart helps find the cause.

When should I worry about my child's growth?

Talk to your pediatrician if your child drops across two or more major percentile lines, grows less than about 2 inches (5 cm) a year before puberty, is much shorter than expected for the family, or has delayed puberty or other symptoms such as diarrhea or fatigue.

Can a child catch up on growth?

Often, yes. Late bloomers catch up during their late teens. Children with treatable causes such as celiac disease, hypothyroidism or poor nutrition usually show catch-up growth after treatment. The earlier treatment starts, the more height can be gained before growth plates close.

What is growth faltering?

Growth faltering, also called faltering growth or failure to thrive, means a child's weight or growth is slower than expected for their age and previous pattern. It is usually identified by a drop across percentile lines and most often relates to feeding or nutrition.

Does a bone age X-ray predict height?

A bone age X-ray shows how mature a child's bones are. A delayed bone age means there is more growing time left, typical of late bloomers. Combined with current height, it helps estimate adult height, though predictions are approximate.