Follow-up care for children with short stature born small for gestational age
Taking care of children with a history of being born small for gestational age (SGA) includes monitoring for adequate catch-up growth and other potential long-term effects of SGA. This article focuses on the evaluation and management of short stature in children born SGA when expected catch-up growth is not attained, including evaluation, referrals, and interventions.
Key Points
Catch-up growth
Most children born SGA achieve catch-up growth to >2 standard deviation scores (SDS) by 2 years of age. Persistent short stature is defined as below −2.5 SDS by the age of 2 or below −2 SDS around 3 years of age without signs of catch-up growth (Hokken-Koelega et al., 2023).
Testing
A traditional workup for short stature should be performed before the initiation of treatment, even with a history of SGA.
Management
Children born SGA with concerns for persistent short stature should be referred to endocrinology for further evaluation and consideration of growth hormone and/or gonadotropin-releasing hormone agonist. Endocrinologists can also help with other risk factors related to SGA not discussed here (e.g., metabolic effects of SGA).
Guidelines
International Consensus Guideline on Small for Gestational Age: Etiology and Management
Hokken-Koelega, A. C. S., van der Steen, M., Boguszewski, M. C. S., et. al. (2023). From Infancy to Early Adulthood. Endocrine Reviews, 44(3), 539–565.
Other Names
- Short length for age
- Low height for age/sex
- Short stature for age
Diagnosis
Diagnosis of SGA and short stature requires the use of standardized growth charts (Schlaudecker et al., 2017). In the United States, experts recommend the 2006 World Health Organization (WHO) growth chart between birth and 2 years and the 2000 Centers for Disease Control & Prevention (CDC) standard growth charts for children between ages 2 and 20 years. Birth centers may use the Fenton premature infant growth charts comparing growth by week of gestational age. Other growth charts are available for children with syndromes associated with atypical growth patterns, such as Trisomy 21, Turner syndrome, and Noonan syndrome (Braun & Marino, 2017).
Diagnostic Criteria & Classifications
Small for Gestational Age
SGA is defined as birth weight and/or length below -2 standard deviation scores (SDS) for gestational age (Hokken-Koelega et al., 2023). While technically, this corresponds with on or below the 2.3 percentile on the WHO 0-24 month growth charts, many experts define SGA as less than the 10th percentile for weight for gestational age whether using WHO or Fenton growth charts at birth (Schlaudecker et al., 2017).
Of note, SGA is distinct from intrauterine growth restriction (IUGR), also known as intrauterine growth retardation (Schlaudecker et al., 2017). IUGR refers to prenatal/fetal weight gain. While typically smaller than average after delivery, an IUGR infant could actually measure SGA, appropriate for gestational age (AGA), or large for gestational age (LGA) once they are born (Braun & Marino, 2017; Hokken-Koelega et al., 2023).
Short Stature
Short stature height is below -2 SDS for age and sex (Rani et al., 2024). Of note, on the WHO growth charts used for children ages 0-2 years, <2 SDS corresponds with less than the 2nd (2.3rd) percentile (Rani et al., 2024). On the CDC growth charts, used for ages 2-20 years, historically, <5th percentile is considered short stature, but statistically, the CDC states it is correct to use –2 SDS (<3 percentile) to define short stature. Not all CDC growth charts include the 3rd percentile line. This lack of consistent terminology can make the identification of short stature confusing. When in doubt, consult an endocrinologist.
Persistent Short Stature
Persistent short stature is below −2.5 SDS by the age of 2 years or below −2 SDS around the age of 3 without signs of catch-up growth (Hokken-Koelega et al., 2023).
Diagnostic Testing & Screening
The most important component of screening and testing for children born SGA is careful monitoring of growth, including length/height, weight, and head circumference (when age-appropriate). A standard workup for short stature should be conducted if a child has persistent short stature. Even if there is a history of SGA that might explain the short stature, children born SGA can also have growth hormone deficiency or other causes of short stature. Additionally, abnormal developmental assessments or dysmorphic features can help detect possible syndromic causes of SGA and short stature.
Height measurements
- For children younger than 2 years, use supine length
- For older children, use standing/erect height. Alternatives include arm span, segmental height, and sitting height.
Labs
Consider cytomegalovirus (CMV) testing for infants born SGA.
Consider labs to evaluate for underlying causes of short stature, such as anemia, chronic renal failure, celiac disease, inflammatory bowel disease (IBD), renal tubular acidosis, growth hormone deficiency, and hypothyroidism.
Basic lab work could include IGF-1, IGFBP-3 , TSH/free T4, CBC, ESR, CMP, celiac testing (i.e., tissue transglutaminase IgA and total serum IgA). For girls with isolated short stature, a karyotype is also recommended to evaluate for possible Turner syndrome. Further genetic testing may be considered for those with disproportionate growth, dysmorphic features, or neurodevelopmental delays (Collett-Solberg et al., 2019).
Imaging
There are no clear recommendations on the utility of bone age for this population, but a bone age X-ray of the left hand and wrist is a standard part of evaluation for a child with short stature. Bone age studies tend to be more reliable when performed at age 5 or older, thus are not typically recommended in children younger than age 5.
- If concerns for skeletal dysplasia (e.g., disproportionate body features and/or skeletal deformities), a skeletal survey might be helpful (Netchine et al., 2021).
Testing for Family Members
Obtaining parental height helps estimate mid-parental height.
Genetics
Multiple genes have been implicated in short stature after being born SGA. Associated syndromes include Noonan syndrome, multiple types of skeletal dysplasia, Turner syndrome, and others. Several imprinting disorders also can lead to short stature after SGA, most notably Silver-Russell Syndrome. Children born SGA are also at risk for GH resistance, possibly due to defects of the IGF receptor gene, IGF1R (Netchine et al., 2021).
If a child has dysmorphic features, microcephaly, body disproportion, developmental delay, or other signs/symptoms of a specific disease, a genetics referral should be considered.
Prevalence
Approximately 2% of children with short stature were born SGA (Collett-Solberg et al., 2019). At least 90% of children born SGA demonstrate spontaneous catch-up growth to normal height in childhood; 85-90% of children born SGA demonstrate catch-up growth by 2 years (Hokken-Koelega et al., 2023).
Differential Diagnosis
The differential for short stature includes (Collett-Solberg et al., 2019):
- Isolated short stature (including idiopathic short stature, familial short stature, and constitutional growth delay)
- Syndromic causes (e.g., Turner syndrome, Noonan syndrome, Silver-Russell syndrome)
- Disorders of the GH/IGF axis, skeletal dysplasia
- Chronic systemic disease (e.g., IBD, hypothyroidism, CKD)
- Sequelae of intrauterine infections (e.g., TORCH infections) (Jaan & Rajnik, 2024)
Although children born SGA can have isolated short stature, it is important to evaluate for other causes of short stature with laboratory evaluation suggested above.
Comorbid Conditions
Children born SGA are also at risk for metabolic disease. It Is important to avoid excessive weight catch-up (Hokken-Koelega et al., 2023).
Prognosis
Approximately 85-90% of children born SGA achieve catch-up growth by 2 years of age (Lee et al., 2003) (Houk & Lee, 2012). For most children who achieve catch-up growth, this happens within the first 6 months postnatally. Approximately 10%-15% of SGA children do not experience catch-up growth by the age of 2 years. This height deficit continues through childhood and, in almost all cases, results in adult short stature (Houk & Lee, 2012). Catch-up growth is generally considered rare after the age of 2 years unless born prematurely.
Treatment & Management
Endocrine
When to refer a child with SGA and concern for short stature:
- Persistent short stature without signs of catch-up growth (faster than the median rate of growth for age:
- <-2.5 SDS for height at age 2
- <-2.0 SDS for height at age 3+
- Has unusually short parents
- A syndrome associated with growth failure (e.g., Turner syndrome, Noonan syndrome)
Growth Hormone
Growth hormone (GH) therapy is recommended in children born with SGA who have persistent short stature once other causes of short stature have been excluded (except for Silver Russell Syndrome, as these patients also benefit from growth hormone therapy). The goal of therapy is to achieve catch-up growth in childhood via accelerated linear growth, maintain a normal growth rate, and achieve a normal adult height (Hokken-Koelega et al., 2023). Treatment should be done in consultation with a pediatric endocrinologist.
The optimal timing for GH therapy initiation lies between 2-4 years of age (Houk & Lee, 2012). Timely initiation of growth hormone therapy is important for both efficacy and cost (Chatelain et al., 2007).
There has been evidence of better efficacy in children who remain prepubertal throughout the treatment period, greater growth response in children with a larger height deficit, and better growth response the younger the child is at the start of treatment.
Although growth hormone therapy can improve linear growth, the decision to treat is complex. The therapy is costly and can have side effects as well as cause pain/distress to the child receiving growth hormone injections.
GnRH Agonists
The addition of GnRH agonist treatment is considered for children who are still very short at the beginning of puberty. This should be done in consultation with a pediatric endocrinologist.
Referrals
Endocrinology
Children with short stature and SGA who do not achieve catch-up growth by 2 years of age should be referred to endocrinology for timely evaluation and initiation of growth hormone treatment if eligible. (See above specifics.) Referral to a pediatric endocrinologist enables a robust discussion of the benefits and risks of therapy and obtaining prior authorization for therapy if needed.
Genetics
Children with short stature, SGA, dysmorphic features, concerns for skeletal dysplasia, and/or developmental delays should be referred to genetics. This is especially important when considering treatment with growth hormone as it is not recommended in genetic conditions with a high predisposition for cancer (Hokken-Koelega et al., 2023).
Clinical Tools for Primary Care
Growth/BMI Charts
Page Bibliography
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Article History
Previously, this article was published by the Medical Home Portal. The Medical Home Portal, retired in July 2024, provided diagnosis and management information for pediatric conditions, guidance for immediate steps after a positive newborn screen result, and in-depth family education to improve outcomes for children with complex medical care needs. The full archive can be found at the Medical Home Portal Archive.
Topical Reviews in Pediatrics (TRIP) includes archival and updated content from the Medical Home Portal and features new, contemporary topics in pediatrics.
- 2020 revision: Jennifer Goldman, MD, MRP, FAAPA; Sarah Winter, MDA; Mary Ann NelinR
- 2014 first publication: Jennifer Goldman, MD, MRP, FAAPA; Sherrily Brown, FNPA; Sarah Winter, MDA; Mary Ann NelinR
AAuthor; CAContributing Author; SASenior Author; RReviewer
