Short stature is defined as height more than 2 SD below the mean (or <2.3rd percentile) for age and sex, assessed using WHO growth charts for Canada. Common nonpathological causes include familial short stature and constitutional delay of growth and puberty. Pathologic causes (e.g. systemic illness, malnutrition, endocrine and genetic causes) should be investigated when growth velocity is reduced on serial measurements over at least 6 to 12 months. Growth hormone (GH) deficiency is rare and should only be suspected when the child’s height is greater than 2 SD below the expected mid-parental range with normal weight, and reduced growth velocity.
Random GH levels should not be ordered: secretion is pulsatile with significant diurnal fluctuations, sleep dependent and influenced by exercise, fasting, intercurrent illness and stress making single measurements unreliable. Diagnosis of GH deficiency requires formal stimulation testing, only indicated in selected circumstances and under endocrinology guidance. IGF-1 level is more stable and may be used as a surrogate marker. However, low IGF-1 is non-specific and can result from malnutrition, systemic illness, liver dysfunction, inflammation, pubertal delay, diabetes or hypothyroidism. GH deficiency is unlikely when IGF-1 is above the mean for age and sex, in a child with normal growth velocity and bone age.
Joint recommendation with the Canadian Society of Endocrinology and Metabolism
Sources:
Canadian Pediatric Endocrine Group. WHO Growth Charts for Canada. [Internet]. Revised March 2014. [cited March 2026].
Collett-Solberg PF, et al. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr. 2019;92(1):1-14. Epub 2019 Sep 12. PMID: 31514194.
Krishnamoorthy P, et al. Optimizing paediatric specialist referrals for short stature in an era of multiple growth hormone indications. Paediatr Child Health. 2024 Jun 6;29(5):306-310. PMID: 39281357.
Richmond E, et al. Testing for growth hormone deficiency in children. Growth Horm IGF Res. 2020 Feb;50:57-60. Epub 2019 Dec 14. PMID: 31865218.