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Causes of Tall Stature in Children

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Definition

Tall stature is defined as a height more than two standard deviations above the mean for age (greater than the 97th percentile).

Phases of childhood growth

Infancy: Birth to 2-3 years: Fastest period of growth determined by nutrition
Childhood: Age 2-3 to Puberty: Determined by hormones. GH, T3/4, Insulin
Adolescent growth: onset of puberty to fusion of epiphyses. Determined by GH and Androgens/Oestrogens

Fusion of Epiphyses

Gradual process initiated by oestrogen from male adrenal and female ovaries
This controls the final height of the person

Growth Charts: Age X axis and Height is Y axis

Ensure you can plot the age/height of a child
RCPCH Girls 0-4
RCPCH Boys 0-4
RCPCH Girls 2-18
RCPCH Boys 2-18

Centiles

Centile lines show the expected range of weights and heights (or lengths).
Centiles are the number of children expected to be BELOW that line
50% of all children are below the 50th
91% of all children are below the 91st

Clinical

Initial evaluation of short and tall stature should include a history and physical examination, accurate serial measurements, and determination of growth velocity, midparental height, and bone age.
Dysmorphic characteristics suggest a genetic disorder
Midline defects suggest an abnormality of the growth hormone axis.
Inspection, measurements, manoeuvres, examination.

Midparental height

Girls : [Sum of Parental height (cm)] 2 - 7 cm
Boys : [Sum of Parental height (cm)] 2 + 7 cm
This calculation is not appropriate if either natural parent is not of normal stature.

Growth Velocity

Birth to 12 months: 23 to 27 cm (9.06 to 10.63 in)
12 months to 1 year: 10 to 14 cm (3.94 to 5.51 in)
2 to 3 years: 8 cm (3.15 in)
3 to 5 years: 7 cm (2.76 in)
5 years to puberty: 5 to 6 cm (1.97 to 2.36 in)
Puberty: Girls: 8 to 12 cm (3.15 to 4.72 in).
Puberty: Boys: 10 to 14 cm (3.94 to 5.51 in)

Bone age

Bone age should be compared with chronologic age to narrow the differential diagnosis of short stature.
Compare X ray of left wrist and hand to a database of norms, although various methods are now available
Children with normal variations of growth may have advanced or delayed bone age, but a bone age that is more than two standard deviations from the mean for age is likely due to a pathological condition

Common causes Tall Stature

Cause	Clinical Features	Investigations	Management
Familial Tall Stature	Tall stature in the context of family history; normal growth velocity and puberty, normal development.	Growth charts, review of family growth patterns, normal hormone levels.	Reassurance and monitoring; no treatment typically required.
Marfan Syndrome	Tall stature with long limbs, arachnodactyly, pectus excavatum, scoliosis, lens dislocation, aortic dilation, normal or delayed puberty.	Clinical evaluation, genetic testing for FBN1 mutations, echocardiogram for aortic root assessment, ophthalmologic examination.	Regular cardiovascular monitoring, beta-blockers or angiotensin receptor blockers (ARBs), surgical repair of aortic root if necessary, management of skeletal abnormalities.
Klinefelter Syndrome (47,XXY)	Tall stature, long legs, small testes, gynecomastia, learning difficulties, infertility, delayed or incomplete puberty.	Karyotype analysis, serum testosterone, FSH, and LH levels, bone age assessment.	Testosterone replacement therapy, educational support, fertility counseling, management of associated conditions (e.g., osteoporosis).
Gigantism	Excessive growth before the closure of epiphyseal plates, large hands and feet, coarse facial features, signs of pituitary tumour (e.g., headaches, visual disturbances).	Serum IGF-1 levels, growth hormone suppression test, MRI of the pituitary gland, bone age assessment.	Surgical removal of pituitary adenoma, somatostatin analogs, dopamine agonists, and/or radiation therapy if surgery is not curative.
Sotos Syndrome (Cerebral Gigantism)	Rapid growth in early childhood, large head, advanced bone age, learning disabilities, hypotonia, distinctive facial features.	Clinical evaluation, genetic testing for NSD1 mutations, bone age assessment, developmental assessment.	Supportive management including physical, occupational, and speech therapy, educational support, regular monitoring for associated complications.
Homocystinuria	Tall stature, long limbs, lens dislocation, intellectual disability, thromboembolic events, osteoporosis, Marfanoid habitus.	Plasma homocysteine levels, genetic testing for CBS gene mutations, amino acid chromatography, ophthalmologic examination.	Dietary restriction of methionine, supplementation with pyridoxine (vitamin B6), folate, and vitamin B12, anticoagulation therapy, management of complications.
Thyrotoxicosis	Accelerated growth, advanced bone age, weight loss despite increased appetite, tachycardia, tremor, goiter.	Serum TSH, free T4, and free T3 levels, thyroid ultrasound, bone age assessment.	Antithyroid medications (e.g., methimazole), beta-blockers, radioactive iodine therapy, or thyroidectomy in refractory cases.
Precocious Puberty	Early onset of secondary sexual characteristics, rapid growth initially, but early closure of epiphyseal plates may lead to short adult stature.	Serum LH, FSH, estradiol/testosterone levels, GnRH stimulation test, bone age assessment, brain MRI if central cause suspected.	GnRH analogs to delay puberty, monitoring growth and development, treatment of underlying causes (e.g., CNS lesions).

Investigations for tall stature

FBC, U&E, LFT, ESR, CRP
Insulin like growth factor 1 if Growth hormone excess
Karyotyping for Klinefelter syndrome (XXY)
Serum luteinizing hormone, follicle-stimulating hormone, testosterone for Precocious puberty
Thyroid-stimulating hormone, free thyroxine (T4) for Hyperthyroidism

References

Evaluation of Short and Tall Stature in Children

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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