Pediatrics · Year 3 · from Pediatrics

Case 1: Constitutional Growth Delay

Patient Demographics

  • Age: 14-year-old male
  • Sex: Male

Chief Complaint

"My son is the shortest boy in his class and hasn't started puberty yet."

History of Present Illness

A 14-year-old male presents with his mother who is concerned about his short stature and lack of pubertal development. He has always been shorter than his peers, consistently tracking at the 5th percentile for height. His mother reports he was a "late bloomer" similar to his father, who reportedly did not reach his full height until age 18. The patient denies any chronic illness symptoms, headaches, visual changes, or fatigue. He eats well and is active in sports despite being smaller than teammates.

Growth Parameters

  • Height: 147 cm (5th percentile, -1.9 SD)
  • Weight: 38 kg (10th percentile)
  • BMI: 17.6 kg/m2 (25th percentile)
  • Growth velocity: 4.5 cm/year (below expected pubertal velocity)

Physical Examination

  • General: Well-appearing, prepubertal male
  • HEENT: Normal, no visual field defects
  • Thyroid: Normal size, no nodules
  • Cardiovascular: Regular rate and rhythm, no murmurs
  • Abdomen: Soft, non-tender, no organomegaly
  • Genitourinary: Tanner stage I pubic hair, Tanner stage I genitalia, testicular volume 3 mL bilaterally (prepubertal)
  • Extremities: No skeletal abnormalities
  • Neurologic: Normal

Workup

  • Bone age (left hand/wrist X-ray): 11.5 years (delayed 2.5 years relative to chronologic age)
  • CBC: Normal
  • CMP: Normal
  • TSH: 2.1 mIU/L (normal)
  • Free T4: 1.2 ng/dL (normal)
  • IGF-1: 185 ng/mL (normal for bone age)
  • LH/FSH: Prepubertal levels
  • Testosterone: 15 ng/dL (prepubertal)

Diagnosis

Constitutional delay of growth and puberty (CDGP)

Clinical Reasoning

The combination of short stature with delayed bone age, prepubertal status at age 14, family history of late puberty in father, otherwise normal health, and normal laboratory values supports the diagnosis of constitutional delay. The bone age delay indicates significant remaining growth potential. This is a normal variant of growth and puberty rather than a pathologic condition.

Management

  1. Reassurance: Explain the benign nature of the condition and expected eventual catch-up growth and pubertal development
  2. Growth prediction: Based on bone age, predicted adult height is within normal range (mid-parental target height)
  3. Observation: Serial monitoring every 6 months to document growth velocity and pubertal progression
  4. Optional treatment: Low-dose testosterone therapy (50-100 mg IM monthly for 4-6 months) can be offered if psychological distress is significant, to initiate puberty
  5. Psychological support: Address any bullying or self-esteem concerns

Clinical Image

Image Description: Bone age radiograph of the left hand and wrist used to assess skeletal maturation in children with growth concerns.

Source: Radiopaedia - Bone age assessment URL: https://radiopaedia.org/cases/bone-age-normal-13 License: CC BY-NC-SA 3.0

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