What is constitutional growth delay?

Constitutional Delay of Growth and Puberty (CDGP)

Constitutional delay of growth and puberty (CDGP) is a variant of normal growth characterized by deceleration of length/height in the first 3 years of life, normal or near-normal height velocity during childhood (4-7 cm/year), delayed bone age and pubertal development, with final adult height ultimately within the normal range. CDGP is the most common cause of delayed puberty and represents a temporary state of hypogonadotropic hypogonadism that resolves spontaneously with time. 1, 2

Key Diagnostic Features

• Growth Pattern:

  • Deceleration of length/height in first 3 years of life
  • Normal or near-normal height velocity during childhood (4-7 cm/year)
  • Delayed pubertal growth spurt
  • Height typically below 3rd percentile during childhood/early adolescence

• Skeletal Development:

  • Significantly delayed bone age compared to chronological age
  • Bone age correlates better with height and pubertal stage than with chronological age

• Pubertal Development:

  • Delayed onset of secondary sexual characteristics
  • Hormonal levels (sex hormones and gonadotropins) correlate with bone age, not chronological age 3

• Family History:

  • Often positive for delayed puberty in parents or siblings
  • Careful questioning about parents' childhood growth patterns and puberty onset is essential 1

Distinguishing Features from Pathologic Causes

CDGP is generally a diagnosis of exclusion. Key differentiating factors include:

• Normal growth velocity for bone age
• No crossing of multiple centile lines after age 3 (which would suggest pathology)
• Absence of other physical or developmental abnormalities
• Normal endocrine evaluation (though some studies show reduced spontaneous GH secretion) 3, 4
• Family history often positive for delayed puberty

Clinical Outcomes

While CDGP is considered a variant of normal growth rather than a disease, research suggests some important considerations:

• Final adult height may be slightly compromised in some cases

  • Studies show adults with history of CDGP may end up 1.2-1.3 SD below the 50th percentile 5
  • Some patients fall 5+ cm below their target heights based on mid-parental heights 5

• Psychological impact can be significant

  • Short stature and delayed sexual development may lead to psychological difficulties
  • Academic performance may be affected 2

Management Considerations

Treatment may be considered if:

• The adolescent experiences significant psychological distress
• Height prediction is concerning
• Pubertal delay is severe

Treatment options include:

• Sex steroid therapy (testosterone in males) to induce pubertal development
• Adjunctive therapies in selected cases may include oxandrolone, aromatase inhibitors, or growth hormone 6

Important Clinical Pitfall

The most challenging aspect of CDGP management is distinguishing it from permanent hypogonadotropic hypogonadism (PHH), as definitive diagnosis of PHH may not be possible until age 18 if puberty hasn't begun spontaneously. This distinction has important clinical implications for long-term management and fertility 2.