What is the appropriate evaluation and treatment for a 17-year-old patient who is 5'0" and has not experienced any growth over the past six months?

Evaluation and Management of Growth Cessation in a 17-Year-Old

For a 17-year-old who is 5'0" (152 cm, approximately -1.5 SD) with no growth over 6 months, the priority is determining remaining growth potential through bone age assessment and pubertal staging, as growth hormone therapy is only indicated if epiphyses remain open and specific criteria are met. 1

Initial Diagnostic Evaluation

Growth Assessment

• Growth velocity is the single most important indicator beyond absolute height when evaluating short stature 1, 2
• Six months of growth cessation at age 17 requires immediate assessment, as this may represent normal epiphyseal closure rather than pathologic growth failure 1
• Remeasurement should confirm true growth cessation, as measurement error can occur 1

Essential Diagnostic Studies

Bone Age Assessment (Priority #1)

• Obtain radiography of the left wrist immediately to determine if growth plates remain open 1, 3
• Growth hormone therapy must be discontinued when bone age exceeds 14.0 years in females, as further growth potential is minimal 4
• If bone age shows epiphyseal closure or near-closure (>14 years), no intervention will be effective 1

Pubertal Assessment (Priority #2)

• Perform Tanner staging to assess pubertal development 1
• At age 17, most females have completed puberty, which significantly limits remaining growth potential 5
• Late pubertal adolescents may still have minimal growth potential if bone age is delayed 2

Laboratory Evaluation

• Measure thyroid function (TSH, free T4) to exclude hypothyroidism 1, 3
• Assess for growth hormone deficiency only if other criteria suggest pathology 3
• Check morning cortisol and other pituitary hormones if hypopituitarism is suspected 3
• Measure IGF-1 levels, though these do not always correlate with growth potential 6

Additional Studies

• Calculate mid-parental target height to assess genetic potential 1, 2
• Review growth chart from infancy to identify pattern: constitutional delay shows deceleration in first 3 years with normal velocity thereafter 1, 2
• Exclude chronic disease, malnutrition, and syndromic causes 1, 7

Differential Diagnosis Framework

Constitutional Growth Delay

• Characterized by delayed bone age relative to chronological age, delayed puberty, and normal final height achievement 1, 2
• Family history often reveals similar growth patterns in parents 1, 2
• This is a non-pathologic variant requiring reassurance rather than intervention 1

Pathologic Short Stature

• Height below 3rd percentile (< -1.88 SD) with velocity below 25th percentile suggests pathology 1, 5
• At 5'0" (~-1.5 SD), this patient is above the threshold for automatic pathologic concern unless velocity has been consistently low 1

Normal Epiphyseal Closure

• Most likely diagnosis at age 17 with 6 months of no growth 1
• Represents completion of linear growth, not a disease process 1

Treatment Considerations

Growth Hormone Therapy Criteria

GH therapy is NOT indicated if:

• Bone age shows closure or near-closure of epiphyses (>14 years in females) 4
• Height velocity has dropped below 2 cm/year with advanced bone age 1
• Patient has reached genetic target height range 1

GH therapy may be considered only if ALL of the following are met:

• Bone age demonstrates open epiphyses (<14 years) 4
• Height is below 3rd percentile with documented growth hormone deficiency 3, 5
• No evidence of completed puberty 5
• Fundoscopic examination excludes papilledema 1

FDA-Approved Indications

• For idiopathic short stature, GH therapy (0.3 mg/kg/week) showed mean height gains of 5.2 cm in males and 6.0 cm in females when started at mean age 9.4 years with mean treatment duration of 5-6 years 4
• Treatment was continued until bone age exceeded 14.0 years in females and growth rate fell below 2 cm/year 4
• Starting treatment at age 17 with likely advanced bone age would provide minimal to no benefit 4

Common Pitfalls to Avoid

• Do not assume pathology without bone age assessment - growth cessation at age 17 most likely represents normal completion of growth 1
• Do not initiate GH therapy without confirming open epiphyses - treatment after epiphyseal closure is ineffective and wasteful 1, 4
• Do not overlook thyroid dysfunction - this is a readily treatable cause of growth failure that must be excluded first 1, 3
• Do not diagnose "idiopathic short stature" without comprehensive evaluation - this label should only be applied after excluding all identifiable causes 1, 7
• Do not rely solely on IGF-1 levels - normal growth can occur despite low circulating IGF-1 in some conditions 6

Most Likely Outcome

At age 17 with 6 months of growth cessation, this patient has most likely completed linear growth through normal epiphyseal closure. 1 If bone age confirms closure or near-closure, reassurance and acceptance of final height is appropriate. If bone age is significantly delayed (<13 years) with open epiphyses, constitutional delay of growth is most likely, and spontaneous catch-up may still occur without intervention. 1, 2