Evaluation and Management of Growth Cessation in Teenagers
When a teenager reports cessation of linear growth, obtain a bone age radiograph of the left wrist immediately to determine if growth plates remain open—this single test determines whether any intervention is possible or if the teenager has simply completed normal growth. 1
Initial Assessment Framework
Growth velocity is the single most important indicator beyond absolute height. 2 Six months of documented growth cessation requires immediate evaluation, though measurement error must be excluded through remeasurement over a 4-6 month interval. 2, 1
Key Diagnostic Studies in Order of Priority:
Bone age radiograph (left wrist): This determines remaining growth potential and whether epiphyses remain open—the critical decision point for any intervention. 1
Calculate mid-parental target height: Father's height + Mother's height ÷ 2, then add 6.5 cm for boys or subtract 6.5 cm for girls. This establishes genetic potential. 1
Review complete growth chart from infancy: Look for crossing centile lines between ages 3 years and early adolescence, which suggests pathology rather than normal variation. 2
Thyroid function tests (TSH, free T4): Hypothyroidism is readily treatable and must be excluded before diagnosing idiopathic short stature. 1
Assess pubertal status (Tanner staging): Delayed puberty beyond age 12-13 years warrants endocrine evaluation. 2
Distinguishing Normal from Pathologic Growth Cessation
Constitutional Delay of Growth (Normal Variant):
- Bone age delayed relative to chronological age 2, 3
- Delayed pubertal development with family history of late bloomers 2
- Normal childhood growth velocity (4-7 cm/year) 2
- Final adult height within normal range for genetic potential 2
Pathologic Short Stature Indicators:
- Height below 3rd percentile with velocity below 25th percentile 2
- Crossing multiple centile lines downward between ages 3 years and early adolescence 2
- Disproportionate body habitus on physical examination 2
- Associated physical or developmental abnormalities 2
Normal Completion of Growth (Most Likely at Age 17):
At age 17 with 6 months of no growth, the most probable diagnosis is normal epiphyseal closure representing completion of linear growth rather than disease. 1
When Growth Hormone Therapy is NOT Indicated
Growth hormone therapy should not be initiated if: 1
- Bone age shows closure or near-closure of epiphyses
- Height velocity has dropped below 2 cm/year
- Patient has reached genetic target height range
- Growth plates are fused on radiograph
When Growth Hormone Therapy MAY Be Considered
Growth hormone therapy is only appropriate if ALL of the following are present: 2, 1
- Bone age demonstrates open epiphyses
- Height is below 3rd percentile
- Documented growth hormone deficiency on dynamic testing
- No evidence of completed puberty
- Treatment continues until bone age exceeds 14.0 years in females or growth rate falls below 2 cm/year 1
Dosing when indicated: 0.025-0.045 mg/kg per day, adjusted according to body weight at regular intervals. 2, 4
Special Considerations for Specific Conditions
Post-Treatment for Cushing Disease or Pituitary Adenoma:
- Perform dynamic GH testing within 3 months after definitive therapy in all patients who have not completed linear growth. 2
- Initiate GH replacement promptly if deficiency is documented, given the limited window to achieve normal adult height. 2
- Consider adding GnRH analogue therapy to delay puberty and epiphyseal closure while maximizing catch-up growth. 2
Hypopituitarism or Secondary Hypogonadism:
- GH deficiency is extremely common, particularly after brain tumors or cranial radiotherapy. 4, 5
- All teenagers with secondary hypogonadism who have not completed growth require dynamic GH testing. 4
- Combined GnRH analog plus GH therapy improves predicted adult height in patients with impaired height prognosis. 4
Genetic Syndromes (Turner, SHOX mutations):
- Consider skeletal survey in familial short stature to identify subtle skeletal changes. 2
- SHOX gene testing if clinical or radiographic findings suggest dyschondrosteosis. 2
Critical 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 start thyroid hormone replacement before addressing adrenal insufficiency in patients with hypopituitarism, as this can precipitate adrenal crisis. 5
Do not overlook nutritional causes: Rapid weight loss from highly restrictive diets can delay linear growth, particularly in preadolescents. 2
Do not rely on TSH levels to monitor central hypothyroidism—use free T4 instead. 5
Do not underdiagnose GH deficiency in children who have not completed growth, especially those with history of CNS tumors, surgery, or radiotherapy. 5, 6
Monitoring Requirements
For patients on GH therapy: