Constitutional Growth Delay Clinical Presentation

Updated: Jan 15, 2020
  • Author: Pamela A Clark, MD; Chief Editor: Sasigarn A Bowden, MD  more...
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Individuals with constitutional growth delay (CGD) are usually of normal size at birth. Deceleration in both height and weight velocity typically occurs within the first 3-6 months of life. This shift downward is similar to that observed in infants experiencing normal lag-down growth but tends to be more severe and prolonged. Individual variation is substantial; however, most children resume a normal growth velocity by age 2-3 years. During childhood, these individuals grow along or parallel to the lower percentiles of the growth curve.

Indeed, looking at height changes from birth to age 5 years, a study by Rothermel et al found that in children with either constitutional growth delay or familial short stature, there was a greater decrease in the height standard deviation score (SDS) in the first 2 years of life than between ages 2 and 5 years, while in children with idiopathic growth hormone deficiency, there was a steady decrease in height SDS during the first 5 years of life. [6]

Similarly, a retrospective study by Reinehr et al indicated that various differences in height SDS and body mass index (BMI) SDS can help to distinguish constitutional delay of growth and puberty from hypogonadotropic hypogonadism (HH). For example, unlike boys with constitutional delay of growth and puberty, those with HH did not experience significantly decreased height SDS and BMI SDS in the first 2 years of life. Moreover, at pubertal age, boys with HH had a significantly higher BMI SDS than did those with constitutional delay of growth and puberty. [7]

Skeletal age, which is estimated from radiographic studies of the left hand and wrist, is usually delayed in constitutional growth delay (typically 2-4 y by late childhood) and is most consistent with the child's height age (age for which a child's height is at the 50th percentile) rather than the child’s chronologic age.

Because the timing of the onset of puberty, pubertal growth spurt, and epiphyseal fusion are determined by a child's skeletal age (biologic age), children with constitutional growth delay are often referred to as "late bloomers."

At the usual age for puberty, these children continue to grow at a prepubertal rate appropriate for their biologic stage of development. Natural slowing of linear growth just before onset of puberty may be exaggerated, emphasizing the difference in size from peers who are accelerating in growth. The timing of the pubertal growth spurt is delayed, and the spurt may be prolonged with a lower peak height velocity. In patients with both constitutional growth delay and familial short stature, the degree of growth retardation may appear more severe, but the adult height is appropriate for the genetic background.



Physical examination findings in patients with constitutional growth delay are essentially normal, with the exception of immature appearance for age. Body proportions may reflect the delay in growth. During childhood, the upper-to-lower body ratio may be greater than normal, reflecting more infantile proportions. In adults, the ratio is often reduced (ie, < 1 in whites, < 0.9 in blacks) as a result of the longer period of leg (long bone) growth. [4]



Constitutional growth delay is thought to be inherited from multiple genes from both parents. The strong role of heredity is reflected in the 60-90% likelihood of this growth pattern in a family member of the same or opposite sex. A delay in the reactivation of the hypothalamic-pituitary pulse generator results in a later onset of puberty. [4, 8]

A study by Barroso et al suggested that familial and sporadic constitutional delay of growth and puberty are marked by genetic heterogeneity, with the investigators finding that in 15 out of 59 patients with these forms of the condition, 15 rare heterozygous missense variants existed in seven different genes (IGSF10, GHSR, CHD7, SPRY4, WDR11, SEMA3A, IL17RD). [9]