What Tests Are Done When a Child Isn’t Growing?

When a child isn't growing as expected, parents often want to know:

What tests are done when a child isn't growing?

The evaluation usually begins with something much simpler than blood work: accurate height measurements and the child's growth chart.

Doctors first determine whether the child is truly growing too slowly by reviewing:

• Current height and weight
• Previous height measurements
• Growth velocity
• Height percentile
• Changes in growth percentiles
• Parents' heights
• Puberty stage
• Medical and birth history

If a child has poor growth velocity, significant short stature, falling height percentiles, delayed puberty, or other concerning findings, additional testing may include a bone age X-ray, thyroid testing, celiac screening, CBC, metabolic testing, IGF-1, IGFBP-3, and other tests based on the child's symptoms and history.[1,2]

A growth hormone stimulation test may be considered when growth hormone deficiency is suspected, but it is not a routine first test for every short child.[3]

What Is Considered Poor Growth in a Child?

Being short is not the same as having a growth problem.

Some healthy children are naturally shorter because of:

• Familial short stature
• Constitutional growth delay
• Later puberty
• Normal genetic variation

The Pediatric Endocrine Society notes that most children with short stature are healthy and do not have an underlying medical disorder.[1]

What can be more important is how quickly the child is growing.

A child who remains near the 5th percentile while growing steadily may be following a normal pattern.

A child who changes from:

50th percentile → 25th percentile → 10th percentile

may deserve additional evaluation because the child's growth trajectory has changed.[1]

Test #1: Growth Chart and Growth Velocity

The first and arguably most important test is not a blood test.

It is the child's growth history.

The Pediatric Endocrine Society describes monitoring growth over time using a growth chart as one of the most useful ways to assess a child's growth.[1]

Doctors review previous measurements to calculate growth velocity, which means how much height the child gains over time.

For example:

Height one year ago: 48 inches

Height today: 50 inches

Growth velocity: approximately 2 inches per year

Growth velocity needs to be interpreted according to the child's age and puberty stage.

Persistent slowing or downward crossing of height percentiles can be an important reason to investigate further.[1,2]

Why Accurate Height Measurements Matter

Before ordering laboratory tests, doctors need to confirm that the child is actually growing slowly.

Even relatively small measurement errors can make growth velocity appear abnormal.

Ideally, clinicians review several measurements taken over time rather than relying on a single office visit.

For older children, approximately six months of reliable growth data can often provide useful information about growth rate.[1]

Test #2: Bone Age X-Ray

One of the most common tests used when evaluating abnormal childhood growth is a bone age X-ray.

A bone age X-ray usually involves an X-ray of the left hand and wrist.

It helps estimate the child's skeletal maturity.

The result is compared with chronological age.

For example:

Chronological age: 13 years

Bone age: 11 years

This indicates that skeletal development appears delayed.

Bone age can provide information about:

• Skeletal maturity
• Puberty timing
• Delayed growth
• Remaining growth potential
• Growth plate development
• Predicted adult height

Bone age is useful in evaluating short stature, although the result must be interpreted with the child's overall growth pattern.[1,2]

What Does Delayed Bone Age Mean?

A delayed bone age means the skeleton appears younger than expected based on chronological age.

This can occur with:

• Constitutional growth delay
• Delayed puberty
• Growth hormone deficiency
• Hypothyroidism
• Poor nutrition
• Certain chronic illnesses

A delayed bone age may indicate that a child has more time remaining for growth, but it does not by itself identify the cause of slow growth.

It also cannot guarantee a particular final adult height.

Test #3: Complete Blood Count (CBC)

A complete blood count, or CBC, may be included in the evaluation of poor growth.

It can help screen for conditions such as:

• Anemia
• Certain infections
• Hematologic abnormalities
• Clues to chronic disease

Poor childhood growth can occasionally be one of the first signs of a broader medical problem rather than a primary hormone disorder.[2]

Test #4: Comprehensive Metabolic Panel

Blood chemistry testing may be used to evaluate overall health and look for conditions affecting growth.

Testing may include markers related to:

• Kidney function
• Liver function
• Electrolytes
• Glucose
• Protein status

Kidney disease, liver disease, metabolic abnormalities, and other chronic conditions can interfere with normal childhood growth.

Test #5: Thyroid Testing — TSH and Free T4

Thyroid hormone is essential for normal growth and skeletal development.

For this reason, thyroid testing is commonly included when a child is growing too slowly.

The main tests are:

TSH

Thyroid-stimulating hormone helps regulate thyroid hormone production.

Free T4

Free thyroxine measures circulating thyroid hormone.

Hypothyroidism can cause:

• Slow height growth
• Fatigue
• Constipation
• Dry skin
• Feeling cold
• Changes in weight
• Delayed skeletal maturation

Importantly, some children with hypothyroidism may have impaired height growth before parents recognize other obvious symptoms.

Test #6: Celiac Disease Screening

Celiac disease can interfere with nutrient absorption and childhood growth.

Some children with celiac disease have classic digestive symptoms such as:

• Abdominal pain
• Diarrhea
• Bloating

Others may have few gastrointestinal symptoms and instead present with:

• Short stature
• Poor growth
• Poor weight gain
• Iron deficiency
• Fatigue

Because celiac disease can sometimes present primarily as poor growth, screening may be considered during a short-stature evaluation.[1,2]

Common testing can include:

• Tissue transglutaminase IgA (tTG-IgA)
• Total IgA

Additional testing may be used depending on the clinical situation.

Test #7: IGF-1 Blood Test

Insulin-like growth factor 1 (IGF-1) is one of the most important laboratory markers used when evaluating the growth hormone pathway.

Growth hormone stimulates the body to produce IGF-1, which contributes to childhood linear growth.

An IGF-1 test may therefore be ordered when growth hormone deficiency is being considered.

However:

Low IGF-1 does not automatically mean a child has growth hormone deficiency.

IGF-1 levels are affected by:

• Age
• Puberty
• Nutrition
• Chronic illness
• Liver function
• Growth hormone secretion

Results must therefore be interpreted using age- and puberty-appropriate reference ranges and alongside the child's growth pattern.[2,3]

Test #8: IGFBP-3

Insulin-like growth factor binding protein 3 (IGFBP-3) may also be measured during evaluation of the growth hormone–IGF axis.

Like IGF-1, it can provide information that helps clinicians decide whether additional endocrine testing is appropriate.

Neither IGF-1 nor IGFBP-3 should be interpreted in isolation.

The child's:

• Height
• Growth velocity
• Bone age
• Puberty stage
• Nutritional status
• Medical history

all matter.

Is a Random Growth Hormone Blood Test Useful?

Usually not.

This is an important point because parents often assume a doctor can simply order a blood test to measure growth hormone.

Growth hormone is released from the pituitary gland in pulses.

Levels can be very low at one moment and considerably higher later.

Therefore, a single random growth hormone measurement generally cannot determine whether a child has growth hormone deficiency.[3]

When growth hormone deficiency remains a concern after the initial evaluation, a growth hormone stimulation test may be considered.

Test #9: Growth Hormone Stimulation Test

A growth hormone stimulation test evaluates the pituitary gland's ability to release growth hormone.

During the test, medications are administered to stimulate growth hormone secretion.

Blood samples are then collected over several hours to measure the growth hormone response.

The Pediatric Endocrine Society notes that stimulation testing is more informative than a random growth hormone measurement, although the test is still imperfect and results must be interpreted carefully.[3]

Growth hormone stimulation testing is generally performed under the guidance of a pediatric endocrinologist.

Does Every Short Child Need a Growth Hormone Stimulation Test?

No.

Most short children do not have growth hormone deficiency.[1,3]

Growth hormone testing may become more appropriate when there is a combination of findings such as:

• Significant short stature
• Poor growth velocity
• Falling height percentiles
• Delayed bone age
• Concerning IGF-1 or IGFBP-3 results
• Clinical features suggesting pituitary dysfunction

A child who is mildly short but growing normally may not need extensive hormone testing.

Test #10: ESR or CRP for Inflammation

When chronic inflammatory disease is a concern, clinicians may order markers such as:

• ESR
• CRP

Inflammatory conditions can interfere with growth.

These tests may be particularly relevant when poor growth occurs with symptoms such as:

• Chronic abdominal pain
• Diarrhea
• Joint symptoms
• Weight loss
• Fatigue
• Persistent fever

Testing should be guided by the child's history rather than ordered automatically in every case.

Test #11: Kidney and Liver Function Tests

Chronic kidney or liver disease can interfere with normal growth.

Blood testing may therefore assess:

• Creatinine
• Electrolytes
• Liver enzymes
• Protein or albumin

These tests help determine whether poor growth could be related to a systemic medical condition rather than primarily an endocrine problem.

Test #12: Calcium, Phosphorus, and Alkaline Phosphatase

In selected children, testing may include:

• Calcium
• Phosphorus
• Alkaline phosphatase

These can provide information about mineral and bone metabolism.

They may be particularly relevant when a child has:

• Abnormal skeletal development
• Bone symptoms
• Nutritional concerns
• Kidney disease
• Disproportionate short stature

Not every child with slow growth requires these tests.

Are Urine Tests Used for Poor Growth?

Sometimes.

A urinalysis may be included when clinicians are screening for kidney disease, metabolic abnormalities, or other systemic conditions that could affect growth.

As with blood testing, the exact workup should be individualized.

Genetic Testing for Short Stature

Genetic testing is not necessary for every short child.

However, it may be considered when the growth pattern or physical examination suggests an underlying genetic condition.

Examples can include:

• Turner syndrome
• Noonan syndrome
• SHOX-related disorders
• Silver-Russell syndrome
• Certain skeletal dysplasias
• Other genetic growth conditions

Genetic evaluation may be particularly useful when there are:

• Unusual body proportions
• Dysmorphic features
• Developmental concerns
• Congenital abnormalities
• Severe unexplained short stature
• Strong family patterns of unusual growth

Testing for Turner Syndrome in Girls With Short Stature

Turner syndrome is an important genetic cause of short stature in girls.

Some girls have obvious physical characteristics, while others may present primarily with:

• Short stature
• Poor growth
• Delayed or absent puberty

When clinical findings suggest Turner syndrome, chromosome testing such as a karyotype may be considered.

This is one reason persistent unexplained short stature in girls should not automatically be attributed to family genetics.

Does a Child Need an MRI for Slow Growth?

Usually not as an initial test.

An MRI may be considered when evaluation raises concern about the pituitary gland or brain.

For example, pituitary MRI may be performed in selected children with confirmed or strongly suspected growth hormone deficiency or other pituitary hormone abnormalities.[3]

An MRI is therefore different from routine screening blood tests or bone age imaging.

What Tests Are Done for Delayed Puberty and Slow Growth?

If poor growth occurs along with delayed puberty, additional hormone testing may be considered.

Depending on the child's age, sex, and pubertal development, this can include:

• LH
• FSH
• Testosterone in boys
• Estradiol in girls
• Thyroid testing
• Other hormone tests when indicated

Puberty timing is important because a child with constitutional growth delay may have both delayed puberty and delayed bone age.

The goal is to distinguish a healthy late bloomer from an underlying endocrine condition.

Which Tests Does My Child Actually Need?

There is no single universal panel for every child who isn't growing.

The Growth Hormone Research Society recommends that laboratory testing be guided by the child's clinical findings rather than automatically applying the same extensive panel to every child with short stature.[2]

A mildly short child who:

• Is healthy
• Is growing normally
• Follows a consistent percentile
• Has shorter parents

may require little or no laboratory testing.

A child who:

• Is below the expected height range
• Has poor growth velocity
• Is falling through percentiles
• Has delayed puberty
• Has systemic symptoms

may need a broader evaluation.

Common Tests for a Child Who Isn't Growing

A typical evaluation may look something like this:

Test	What It Helps Evaluate
Growth chart	Growth pattern over time
Growth velocity	How quickly the child is gaining height
Mid-parental height	Genetic height expectations
Bone age X-ray	Skeletal maturity and remaining growth potential
CBC	Anemia and clues to systemic illness
CMP	Kidney, liver, electrolytes and general health
TSH + Free T4	Thyroid function
Celiac screening	Celiac disease/malabsorption
IGF-1	Growth hormone–IGF pathway
IGFBP-3	Additional GH-axis information
ESR/CRP	Inflammation when clinically indicated
GH stimulation test	Possible growth hormone deficiency
Genetic testing	Selected genetic causes of short stature
Pituitary MRI	Selected pituitary or confirmed/suspected GHD cases

Not every child needs every test on this list.

What Happens at a Pediatric Growth Evaluation?

A comprehensive evaluation should usually start by answering several basic questions.

How Tall Is the Child?

Height is plotted on an age- and sex-appropriate growth chart.

How Fast Is the Child Growing?

Previous measurements are used to calculate growth velocity.

Is the Child Falling Across Percentiles?

A changing trajectory can be more important than absolute height.

How Tall Are the Parents?

Parental height helps estimate genetic expectations.

Has Puberty Started?

Puberty significantly changes expected growth velocity.

What Does Bone Age Show?

Bone age helps estimate skeletal maturity.

Are There Symptoms of Another Medical Condition?

Nutrition, gastrointestinal health, thyroid symptoms, chronic illness, medications, and birth history are reviewed.

Only then can laboratory testing be selected appropriately.

When Should Parents Consider a Pediatric Endocrinology Evaluation?

Consider discussing further evaluation if your child:

• Has not grown significantly over the past year
• Has persistent poor growth velocity
• Is falling across height percentiles
• Is below approximately the 3rd percentile
• Is much shorter than expected from parental height
• Has delayed puberty
• Has delayed or advanced bone age
• Has abnormal IGF-1 or thyroid testing
• Has symptoms suggesting an underlying medical disorder

The Pediatric Endocrine Society notes that a child who is growing progressively more slowly or crossing downward through growth percentiles may warrant additional investigation.[1]

The Bottom Line: What Tests Are Done When a Child Isn't Growing?

When a child isn't growing normally, the goal is not to immediately test every hormone possible.

The evaluation should begin with:

1. Accurate height and weight
2. Growth chart review
3. Growth velocity
4. Family height
5. Puberty assessment
6. Medical and nutritional history

If the growth pattern is concerning, the next steps may include:

• Bone age X-ray
• CBC
• Metabolic testing
• TSH and Free T4
• Celiac screening
• IGF-1
• IGFBP-3
• Other targeted laboratory tests

If the initial evaluation raises concern for growth hormone deficiency, growth hormone stimulation testing may then be considered under specialist guidance.

The most important question is not:

“Which growth hormone test should my child get?”

It is:

“Why isn't my child growing normally?”

Answering that question requires looking at the entire growth pattern—not one laboratory result.

Concerned Your Child Isn't Growing Normally?

If your child has experienced little height gain, is falling on the growth chart, has delayed puberty, or is significantly shorter than expected for your family, a pediatric growth evaluation can help determine which tests are actually appropriate.

At HGH for Children, an evaluation may review:

• Previous height measurements
• Growth velocity
• Height percentile
• Family height
• Puberty timing
• Bone age
• Growth plate maturity
• IGF-1
• Thyroid and other relevant laboratory findings
• Growth hormone deficiency
• Remaining growth potential

The goal is to identify whether your child's growth pattern represents a healthy variation, delayed development, or a condition that deserves further evaluation.

Medically Reviewed By

Dr. Devin Stone, ND

Dr. Devin Stone, ND is a licensed naturopathic doctor and founder of HGHforChildren.com. His clinical focus includes pediatric growth evaluation, short stature assessment, poor growth velocity, delayed puberty, bone age analysis, growth hormone deficiency screening, IGF-1 interpretation, and individualized growth planning for children and adolescents.

Through HGHforChildren.com, Dr. Stone educates families about childhood growth patterns, growth testing, bone age, growth velocity, skeletal maturity, growth hormone evaluation, and treatment options when medically appropriate.

Medical References

1. Pediatric Endocrine Society. Short Stature: A Guide for Families. Pediatric Endocrine Society/American Academy of Pediatrics Section on Endocrinology. Reviews growth charts, growth velocity, bone age, short stature, and when laboratory testing may be appropriate.

2. Collett-Solberg PF, Ambler G, Backeljauw PF, et al. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Hormone Research in Paediatrics. 2019;92(1):1–14. Reviews clinical assessment, bone age, laboratory testing, genetic evaluation, and endocrine causes of short stature.

3. Pediatric Endocrine Society. Growth Hormone Deficiency: A Guide for Families. Reviews IGF-1, growth hormone stimulation testing, bone age, pituitary imaging, and limitations of random growth hormone measurements.

4. Grimberg A, DiVall SA, Polychronakos C, et al. Guidelines for Growth Hormone and Insulin-Like Growth Factor-I Treatment in Children and Adolescents: Growth Hormone Deficiency, Idiopathic Short Stature, and Primary IGF-I Deficiency. Hormone Research in Paediatrics. 2016;86(6):361–397. doi:10.1159/000452150.

5. Seaver LH, Irons M. ACMG Practice Guideline: Genetic Evaluation of Short Stature. Genetics in Medicine. 2009;11(6):465–470. Reviews genetic causes and diagnostic evaluation of children with unexplained short stature.