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New guidance is needed on diagnosing microcephaly in severely malnourished children

The American Academy of Pediatrics recommends that all children have a head circumference measurement at each well-child visit until 2 years of age. Low head circumference is associated with preterm birth and very low birthweight as well as a variety of genetic, nutritional and health factors (1). Microcephaly is an important neurological sign, but there is no uniformity in its definition and no standardisation. It is important to measure head circumference in infants, because this correlates with brain size and growth. Deviations from normal head growth may be the first indication of an underlying congenital, genetic or acquired problem. Microcephaly is usually defined as a head circumference of two or more standard deviations below the mean or less than the second percentile for age and sex. Severe microcephaly is defined as a head circumference that is three or more standard deviations below the mean for age and sex. If the brain is not growing, the skull will not grow and, therefore, a small head reflects microcephaly. Microcephaly combined with delay and regression might be an indication of Rett syndrome or infantile neuronal lipofuscinoses (2). An infants head circumference depends upon the nutritional and socio-economic status of the child, and its mother and genetic factors play a role in head circumference (3). Mental retardation is likely if the head circumference is less than the third percentile. In chronic malnutrition, weight for age, height for age and weight for height are less than normal. Traditionally, it has been stated that the brain sparing effect is present in malnutrition on the basis of an increased brain weight to body weight ratio. Naturally, the head circumference for age is reduced in malnourished children by up to three standard deviations. So in chronic malnutrition, the effect on the length and height should correlate with the head circumference. No standards are currently available for older children. The head size is small or microcephaly is present if it is less than the third percentile of the World Health Organization charts, but this does not consider the stature of older children. Most of these children do not have mental retardation, delayed gross motor development or adaptive development. Can we label the severely malnourished child as having microcephaly if their weight and height are affected by up to three standard deviations? It is clear that new methods or charts are needed to enable us to detect microcephaly in malnourished children.