Physician: Microcephaly: Small Head Size

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We just received a referral for a 14 month-old Russian girl. Her orphanage medical records are surprisingly detailed. I am concerned about her head measurements (microcephaly?) as they are consistently below the 3rd percentile on the CDC charts. I have read that it is easier to make measurement mistakes erring to the small side than to the large side. Perhaps I am making too much of this; but I have read several articles stressing the significance of this condition when it exceeds 2 Standard Deviations (3rd percentile). I have also read that this is not the type of thing that nutritional improvements, etc. will have much effect on after the first year and a half.

Plotting head growth is the standard of care in all offices that provide medical care for infants and children. While there are numerous medical factors that can adversely affect a child’s head size, living in an institution itself can cause of global growth delay. It is a well known fact that children that live in orphanages tend to have a syndrome called Institutional growth delay. For every three months that a child lives in an orphanage, one could expect approximately 1 month of delay in both growth parameters (height, weight, and head circumference) as well as developmental delays in milestones.

Unfortunately, a small head can not be dismissed just because the child lived in an orphanage or that the measurements were wrong. It is imperative to analyze the entire medical record for any medical risk factors, view the video tape to look for any significant delays in development. It is also important to view pictures of the child in order to determine if there is any concern for genetic syndromes, birth defects or fetal alcohol syndrome. It is only after this that an limited educated determination can be assessed.

The growth charts that are used in the USA today are developed from data merged from two studies performed in 1948 and 1965. In the data collection children measured were well nourished and ethnically diverse. Unfortunately, neither or the two studies incorporates data from any country in the world that places children for International adoption today. One should not dismiss growth parameters because they do not pertain to these children. They do provide an arsenal of information. They must however be used with the understanding that there are some short comings to the data. If a growth chart is available for the child’s country of origin it should be used in order to determine the individuals head size in relation to its peers. It is also very important to realize that growth parameters over time are much more informative than individual points.

Microcephaly: is defined as a head circumference of less than 2 standard deviations below the mean for age and sex. Growth parameter over a prolonged period of time is more important that single measurements. Head circumferences that progressively drop to lower percentiles with the increasing age are indicative of a medical condition or process that has impaired the brain development. A very small head size at birth is a red flag that there was some type of intrauterine insult.

Causes of Microcephaly (small head circumference)

  1. Genetic Disorders or syndromes
  2. Toxin Ingestions during pregnancy: (alcohol, anticonvulsants)
  3. Infections during pregnancy: (TORCHES: toxoplasmosis, rubella, cytomegalovirus, herpes simplex, syphilis)
  4. Perinatal trauma or hypoxia (birth injury)
  5. Perinatal Infections: (bacterial meningitis or viral encephalitis)
  6. Metabolic and degenerative disorders (very rare types of disorders). In the USA these disorders are check for during the state mandated universal newborn screening test.
  7. Familial trait: small heads in the family
  8. Growth failure seen in orphanages secondary to psychosocial growth retardation. There is generally a lag in height and weight as well.
  9. Severe protein energy malnutrition: during times of acute malnutrition, these children tend to demonstrate developmental delays in all milestones (speech, motor and social), they have abnormal crying patterns as well as social interactions and apathy. When taken out of the hostile environment and are recovering from malnutrition, there is a dramatic reversal in the apathy, improved motor and exploratory skills. There may be even after adequate correction of the malnutrition some reduced developmental quotients in the future.

As you can see an exact explanation for a small head cannot be determined with just a few growth parameters. An adequate history and physical examination is a must. We as health care providers are often faced with the task of determining the overall well being of an internationally adopted child, and we are asked to determine if a child brain is neurologically intact. Head and other growth parameters are extremely important in making and generalized assumption of the child health status; but they can not be used as the sole factor in making an overall decision. It is imperative to evaluate the medical record and determine if there are any underlying medical, genetic, or other biological or pregnancy related risk factors. Any specific medical diagnosis will obviously increase the overall risk and prognosis. A careful evaluation of the video can give us incite as to the developmental milestones attained by this child, and close up pictures can help to determine if any types of genetic syndromes or fetal alcohol syndrome.

Unfortunately, consistent and progressively decreasing head size markedly increases the risk of developmental delays and the smaller the head the more profound the deficit.

While the ultimate decision making power resides solely within the adoptive parents. No one Doctor can tell you to adopt or not adopt a particular child. All that we as physicians can do is adequately educate and inform the family of all foreseen and unforeseen risk factors, and then prepare them for all possible scenarios both with good and bad outcomes.

by George Rogu M.D.

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The information and advice provided is intended to be general information, NOT as advice on how to deal with a particular child's situation and or problem. If your child has a specific problem you need to ask your pediatrician about it - only after a careful history and physical exam can a medical diagnosis and/or treatment plan be made. This Web site does not constitute a physician-patient relationship.

This material has been provided by, an innovative adoption medicine private practice and educational service, dedicated to helping parents and adoption agencies with the complex pre-adoption medical issues of internationally adopted children. All medical interactions are performed via, e-mail, express mail, telephone, and fax. There is no need to make a live appointment or travel outside of your hometown. For more information, visit or call 631-499-4114.

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