• child development
• child health
• global health
• paediatrics

Performance-based assessment is considered the gold standard for measuring child neurodevelopment (ND). However, such assessment is often not feasible in low-resource settings (LRSs) because it is time-consuming, resource-intensive, and available assessment tools are often not validated in the local language or lack regional or local norms. In the absence of direct developmental assessment, estimates of children at increased risk of ND impairment (‘ND risk’) and health policies that aim to improve child ND are usually based on population-based metrics of child linear growth (i.e., stunting defined as <2 SD below the mean in height-for-age or length-for-age, WHO). However, there is growing evidence that while stunting continues to be a robust proxy for child physical health and nutritional status, it is likely not the best proxy for ND risk, as the causal pathways of stunting and ND are complex and incompletely overlap.1

We propose that occipitofrontal head circumference (OFC) may be a more direct and appropriate proxy, as well as a feasible and cost-effective method of identifying children at highest ND risk in LRSs. Research from high-income countries (HICs) suggests that OFC is a robust anthropometric measurement of brain volume, and several studies have demonstrated this relationship on neuroimaging.2 An extensive body of research from HICs has shown that when an OFC is 2 SD or more below the mean on the WHO growth charts, consistent with a diagnosis of microcephaly, there is an elevated …