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Head circumference may be the best proxy for neurodevelopmental risk in children in low-resource settings
  1. Amy Connery1,2,
  2. Alison Colbert1,2,
  3. Molly Lamb3
  1. 1 Children's Hospital Colorado, Aurora, Colorado, USA
  2. 2 Department of Physical Medicine and Rehabilitation, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  3. 3 Center for Global Health and Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
  1. Correspondence to Dr Amy Connery, Children's Hospital Colorado, Aurora, CO 80045, USA; amy.connery{at}

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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 …

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  • Contributors A Connery, A Colbert and ML contributed to the ideas in the paper, as well as the writing and the research. They have collaborated on previous research at our research and clinic site that have led to the ideas put forth in the paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.