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World variation in head circumference for children from birth to 5 years and a comparison with the WHO standards
  1. Lai Ling Hui1,2,
  2. Frederick K Ho3,
  3. Charlotte Margaret Wright4,
  4. Tim J Cole5,
  5. Hugh Simon Lam1,
  6. Han-Bing Deng1,
  7. Hung-Kwan So6,
  8. Patrick Ip6,7,
  9. E Anthony S Nelson1,8
  1. 1 Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong SAR, People's Republic of China
  2. 2 Department of Food Science and Nutrition, The Hong Kong Polytechnic University, Hong Kong SAR, People's Republic of China
  3. 3 School of Health and Wellbeing, University of Glasgow, Glasgow, UK
  4. 4 Department of Child Health, School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
  5. 5 UCL Great Ormond Street Institute of Child Health, London, UK
  6. 6 Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong SAR, People's Republic of China
  7. 7 Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, People's Republic of China
  8. 8 Faculty of Medicine, The Chinese University of Hong Kong - Shenzhen, Shenzhen, Guangdong, People's Republic of China
  1. Correspondence to Professor E Anthony S Nelson, Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong, People's Republic of China; tony-nelson{at}; Dr Patrick Ip, 1/F, New Clinical Building, Queen Mary Hospital, Pokfulam Road, Hong Kong, People's Republic of China; patricip{at}


Objective A recent review reported that the WHO 2006 growth standards reflect a smaller head circumference at 24 months than seen in 18 countries. Whether this happens in early infancy and to what extent populations differ is not clear. This scooping review aimed to estimate the rates of children in different populations identified as macrocephalic or microcephalic by WHO standards.

Methods We reviewed population-representative head circumference-for-age references. For each reference, we calculated the percentages of head circumferences that would be classified as microcephalic (<3rd WHO centile) or macrocephalic (>97th WHO centile) at selected ages.

Results Twelve references from 11 countries/regions (Belgium, China, Ethiopia, Germany, Hong Kong, India, Japan, Norway, Saudi Arabia, UK and USA) were included. Median head circumference was larger than that for the Multicentre Growth Reference Study populations in both sexes in all these populations except for Japanese and Chinese children aged 1 month and Indians. Overall, at 12/24 months, 8%–9% children would be classified as macrocephalic and 2% would be classified as microcephalic, compared with the expected 3%. However at 1 month, there were geographic differences in the rate of macrocephaly (6%–10% in Europe vs 1%–2% in Japan and China) and microcephaly (1%–3% vs 6%–14%, respectively).

Conclusions Except for Indians and some Asian neonates, adopting the WHO head circumference standards would overdiagnose macrocephaly and underdiagnose microcephaly. Local population-specific cut-offs or references are more appropriate for many populations. There is a need to educate healthcare professionals about the limitations of the WHO head circumference standards.

  • child development
  • growth

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • LLH and FKH are joint first authors.

  • Contributors All the authors contributed to the interpretation of the data, critically revising the paper and approval of the manuscript as submitted. In particular, LLH developed the study conception, directed the study’s analytic strategy and wrote initial draft of the manuscript. EASN is guarantor.

  • Funding This work is part of the 'Hong Kong Growth Study', which was supported by the Health and Medical Research Fund, Government of the Hong Kong SAR (GC-CUHK).

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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