1. Abnormal Head Size in Growth Chart
Dr. Khalid Ibrahim
Senior Consultant and Chief of Pediatric Neurology Division

2. Objectives Introduction. How to get the measurement.
Deviation from normal.
The large head.
The small head.

3. Introduction 1
Head circumference is an essential component of physical assessment in children.
Head size reflects brain size and growth.
Large or small head can be cause of concern.
Not all abnormal head sizes are necessarily alarming.
Pattern of growth and serial measurements are more important than a single recording.
DeMyer W. Small head, large, or abnormally shaped head. In: Maria BL, ed. Current management in child neurology. 4th ed. Shelton: BC Decker Inc; 2009:

4. Introduction 2
Inclusion of other growth parameters are essential (Weight and Height).
Relationship of the 3 measurement will determine intervention(s) needed.

5. Definitions
Head Circumference: A measurement of the head around its largest area.
Microcephaly: Head circumference more than 2 standard deviations below the mean for age and sex.
Macrocephaly: : Head circumference more than 2 standard deviations above the mean for age and sex.

6. How To Get The Measurements 1
Use the correct tape measure (Lasso-o)
Place the tape above the ears, halfway between eyebrows and hair line to the occiput.
Bartram JL, Rigby AS, Baxter PS. The "Lasso-o" tape: stretchability and observer variability in head circumference measurement. Arch Dis Child Aug;90(8):820-1.

7. How To Get The Measurements 2
Take 3 measurement and record the maximum.
Plot in the correct centile chart.
Document date.
Record other parameters and plot them.
Obtain serial measurements.
Measure the first postnatal HC after 36 hours!!
RCPCH
Early years-UK-WHO growth charts and resources. London: Royal College of Paediatrics and Child Health

8. How To Get The Measurements 3
Adjust for prematurity (Before 37 weeks).
Adjust for prematurity until one year of age.
Measure parents’ head size.
Consistency (training).

10. National Centre for Health Statistics

12. What Do You Think??

13. Familial Macrocephaly

14. Approach to A Child with Large Head 1
Etiologies:
Congenital Anatomic:
E.G. Acqueductal Stenosis; Intrauterine
Infections.

15. Approach to A Child with Large Head 2
Genetic:
Includes neurogenetic, neurometabolic and
chromosomal as well as familial. Examples:
White matter disorders (Canavan and
Alexander diseases); Overgrowth Syndromes;
Glutaric Acidurias; Chromosomal (Fragile X,
Noonan); Neuorcutaneous Syndromes (NF1
and TS).

16. Approach to A Child with Large Head 3
Environmental:
Infections; Trauma causing collections; bleeds.
Neoplasm.
Hydrocephalus.

17. Approach to A Child with Large Head 4
History:
Ante/Peri and Postnatal history.
Developmental progress (All areas).
Trauma.
Family History.
Social History (NAI).

18. Approach to A Child with Large Head 5
Examination: Head size (serial measurements); Other growth parameters; anterior fontanel; Eyes; Dysmorphism; Skin; Developmental assessment; Back; Other systems …..

19. Approach to A Child with Large Head 6
Investigations:
Imaging: US; MR; CT.
Bloods.
Urine.
Others.

20. Approach to A Child with Large Head 7
Intervention:
Multidisciplinary input.
Neurosurgical.
Counseling.

21. What Do You Think??

22. ? Rett Syndrome

23. Approach to A Child with Small Head 1
Etiologies: (Consider the shape of the skull)!!
Craniosynostosis. Premature fusion of skull plates. Usually abnormal, asymmetrical shape of the skull.
Brain Growth:
Congenital (antenatal onset):
Chromosomal; Genetic (Primary AR);
Infections (TORCH/Zika).

24. Approach to A Child with Small Head 2
Postnatal onset: (HC normal at birth)
Metabolic including mitochondrial; Infections;
HIE; Neurodegenerative (Rett and NCL).

25. Approach to A Child with Small Head 3
History:
Ante/Peri and Postnatal history.
Developmental progress (All areas).
Regression.
Family History.

26. Approach to A Child with Small Head 4
Examination: Head size (serial measurements); Other growth parameters; Shape of the Skull; Eyes; Dysmorphism; Skin; Developmental assessment; Other systems …..

27. Approach to A Child with Small Head 5
Investigations:
Imaging: US; MR; XR and CT.
Bloods.
Urine.
Others.

28. Approach to A Child with Small Head 6
Management/Intervention:
Multidisciplinary input.
Neurosurgical/Maxillofacial Surgeon.
Counseling.

29. When to Refer?? Serial measurements are crossing centiles.
The child’s head circumference measurement indicates excessive or limited growth. 
Their head is an abnormal shape or size (eg if the measurement falls outside 99.6th or 0.4th centile on the chart. 
The head circumference is >2 centile lines above or below their height or length measurement.

30. Research Work
Project “Brain Growth and Development”. Funded By QNRF. Enriched the world literature.

33. THANK YOU