Manual Head growth in Children

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Physical Growth of Infants and Children and Pediatrics - Learn about from the Merck Manuals - Medical Professional Version. Head Circumference. Head.
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The Spanish Association of Pediatrics has as one of its main objectives the dissemination of rigorous and updated scientific information on the different areas of pediatrics. Annals of Pediatrics is the Body of Scientific Expression of the Association and is the vehicle through which members communicate.

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published. Read more. SRJ is a prestige metric based on the idea that not all citations are the same.

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SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Our aim was to investigate the correlations between patterns of head growth and intellectual disability among distinct aetiological presentations of microcephaly.. We classified patients according to the presence or absence of intellectual disability IQ below 71 and according to the cause of microcephaly idiopathic, familial, syndromic, symptomatic and mixed..

We defined a HC growth function which discriminates intellectual disability of microcephalic patients better than isolated HC measurements, especially for those with secondary and mixed aetiologies.. Head circumference HC measurement is an easy method to assess brain growth. Microcephaly, defined as a statistically abnormally low HC, has a relationship with mental retardation which is well known since the 19th century.

Head growth patterns have been proposed as an important tool in the assessment of microcephaly. It is clear that the lower the HC the child has the greater the likelihood of neurological impairment is. There are many different neurological conditions causing microcephaly or slow HC growth and some of them have already been object of research. In hypoxic—ischaemic encephalopathy slight decelerations imply neurological impairment even before the microcephalic range is attained 13 and the patterns of lesions found in magnetic resonance imaging MRI correlate with HC growth and neurological status.

Conversely, microcephaly was the most specific early predictor of mental retardation in congenital CMV infection 16 while neurologic disorders do not develop in the majority of congenitally infected infants. In another study the presence of HC catch-up growth before the age of 6 months was associated with fewer motor abnormalities at 12 months.

Ionizing radiation exposure, 22 malnutrition, 23 medication during pregnancy 24 and genetic or primary microcephaly 25,26 are other known causes of small head and mental retardation. Microcephaly is also a clinical feature of hundreds of multiple malformation syndromes.. In our study we aimed to investigate the concordance of a HC growth function with intellectual disability among different aetiological clinical presentations in a sample of microcephalic infants and children..

We retrospectively studied patients from a tertiary hospital neuropaediatric unit in Spain which serves as a referral area for three million people.

Small changes to a child's head size should not concern parents

Since a follow-up HC Nellhaus Chart 11 according to patient's sex was routinely placed in every medical record during the first visit regardless of the reason of referral. In more than a half of the visits the neuropaediatrician measured with a flexible tape the maximum HC in cm, to one decimal point, and plotted it onto the chart. Neither parent's HC nor patient's height were part of the protocol. Since MRI has been available in our hospital and it has become a part of the assessment in most of the microcephalic children..

After a decade using this protocol we started to collect the data.


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We reviewed all records of patients receiving care in our unit during the years — On each one of the patients HC chart was checked and all patients with one or more HC measurements more than two SD below the mean for age and sex were fully reviewed. Following Brandt recommendations 29 we excluded pre-term infants under 34 weeks of gestation whose HC was in the normal range after the age of 18 months.

Parent's HC was recorded in those cases where hereditary microcephaly was suspected.. We plotted all available HC points of every patient onto the Nellhaus. Once all Z -scores were calculated we defined the following variables as the descriptors of the patient HC curve pattern:.

It is the lowest registered Z -score per participant. It was obtained, in all those patients whose Z -scores became more negative over time, by subtracting from the lowest registered Z -score the highest previous z -score. This variable was always negative. It was obtained, in all those patients whose Z -scores increased after the smallest registered Z -score, by substracting the lowest previously registered Z -score from the highest final Z -score.

This variable was always positive. All HC Catch-up below 0.

5. How to measure growth in infants and toddlers: Height/Length

In order to establish the neurological outcome we reviewed the level of intellectual impairment of every patient with his or her paediatric neurologist. WISC-R tests in children older than 6 years with a sufficiently preserved mental status to allow them to collaborate with the test, school and parent reports in normal functioning children older than 6 years and Terman Merill or Leiter developmental tests in those older than 3 years, were considered..

We distributed patients into two groups according to their outcome:. Clinical groups were established according to the most probable cause of microcephaly. Following the criteria proposed by Baxter et al. Mean, median, standard deviation and interquartile range were used to express the central tendency and statistical dispersion of data.

Graphical comparison between disabled and non disabled groups was performed by the box-plot diagram. Multivariate discriminant analysis was carried out to study the HC growth pattern descriptor variables jointly and their influence on patient adscription to either disabled or non disabled groups. After the revision of charts, patients satisfied the study inclusion criteria. Male to female ratio was The mean age of the first available HC measured by the paediatric neurologist was 20 months median 10 months.

The mean length of the HC follow-up was 56 months median 38 months and the mean number of HC measurements recorded was 5. We included 16 infants born before the 34th week of gestation, as they remained microcephalic after the age of 18 months. MRI reports were available in patients.. Disabled and non disabled groups showed different HC growth patterns. Box plot of standardized HC Minimum by neurological outcome. The median and the mean are depicted within the boxes as solid and dashed lines, respectively.

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Box plot of standardized HC Drop by neurological outcome. The mean HC Catch-up was 0. Box plot of standardized HC Catch-up by neurological outcome. Discriminant analysis stepwise procedure accepted HC Drop in a second step but HC Catch-up was rejected as it did not add new information..


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We analyzed the differences in concordance between the function outcome prediction and the actual intellectual status. In every cell, from the top: frequency, percentage, row percentage, column percentage.. We also analyzed the differences in concordance for each one of the five aetiological clinical presentations proposed by Baxter et al.

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As depicted in Table 2 , the presentations with a higher concordance were symptomatic and mixed ones. We decided to merge them considering that in all mixed patients there was, at least, one pathogenic event contributing to microcephaly. The rest of the participants from idiopathic and syndromic presentations were also merged into a second group, bearing in mind that most of patients with primary or genetic microcephalies belonged to them..

Outcome prediction by aetiological group.. Serial HC measurement can be used to identify markers of neurological outcome. Our results confirm the importance of taking into account not only the degree of microcephaly, as reflected by HC Minimum, but also the fall in head growth velocity reflected by HC Drop. This approach has been used in some conditions leading to microcephaly, as in hypoxic-ischaemic encephalopathy, 13 but we have broadened this concept to include most conditions where microcephaly is a relevant clinical sign.

Our study may refine this statement by adding the predictive value of the amount of HC Z -score drop that many times precedes the minimum Z -score achieved by the patient. A general feature of data for both HC Minimum and HC Drop was a lower value more negative of the mean and the median in the intellectually impaired group Figs.

The statistical measurements of dispersion standard deviation or IQR were higher in the impaired group for both variables with respect to the non intellectually disabled group. Regarding HC Catch-up Fig. This finding is consistent with our observation pointing to the significant relationship between HC Minimum and Intellectual Disability. Interestingly this variable did not add any information to HC Minimum and HC Drop in order to distinguish impaired from normal participants as it was refused by the discriminant analysis method to create the Intellectual Disability prediction function.

The fact that catch-up growth appears late in child neurodevelopment, after the HC Minimum is already reached, it also reduces its value to anticipate outcome.. Although we used a clinical classification for children with acquired microcephaly we found their group definitions useful for our wider sample. As a matter of fact, the British study 12 in which this classification was proposed, was unable to find associations between growth patterns and IQ while our multivariate discriminant analysis approach succeeded. Some differences between the two studies are: the number of participants 51 participants in contrast to in our sample , the number of MRI results available 29 patients in contrast with in our sample and the measurement of the height of the patients and the HC of the parents in the Baxter et al.

We hypothesize that in secondary or symptomatic microcephalies the use of head growth patterns to predict neurological impairment is more reliable than in primary or idiopathic microcephaly. Microcephaly is common, affecting more than 25, infants in the United States each year. If it is not present at birth, it usually has developed by the time a child is two years old. While microcephaly is not a disease, it is an important sign that may point to other conditions.

For these reasons, it is necessary for doctors to recognize microcephaly and check the child for these associated problems, which often require special treatments. After a decade using this protocol we started to collect the data. We reviewed all records of patients receiving care in our unit during the years — On each one of the patients HC chart was checked and all patients with one or more HC measurements more than two SD below the mean for age and sex were fully reviewed.

Following Brandt recommendations 29 we excluded pre-term infants under 34 weeks of gestation whose HC was in the normal range after the age of 18 months. Parent's HC was recorded in those cases where hereditary microcephaly was suspected.. We plotted all available HC points of every patient onto the Nellhaus. Once all Z -scores were calculated we defined the following variables as the descriptors of the patient HC curve pattern:. It is the lowest registered Z -score per participant. It was obtained, in all those patients whose Z -scores became more negative over time, by subtracting from the lowest registered Z -score the highest previous z -score.

This variable was always negative. It was obtained, in all those patients whose Z -scores increased after the smallest registered Z -score, by substracting the lowest previously registered Z -score from the highest final Z -score. This variable was always positive.