Does Size Matter...or Is Bigger Better? Click here for video clip showing proper head circumference measurement (11MB MOV file, requires QuickTime Player)

by Dr. Dana Johnson, M.D., Ph.D., Professor of Pediatrics & Director of International Adoption Clinic, University of Minnesota

INTRODUCTION

Reviewing referral documents to assess the well-being of a child is a challenging task for every health-care provider. While ultimate decision-making power resides with the family, frequently the information we provide determines whether a child is accepted or rejected. I view this as a grave and often a burdensome responsibility, primarily because there is so little objective data on which to base my opinion.

Much of the information I would like to have at my disposal is not present in the medical abstract. Frequently absent are maternal medical history; details on the pregnancy, labor and delivery; whether the mother used drugs or alcohol; and gestational age at delivery. Many children are referred in the first few months of life. While I support any initiative that reduces the length of time a child remains within an institutional care setting, young infants are exceptionally difficult to evaluate since developmental milestones are few and easily attained by all but the most neurologically damaged.

Most information contained in referral documents is subjective, dependent upon the interpretation of the physician collecting the information. In these situations, unless the videotape is particularly informative, I am totally dependent upon the ability of another health-care provider to identify conditions such as fetal alcohol syndrome, profound developmental delays, autism, etc. As I often cannot rely on subjective information, objective data (particularly body measurements) assume an important role in my evaluation.

I occasionally speak with adoptive families who seek children with whom to share unique gifts. Parents often desire children with their own specific disabilities, such as blindness or deafness. Other families who have parented a child with a specific medical condition feel able to face those specific challenges with another similarly affected child. Others are attached to their child's image as firmly as parents who cradle their newborn in the delivery room, and would never consider abandoning what is now their child-even facing the prospect of severe medical problems. However, most parents seek a child with a good chance of living a "normal life"-a desire no different from those who await birth children.

While many factors enter into a child's quality of life, no one would dispute that a healthy brain is important. The dilemma we face in adoption medicine is that we are not only tasked with determining the health status of a child, but are asked to judge whether a child's brain is healthy. We are requested to assist the family in choosing a child who has a good chance of being a happy and productive member of society, able to participate fully in life's joys and opportunities.

Head growth has been used by generations of health-care providers as a marker of brain well-being. Plotting head growth is a ritual in the offices of child health-care providers worldwide, and children whose heads measure too small or too large for their age are viewed with great concern. However, problems are encountered with obtaining and interpreting this measurement in the case of an individual child. These problems are magnified when the child's head is being measured by another individual, and interpreted in the absence of complete medical and social information on the mother and child. Nevertheless, head circumference is one of the few pieces of objective information present within the referral document. The purpose of this presentation today is to discuss the positives and negatives of using measurement of head circumference (occipitofrontal circumference, or OFC) as a measure of brain health and, by inference, long-term developmental potential.

Technicalities...