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Newborn and Infant Care

Head circumference



We were informed of an infant in foster care that is up for adoption. She is 4 months old. Her paperwork says she is 14 lbs, 21 1/2 inches long, and 38 cm head circumference. It also has a <3 in percentile for head circumference. What concerns would you have for her well being?


I plotted her measurements on the most recent version of the CDC Growth Charts for girls birth to 36 months. Her weight is slightly over the 50th percentile, which means that about half of little 4 month old girls weigh more and the other half weigh less than she does. Both her length and head circumference are below the 3rd percentile meaning that only 3% of four month old girls are shorter and have smaller head sizes.

The fact that both of these measures are so small suggests that she was intrauterine growth retarded at birth. In other words, for the majority of her prenatal life, this little girl received poor nutrition and oxygenation through her birth mother's placenta. We also call this symmetrical growth retardation because more than just her birthweight were affected. Children who are simply thin babies but have normal length and head circumference experience poor placental nutrition for a brief period of time. Symmetrically growth retarded children tend to remain small throughout their lives and are at a higher risk for becoming overweight because their bodies seem to be programmed to store extra nutrition against any further times of nutrition scarcity. Hence, at this time, she is quite overweight for her length. This may also reflect her caregiver's reliance on feeding for soothing regardless of the cause of baby upset.

Babies who start life smaller than they should be do tend, as a group, to have more problems with learning and behavior. This is not surprising given that during the prenatal time when the brain is growing at a tremendous rate, this little girl's brain did not receive the supplies of nutrition and oxygenation it needed for normal growth. However, it is impossible to tell for any one child what his or her developmental outcome will be. The developmental assessments we currently use actually do not accurately forecast development after age 2. So developmental assessment now at 4 months will not be very helpful in forecasting her future.

We also know that in the first three years of life the child's brain is tremendously flexible and with a good home with loving parents and a stimulating environment, many babies do extremely well despite even a very difficult start in life. Because building a solid attachment relationship is so key to infant learning and behavior, it is important to adopt children into good homes as soon as possible. It gives parents and babies the best opportunity to have a happy and successful life together.

The state of Ohio and all states in the US have a system of services for early intervention. if you decide to adopt this little girl and you or your pediatrician are concerned about her development, these free services are available to all citizens regardless of income. In Ohio, these services are accessed through the Help Me Grow program. Parent scan refer their own children for evaluation for services. Their website is www.ohiohelpmegrow.org.

So, are you taking a larger than usual chance that this little girl may have learning disabilities? The answer is yes. But you may also be adopting a little girl who will turn out just fine thanks to your loving care. It is a very difficult decision and only you know and your partner know your resources and ability to accept a child who may be different. It often helps to spend time with the child and see if you click together. The best of luck in making this important decision. 

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University