Introduction

It is reported that 55% of the deaths of children below five years of age are due to malnutrition (1). India has the highest occurrence of childhood malnutrition in the world (2). The assessment of growth is essential during preschool age, more particularly in pediatric neurological examination, measurement of the head circumference plays a vital role. Very important information can be suggested from the head size and shape that will guide the differential diagnosis and the need for further investigations. Head circumference (HC) is a simple and non-invasive anthropometric measure. Also known as the frontal occipital circumference, HC has been cautiously used to assess the frequencies of undernutrition among preschool children (3). This circumference is an index of cranial growth and is also considered to be an index of once nutritional status and development of the brain and brain size (4,5). Growth assessment best defines the health and nutritional status of children, because disturbances in health and nutrition, anyhow of their aetiology, always affect child growth and hence give an indirect measurement of the quality of life of an entire population (6). Anthropometry plays a significant part in the evaluation of nutritional status among preschool children. Several anthropometric measurements have been suggested for studies on growth and nutritional status, but height, weight, mid-upper arm circumference, head circumference (HC), and skin fold thickness are most frequently used. Regular monitoring of head circumference is an essential component of nutritional assessment in children up to age three and longer in children who are at high nutritional risk (7). Undernutrition produces notable morphological changes in brain size development which may damage intellectual potentiality and can limit productivity in preschool children (8). Head Circumference is a good indicator for marginal cases of protein-energy malnutrition in both survey and screening programs (9). Head circumference (HC) is a physical index of both past and present nutrition and brain development (10). In the field of pediatrics, it is a routine measurement to assess brain development, though micro and macrocephaly are considered dependable indicators of brain pathology (11). It has been defined as the most sensitive anthropometric indicator of undernutrition during infancy, associated with intellectual impairment (12,13). Poor attainment of physical growth of the brain affects cognitive capacities (14-16).

HC is an especially useful indicator that should be measured more frequently (17-19). Veritably many published data are available on growth patterns and prevalence of undernutrition among preschool children using HC. Most of the earlier studies had published data on HC along with growth increments in children (20-23). Several research investigations have reported the physical growth pattern and magnitude of undernutrition (low HC-for-age; <-2SD) among preschool children in India (7,9,18,24-28).

The present research work attempted to study age and sex variation of Head circumference and assessment of the nutritional condition among rural preschool children of Maynaguri, Jalpaiguri, West Bengal, India, by using WHO (2007) recommended cut-off points for head circumference for age. We try to assess the nutritional status of studied preschool children by using Head Circumference as an indicator.

Materials and Methods

Cross-sectional study has been conducted to determine age and sex-specific prevalence of undernutrition by using HC among rural preschool children of Jalpaiguri, India. It also focuses on the implicit part of HC in assessing nutritional status among rural preschool children. The present cross-sectional study was carried out among preschool children aged 24-60 months under the Integrated Child Development Scheme (ICDS) located in the rural areas of Maynaguri block of Jalpaiguri district. Jalpaiguri is situated at the northern region of West Bengal. Jalpaiguri is located 26° 16’ & 27° 0’ North latitude and 88° 4‘& 89° 53‘East longitude. According to the Census of India 2011 (29), 51.47 % live in urban areas and 48.9 % live in rural areas. A total of 782 preschool children (boys= 384, girls = 398) aged 24-60 months were studied. Information about the non-anthropometric variables such as age and sex, was collected by pre-structured interview schedule. All children come from rural backgrounds.

Ethical consideration was guided by Helsinki Declaration (30). Ethical approval and prior permission were obtained from the University of North Bengal. The measurement (head circumference in cm.) was taken following the standard method by Lohman et al. 1988 (31). Nutritional status of the children was evaluated using the following criteria, Moderate undernutrition < - 2 SD, Severe undernutrition < - 3 SD where SD refers to the age and sex-specific WHO standard deviations of Head circumference. Statistical analysis done on SPSS version 18. Age and sex specific differences were done by t Test, and ANOVA test at the level p<0.05. WHO anthro software was used to assess the nutritional status.

After an extensive literature review, no result has been found from the study area of Maynaguri. Hence, the present study aims to analyse age and sex variation of Head circumference among studied children and also observe the prevalence of undernutrition by the Head circumference cut-off (WHO 2007) among preschool children of Maynaguri.

Results

Table 1 describes sex differences in head circumference by age. The mean ± SD HC of boys was higher (47.68 ± 1.63) than the girls (46.78 ± 1.58). There were statistically significant mean differences in HC of boys and girls (t= 7.856, p< .001). The mean value of HC increased with the advancement of age. Highly significant sex differences in mean HC were observed at all age groups, 30-35 months (t= 4196 p< .001), 36-41 months (t= 3.333 p<.001), 42-47 months (t = 3.224 p< .01), 48-53 months (t = 4.869 p< .001), 54-60 months (t = 4.862 p< .001) except 24-29 months. Significant age variations in mean HC were found among both sexes (boys: F = 24.367, p< .001, Girls: F = 12.86, p< .001). Fig 1 shows the age specific sexual dimorphism of the mean Head circumference of the studied population.

Figure 1: Sexual dimorphism of the Head Circumference of the studied children

Table 2 describes the age and sex specific mean and SD of HC for Z score. The mean HC for Z score is lower among boys -1.45 (±.99) than girls -1.49 (±1.05). The lowest value of HC for Z score was seen among boys in the age group of 24-29 months on the other hand lowest value of HC for Z score was observed in the age group of 48-53 months among girls. Statistically significant sex difference in mean HC for Z score found at the age group of 24-29 months.

Table 3 describes age and sex specific prevalence of undernutrition. Age combined rates of moderate undernutrition for boys was 21.87 % and for girls was 25.37 %. Age-combined severe undernutrition among boys and girls were 5.72% and 6.53 %, respectively. The highest number of moderate undernutrition was found in the age group of 42-47 months (33.33%) among boys, and in the case of girls in the age group of 48-53 months (39.18 %). The highest number of severe undernutrition was seen at 24-29 months (13.46 %) among boys and at 42-47 months (9.38 %) among girls.

Discussion

Studies were done by various researchers to find out the prevalence of undernutrition by Head Circumference for Z score. The highest amount of malnourished preschool children is seen among rural preschool children of Hooghly district (boys 64.9 % and girls 62.8 %) (18). Whereas the lowest prevalence of malnourished children was seen among Bengalee preschool children of Midnapore, West Bengal (boys: 19.2%, Girls: 22.6%) (24). Current study reveals that a higher percentage of malnourished boys observed from the previous study on Midnapore (24) and slightly lower than children of 24 Pargana (26). A higher percentage of malnourished girls was seen than in the previous study done on Bangalkot and Midnapore (7,24). Several research reported sexual dimorphism in HC among preschool children, age and sex-specific mean HC were significantly (p<0.05) higher among boys than girls (18,25,31,32). The overall prevalence of undernutrition using the HC among girls (31.91 %) seems to be higher than that in the case of boys (27.6 %). The prevalence of undernutrition according to head Circumference was higher among girls than boys in the present study similar to previous studies (18,24-27). Fig 2 shows Head Circumference based undernutrition with previous studies.

Figure 2: Comparison of Head Circumference based undernutrition with previous studies.

Several studies have recommended that age and sex specific population-wise references be developed to assess the physical growth and nutritional status among preschool children by using HC as an indicator (33-39). Studies reported that gender differences in the prevalence of undernutrition were more pronounced in poor socio-economic groups and lower segments of the tribal populations with girls being more undernourished than boys (24,25,40). Age-specific prevalence of undernutrition is higher between 42-60 months similar to the previous study (7,24,25). In the present study the form of moderate malnutrition is higher than severe malnutrition, many other studies conducted by researchers (7,18,25) supported the same type of results. Head circumference is considered as most important anthropometric measurement during infancy and early childhood (41). Head circumference is a non-invasive and inexpensive anthropometric indicator of both nutritional background and brain development (42). It has been widely recognized as the most sensitive anthropometric index of prolonged undernutrition during infancy, associated with intellectual impairment and especially IQ (43). In the present study, we observed that the mean HC for girls is 46.78 cm (1.58) lower than the mean HC of boys 47.68 cm (1.63) similar study reported by other researchers (7, 18, 24-27).

Conclusion

The present study observed the prevalence of undernutrition found to be a persistent health problem among preschool children of Jalpaiguri. The frequency of moderate undernutrition was higher than severe undernutrition in the study. Girls were more affected by moderate and severe undernutrition compared to boys. Prevalence of undernutrition during preschool age is also a cause of impaired development of brain volume and size and a result of reducing cognitive and intellectual potentiality of future life. Head circumference is a non-invasive technique that may be utilized to assess nutritional conditions among pre-schoolers as a routine practice. Head Circumference is an indicator of brain development so initiative should be taken to improve the nutritional condition of rural preschool children. Therefore, regular monitoring of growth patterns and volume of head circumference during preschool age is essential to detect neurological undernourishment.

Acknowledgement

The researchers would like to thank all the concerned ICDS workers and also the parents of the subjects for their cooperation. We thank those children who participated in this research work. Special thanks to the CDPO of Maynaguri for his support. However, the authors assume full responsibility for all data and content presented. Arindam Biswas is a recipient of a Senior Research Fellowship (SRF-UGC-NET) by the Government of India.

References

1. UNICEF. The Progress of Nations. UNICEF, New York; 1994.
2. Bamji, MS. Early nutrition and health – Indian perspective. Current Science. 2003;l85:1137–114
3. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Head circumference for age, arm circumference for age, triceps skinfold for age and subscapular skinfold for age: Methods and development. Geneva: World Health Organization, 2007;1-237. Available at https://iris.who.int/bitstream/handle/10665/43706/9789241547185_eng.pdf
4. Plaza LB, Brito IN, Torrejón PH, et al. The impact of malnutrition on brain development, intelligence and school work performance. Arch Latinoam Nutr. 2001;51:64-71.
5. Ivanovic DM, Leiva BP, Pérez HT, et al. Head size and intelligence, learning, nutritional status and brain development. Head, IQ, learning, nutrition and brain. Neuropsychologia. 2004;42:1118-31
6. de Onís, M, Monteiro C, Akré J, et al. The worldwide magnitude of protein energy malnutrition, an overview from the WHO global database on child growth. Bulletin of WHO. 1993;71:703-712.
7. Sukanya BV, Baragundi MC, Surekharani CS, et al. Assessment of nutritional status of preschool children using head circumference. International Journal of Current Medical and Applied Sciences. 2014;4:72-75
8. Cornelio-Nieto JO, The effect of PEM on the central nervous system in children. Rev Neurol. 2007;44(2):S571-S574.
9. Singh S, Bisnoi I. Trend of growth in mid-arm circumference and head circumference of preschool female children of Faizabad District, U.P. Indian Journal of Preventive & Social Medicine. 2005;36(3 & 4):143-146.
10. Rumsey JM, Rapoport JL. Assessing behavioral and cognitive effects of diet in pediatric populations [Wurtman RJ, Wurtman JJ, editors]. New York, NY: Raven Press. 1983;101–161
11. Menkes JH, Baltimore. Textbook of Child Neurology, United Kingdom: Williams & Wilkins. 1995.
12. Stoch MB, Smythe PM, Moodie AD, et al. Psychosocial outcome and CT findings after gross undernourishment during infancy: a 20-year developmental study. Developmental Medicine and Child Neurology. 1982;24:419–436.
13. Winick M, Rosso P. Head circumference and cellular growth of the brain in normal and marasmic children. Journal of Pediatrics. 1969;774-778.
14. Gale CR, O’Callaghan FJ, Godfrey KM, et al. Critical periods of brain growth and cognitive function in children. Brain. 2004;127(2):321-329.
15. Lee KS, Cheong HK, Eom JS, et al. Cognitive decline is associated with nutritional risk in subjects with small head circumference (HC). Arch Gerontol Geriatr, 2010;51(1):105-109.
16. Talebian A, Soltani B, Moravveji A, et al. A study on causes and types of abnormal increase in infants’ head circumference in Kashan/Iran. Iran J Child Neurol. 2013;7(3):28-33.
17. Savage SA, Reilly JJ, Edwards CA, et al. Adequacy of standards for assessment of growth and nutritional status in infancy and early childhood. Archives of Disease in Childhood. 1999;80:121-124.
18. Mandal GC. & Bose K. Undernutrition among the rural preschool children (ICDS) of Arambag, Hooghly District, West Bengal, India, using new head circumference cut-off points. International Journal of Current Research. 2010;10:007-011
19. Tiwari K, Goyal S, Malvia S, et al. Impact of malnutrition on head size and development quotient. International Journal of Research in Medical Science. 2017;5(7):3003-3006
20. Purohit M, Purohit NN, Saxena SS. Physical Growth of Indian Infants from Birth to Six months. (A Longitudinal Study). Ind J of Pediatr. 1977;44:289- 90.
21. Bhandari A, Ghosh, BN. A longitudinal study on physical development of the children from birth to one year of age in an urban community. Ind J Pub Health. 1979;23:147–54.
22. Bhargava SK, Kumari S, Choudhury P, et al. A Longitudinal Study of Physical Growth from Birth to Six Years in Children with Birth Weight of 2501g or More. Ind Pediatr. 1980;17:495-502.
23. Bhalla AK, Walia, BNS. Longitudinal growth of head circumference in Punjabi infants in Chandigarh (India). Int J Anthropol. 1993;8:123-31.
24. Maiti S, Ali KM, Ghosh D, et al. Assessment of head circumference among pre-school children of Midnapore town, west Bengal using WHO (2007) recommended cut-off points. Int J Prev Med. 2012;3(10):742-744
25. Tigga PL, Mondal N, Sen J. Head circumference as an indicator of undernutrition among tribal preschool children aged 2-5 years of North Bengal, India. Hum Biol Rev. 2016;5(1):17-33.
26. Giri SP, Biswas S, Bose K. Head circumference based nutritional status of rural Bengalee preschool children from Sagar Island, West Bengal, India. Mankind Quarterly. 2018;58(4):599-610.
27. Sharma J, Mondal N, Assessment of Undernutrition using Head Circumference-for-Age among Karbi Preschool Children of Karbi Anglong, Assam, India. J Life Science. 2019; 11(1-2): 7-16 DOI: 10.31901/24566306.2019/11.1-2.238
28. Singh I, Grover K. Nutritional profile of urban pre-school children of Punjab. Anthropologist 2003;5(3):149-153.
29. Govt. of India. Census 2011. Available at https://censusindia.gov.in
30. Goodyear MDE, Krleza-Jeric K, Lumment T. The Declaration of Helsinki. BMJ. 2007;335:624-625.
31. Lohman, TG, Roche AF, Martorell R. Anthropometric Standardization Reference Manual, Human Kinetics Books, Chicago; 1988.
32. Oyedeji GA, Olamijulo SK, Osinaike AI, et al. Head circumference of rural Nigerian children-the effect of malnutrition on brain growth. Cent Afr J Med. 1997;43(9):264-268.
33. Zaki ME, Hassan NE, El-Masry SA. Head circumference reference data for Egyptian children and adolescents. East Mediterr Health J. 2008;14(1):69-81.
34. Júlíusson PB, Roelants M, Nordal E, et al. Growth references for 0-19 year-old Norwegian children for length/ height, weight, body mass index and head circumference. Ann Hum Biol. 2013;40(3):220-2
35. Rollins JD, Collins JS, Holden KR. United States head circumference growth reference charts: Birth to 21 years. J Padiatr. 2010;156(6):907-913
36. Elmali F, Altunay C, Mazicioglu MM, et al. Head circumference growth reference charts for Turkish children aged 0- 84 months. Pediatr Neurol. 2012;46(5):307-311.
37. Xie S, Shi J, Wang J, et al. Head circumference growth reference charts of children younger than 7 years in Chinese rural areas. Pediatr Neurol. 2014;51(6):814-819
38. Neyzi O, Bundak R, Gökçay G, et al. Reference values for weight, height, head circumference, and body mass index in Turkish children. J Clin Res Pediatr Endocrinol. 2015;7(4):280-293
39. Amare EB, Idsøe M, Wiksnes M, et al. Reference ranges for head circumference in Ethiopian children 0-2 years of age. World Neurosurg. 2015;84(6):1566-1571
40. Sen J, Mondal, N. Socio-economic and demographic factors affecting the Composite Index of Anthropometric Failure (CIAF). Ann Hum Biol. 2012;(39):129-36.
41. Hall JG, Allanson JE, Gripp KW, et al. Handbook of Physical Measurements. New York: Oxford University Press. 2007.
42. Vernon PA, Wickett JC, Bazana PG, et al. The neuropsychology and psychophysiology of human intelligence. In Sternberg RJ (Ed.), Handbook of intelligence. Cambridge: Cambridge University Press. 2000;245-264
43. Inzunza LB, Castro NPH, Jansana VJM, et al. Algunas consideraciones sobre el impacto de la desnutrición en el desarrollo cerebral, inteligencia y rendimiento escolar. Archivos Latinoamericanos de Nutrición. 2001;51:64-71.