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Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Author
George T Mandy, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD
Small for gestational age infant
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2014. | This topic last updated: Apr 24, 2014.
INTRODUCTION Fetal growth restriction (FGR, also called intrauterine growth restriction [IUGR]) is the term
used to designate a fetus that has not reached its growth potential because of genetic or environmental factors.
FGR results in the birth of an infant who is small for gestational age (SGA). Mortality and morbidity are increased in
SGA infants compared with those who are appropriate for gestational age (AGA). (See "Fetal growth restriction:
Causes and risk factors".)
DEFINITION The most common definition of small gestational age (SGA) refers to a weight below the 10
percentile for gestational age (table 1) [1]. However, this definition does not make a distinction among infants who
are constitutionally small, growth-restricted and small, and not small but growth-restricted relative to their potential.
As an example, as many as 70 percent of fetuses who weigh below the 10 percentile for gestational age are small
simply because of constitutional factors such as female sex or maternal ethnicity, parity, or body mass index; they
are not at high risk of perinatal mortality or morbidity [1].
Moderate and severe fetal growth restrictions (FGR) are defined as birth weight in the 3 to 10 percentile and less
than 3 percentile, respectively. Normal term infants typically weigh more than 2500 g by 37 weeks gestation [2].
Ponderal index Ponderal index (PI) is a ratio of body weight to length expressed as [3]:
PI = [weight (in g) x 100] [length (in cm)]
With normal growth, the PI increases gradually from 30 to 37 weeks gestation and then remains constant.
Decreased growth of adipose tissue and skeletal muscle, the major contributors to body weight, results in a
reduced PI. Reductions in PI or other indices, such as the ratio of mid-arm to occipito-frontal circumference, can
identify growth restriction in newborns whose weight is greater than the 10 percentile [3]. PI of less than 10
percentile reflects fetal malnutrition; PI of less than 3 percentile indicates severe wasting [4].
GROWTH CURVES Anthropometric data from infants born at different gestational ages have been used to
generate cross-sectional growth curves [1,5-7]. These curves are not uniform and may vary by 100 to 200 g at any
gestational age. The following factors may contribute to these variations:
In general, a customized optimal growth curve developed for a specific fetus, which accounts for individual
differences (ie, maternal age and ethnicity), improves the detection of fetal growth restriction (FGR) [8-10]. In one
report, the use of customized growth curves in a cohort of 13,661 singleton deliveries improved the ability to detect
FGR and improved the ability to predict adverse neonatal outcome [8]. Ideally, separate growth curves should be
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Differences in maternal characteristics, including age, parity, race, ethnic background, socioeconomic status,
and body habitus.
Viruses and parasites (eg, rubella, toxoplasmosis, cytomegalovirus, varicella-zoster, malaria) that gain
access to the fetus transplacentally or across the intact fetal membranes.
Maternal substance abuse, including cigarette smoking, alcohol consumption, and illicit drug use.
Toxic exposures, including various medications such as warfarin, anticonvulsants, antineoplastic agents, and
folic acid antagonists.
High altitude.
Demographic variables including race, pregnancy at the extremes of reproductive life, maternal age at first
childbirth, nulliparity or grand multiparity, and previous delivery of a SGA newborn.
Karyotypic abnormalities, such as trisomies, autosomal deletions, ring chromosomes, uniparental disomy,
and confined placental mosaicism. The presence of a chromosomal abnormality often results in the
appearance of FGR early in pregnancy, most likely of the symmetric type.
Genetic syndromes, such as Bloom syndrome, dwarfism, and Russell-Silver syndrome. (See "Bloom
syndrome".)
Major congenital anomalies. In one study reviewing data from the National Birth Defects Prevention Study,
infants with congenital heart disease, in particular conotruncal and septal defects, were twice as likely to be
small for gestational age compared with those without a birth defect (15.2 versus 7.8 percent) [26].
Multiple gestation is related to fetal growth abnormalities in direct relationship to the number of fetuses
present. (See "Neonatal outcome, complications, and management of multiple births", section on 'Fetal
growth'.)
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<10 percentile 26 percent
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10 to 24 percentile 20 percent
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25 to 49 percentile 15 percent
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50 to 74 percentile 13 percent
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75 to 89 percentile 12 percent
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>90 percentile 16 percent
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Perinatal mortality increases as growth restriction becomes more severe, rising abruptly when birth
weight is below the 6 percentile (figure 1) [43]. Congenital malformations, perinatal asphyxia, and
transitional cardiorespiratory disorders contribute to the high mortality rate in term infants. Complications
of prematurity play a greater role as gestational age decreases [41].
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In the French EPIPAGE study that prospectively followed premature live births born in 1997, 536 of the 2846
infants born alive were SGA [44]. Mortality increased with decreasing gestational age and birth percentiles as
follows:
Among the infants born between 24 and 28 week gestation, the mortality was 30, 42, and 62 percent for
infants born AGA (birth weight >20 percentile), mild SGA (birth weight between the 10 and 19
percentile), and SGA (birth weight <10 percentile), respectively.
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Among the infants born between 29 and 32 weeks gestation, the mortality was 4.8, 4.2, and 10.5
percent for infants born AGA, mild SGA, and SGA, respectively.
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In another report, adolescents born SGA (3 percentile) at term were more likely to have learning difficulties
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Premature infants Cognitive and neurodevelopmental abnormalities are more common in survivors who were
growth restricted premature infants compared with those who were AGA and born at the same gestational age.
In comparison with AGA controls, children who were premature and growth restricted are more likely to have:
Other factors
Relationship to chronic disorders
(32 versus 18 percent) compared with those born AGA, although cognitive ability was not affected [51].
Learning difficulties were related to the severity of growth restriction, but not symmetry. Attentional problems
were more frequent in the SGA girls, but not boys.
In a population-based cohort study of young adult Swedish males evaluated at the time of military
conscription, multiple logistic regression analysis demonstrated low intellectual performance scores were
associated with birth weight <2 standard deviations (SDS) below the mean (OR 1.22, 95% CI 1.13-1.33), birth
length <2 SDS below the mean (OR 1.33, 95% CI 1.22-1.46), and birth head circumference <2 SDS below the
mean (OR 1.28, 95% 1.20-1.37) [52].
In a registry-based cohort Norwegian study of 36,604 term SGA singleton births, 104 patients died in the
neonatal period and 69 developed cerebral palsy [53]. Retrospective review of cases suggested that cerebral
palsy was due to an antenatal cause in about 90 percent of affected SGA children.
In a study of young adults born at term, IQ scores on the Wechsler Adult Intelligence Scale 3 edition were
lower in individuals who were born SGA compared with those who were born AGA (mean difference -6.3, 95%
CI -2.8 to -9.7) [54].
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Lower scores on cognitive testing [29,41,44,55]
School difficulties or require special education [41,44]
Gross motor and minor neurologic dysfunction [29,41]
Behavioral problems (attention deficit hyperactivity syndrome) [44]
Growth failure [29]
Perinatal factors Other perinatal factors that may affect neurodevelopmental outcome were evaluated in a
cohort of 282 SGA infants (mean gestational age and birth weight 36.5 weeks and 2095 g, respectively) born
in the mid 1990s in New Zealand and examined at 18 months of age [56]. The proportion of SGA infants with
low Mental Developmental Index (MDI) scores of the Bayley Scales of Infant Development was significantly
less when mothers had pregnancy-induced hypertension compared with normal blood pressure in pregnancy
(23 versus 44 percent). Although hypertension may be protective, a more likely explanation is that other
causes of SGA are associated with a greater risk of poor outcome. Factors associated with low Psychomotor
Development Index (PDI) scores were not being breastfed at three months, long hospital stay, and need for
mechanical ventilation. A low Behavioral Rating Scale (BRS) score was associated with small head
circumference at birth and increased arterial base deficit in cord blood. No relationship was found between
maternal demographic factors, including age, ethnicity, parity, smoking, education, or severe deprivation, and
abnormal MDI, PDI, or BRS scores.
Postnatal growth Excessive or poor postnatal weight gain during the first four months of life appears to have
a negative impact on neurodevelopmental outcome. This was illustrated in a study from the Collaborative
Perinatal Project (CPP) that evaluated the cognitive outcome of 463 children who were SGA at birth at seven
years of age using the Wechsler Scale of Children's Intelligence (WISC) [57]. Children who gained less than
1200 g or more than 5000 g during the first four months of life had lower WISC scores than children with
weight gains between these two extremes. In addition, body mass index at seven years of age correlated with
postnatal weight gain.
The most common definition of SGA is a birth weight that is below the 10 percentile for gestational age
(table 1). (See 'Definition' above.)
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Mortality and morbidity are increased in SGA infants when compared with infants who have appropriate birth
weights (birth weight 10 percentile) for gestational age (AGA).
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Infants who are SGA typically appear thin with loose, peeling skin, and decreased skeletal muscle mass and
subcutaneous fat tissue. The face generally has a shrunken or "wizened" appearance, and the umbilical cord
often is thin (picture 1).
Complications associated with SGA during the neonatal period include prematurity, poor thermoregulation,
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hypoglycemia, polycythemia resulting in hyperviscosity, and impaired immune function. (See 'Complications'
above.)
Population-based data demonstrate a 20- to 30-fold increase in mortality between term infants born AGA
compared with those born SGA with birth weights of 1500 to 2500 g, and rises to 70- to 100-fold increase with
birth weights below 1500 g. The mortality rate also increases with decreasing gestation.
Long-term complications of patients who were born SGA include impaired growth and neurodevelopment. In
addition, individuals who were SGA infants may be predisposed to cardiovascular disease, hypertension, and
chronic kidney disease. (See 'Outcomes' above.)