SMALL FOR GESTATIONAL AGE

I. DEFINITION/ DESCRIPTION
II.

III.  

Small for gestational age (SGA) refers to an infant born with a birth weight less than the 10th centile.
Severe SGA refers to an infant born with a birth weight less than the 3rd centile. They fall into three
groups:

 Babies whose growth at all gestational ages has been low. They are SGA but otherwise healthy.
50-70% of SGA fetuses are constitutionally small, with fetal growth appropriate for maternal size
and ethnicity.
 Growth is normal in the early part of pregnancy but slows in utero by at least two
measurements (normally from ultrasound assessments). This is due to intrauterine growth
restriction (IUGR). The newborn baby has a wasted appearance with little subcutaneous fat and
a greater risk of complications.

Non-placenta mediated growth restriction - e.g., structural or chromosomal anomaly, inborn errors of
metabolism or fetal infection.

II. INCIDENCE
 Embleton (2015), estimated that in 2010 32.4 million babies were born SGA in low- and middle-
income countries, constituting 27% of all live births. The estimated prevalence of SGA is highest
in South Asia and in Sahelian countries of Africa. India has the world's largest number of SGA
births, 12.8 million in 2010, due to the large number of births and the high proportion, 46.9%, of
births that are SGA. The prevalence of SGA births is approximately double the prevalence of low-
birthweight births (using the common indicator of <2,500 g birthweight) globally and in the
world's regions.
III. RISK FACTOS
 Minor risk factors
o Maternal age ≥35 years.
o IVF singleton pregnancy.
o INulliparity.
o BMI <20.
o BMI 25-34.9.
o Smoker - 1-10 cigarettes per day.
o Low fruit intake pre-pregnancy.
o Pregnancy interval <6 months.
 o Pregnancy interval ≥60 months.
 Major risk factors
o Maternal age >40 years.
o Smoker - ≥11 cigarettes per day.
o Paternal or maternal SGA.
o Cocaine use.
o Daily vigorous exercise.
o Previous SGA baby.
o Previous stillbirth.
o Chronic hypertension.
o Diabetes with vascular disease.
o Renal impairment.
o Antiphospholipid syndrome.
o Heavy bleeding similar to menses.
o Pregnancy associated plasm protein-A (PAPP-A) <0.4 multiples of the median (MOM).

Fetal echogenic bowel has been shown to be independently associated with an SGA neonate and fetal
demise.

IV. MANIFESTATIONS
 Despite their size, SGA infants have physical characteristics (e.g., skin appearance, ear cartilage,
sole creases) and behavior (e.g., alertness, spontaneous activity, zest for feeding) similar to
those of normal-sized infants of like gestational age. However, they may appear thin with
decreased muscle mass and subcutaneous fat tissue. Facial features may appear sunken,
resembling those of an elderly person ("wizened facies"). The umbilical cord can appear thin and
small.

Complications
 Full-term SGA infants do not have the complications related to organ system immaturity that
premature infants of similar size have. They are, however, at risk of
o Perinatal asphyxia
o Meconium aspiration
o Hypoglycemia
o Polycythemia
o Hypothermia

Perinatal asphyxia during labor is the most serious potential complication. It is a risk if intrauterine
growth restriction is caused by placental insufficiency (with marginally adequate placental perfusion)
because each uterine contraction slows or stops maternal placental perfusion by compressing the spiral
arteries. Therefore, when placental insufficiency is suspected, the fetus should be assessed before labor
and the fetal heart rate should be monitored during labor. If fetal compromise is detected, rapid
delivery, often by cesarean delivery, is indicated.
Meconium aspiration may occur during perinatal asphyxia. SGA infants, especially those who are post
mature, may pass meconium into the amniotic sac and begin deep gasping movements. The consequent
aspiration is likely to result in meconium aspiration syndrome. Meconium aspiration syndrome is often
most severe in growth-restricted or post mature infants, because the meconium is contained in a
smaller volume of amniotic fluid and thus more concentrated.

Hypoglycemia often occurs in the early hours and days of life because of a lack of adequate glycogen
synthesis and thus decreased glycogen stores and must be treated quickly with IV glucose.

Polycythemia may occur when SGA fetuses experience chronic mild hypoxia caused by placental
insufficiency. Erythropoietin release is increased, leading to an increased rate of erythrocyte production.
The neonate with polycythemia at birth appears ruddy and may be tachypneic or lethargic.

Hypothermia may occur because of impaired thermoregulation, which involves multiple factors

including increased heat loss due to the decrease in subcutaneous fat, decreased heat production due to
intrauterine stress and depletion of nutrient stores, and increased surface to volume ratio due to small
size. SGA infants should be in a thermoneutral environment to minimize oxygen consumption .

V. MANGEMENT
 LAB EXAM/ DIAGNOSTIC PROCEDURE
o Abdominal palpation has limited accuracy for the prediction of an SGA
neonate and thus should not be routinely performed in this context.
o Serial measurement of symphysis fundal height (SFH) is recommended at
each antenatal appointment from 24 weeks of pregnancy as this improves
prediction of an SGA neonate.
o SFH should be plotted on a customized chart rather than a population-based
chart as this may improve prediction of an SGA neonate.
o Women with a single SFH which plots below the 10th centile or with serial
measurements which demonstrate slow or static growth by crossing centiles
should be referred for ultrasound measurement of fetal size.
o Women in whom measurement of SFH is inaccurate (for example, BMI >35,
large fibroids, hydramnios) should be referred for serial assessment of fetal
size, using ultrasound.

 TREATMENT/PHARMACOLOGIC MANAGEMENT

o A review found that effective interventions are available for reducing the
occurrence of SGA fetuses and preventing related perinatal mortality. Some
interventions are effective in all women, while others target specific
comorbidities.
o The most effective interventions to prevent the SGA fetus were antiplatelet
agents like aspirin before 16 weeks in women at risk of pre-eclampsia, and
progesterone therapy for prevention of preterm birth.
o For the prevention of perinatal mortality in high-risk women, antiplatelet
and antenatal corticosteroids were found to be effective interventions.
 Antenatal
 o Women who have a major risk factor should be referred for serial ultrasound
measurement of fetal size and for assessment of well-being with umbilical artery
Doppler from 26-28 weeks of pregnancy.
o Women who have three or more minor risk factors should be referred for uterine artery
Doppler at 20-24 weeks of gestation.
o In high-risk populations, uterine artery Doppler at 20-24 weeks of pregnancy has a
moderate predictive value for a severely SGA neonate.
o In women with an abnormal uterine artery Doppler at 20-24 weeks of pregnancy,
subsequent normalization of flow velocity indices is still associated with an increased
risk of an SGA neonate. Therefore, repeating uterine artery Doppler is of limited value.
o Women with an abnormal uterine artery Doppler at 20-24 weeks (pulsatility index >95th
centile) and/or notching should be referred for serial ultrasound measurement of fetal
size and for assessment of well-being with umbilical artery Doppler commencing at 26-
28 weeks of pregnancy.
o Women with a normal uterine artery Doppler do not require serial measurement of
fetal size and serial assessment of well-being with umbilical artery Doppler unless they
develop specific pregnancy complications - e.g., antepartum hemorrhage or
hypertension. However, they should be offered a scan for fetal size and umbilical artery
Doppler during the third trimester.
o Serial ultrasound measurement of fetal size and assessment of well-being with umbilical
artery Doppler should be offered in cases of fetal echogenic bowel.
 Investigations that are indicated in SGA fetuses
o Offer referral for a detailed fetal anatomical survey and uterine artery Doppler by a fetal
medicine specialist if severe SGA is identified at the 18- to 20-week scan.
o Karyotyping should be offered in severely SGA fetuses with structural anomalies and in
those detected before 23 weeks of gestation, especially if uterine artery Doppler is
normal.
o Serological screening for congenital cytomegalovirus (CMV) and toxoplasmosis infection
should be offered in severely SGA fetuses.
o Testing for syphilis and malaria should be considered in high-risk populations.
o Uterine artery Doppler has limited accuracy to predict adverse outcome in SGA fetuses
diagnosed during the third trimester.
 Interventions to be considered in the preterm SGA fetus
o Women with an SGA fetus between 24+0 and 35+6 weeks of gestation, where delivery is
being considered, should receive a single course of antenatal corticosteroids.
o Optimal method and frequency of fetal surveillance in SGA
o In a high-risk population, the use of umbilical artery Doppler has been shown to reduce
perinatal morbidity and mortality. Umbilical artery Doppler should be the primary
surveillance tool in the SGA fetus.
o When umbilical artery Doppler flow indices are normal it is reasonable to repeat
surveillance every 14 days. More frequent Doppler surveillance may be appropriate in a
severely SGA fetus.
o When umbilical artery Doppler flow indices are abnormal (pulsatility or resistance index
>+2 standard deviations above the mean for gestational age) and delivery is not
 indicated, repeat surveillance twice each week in fetuses with end-diastolic velocities
present and daily in fetuses with absent/reversed end-diastolic frequencies.
o Cardiotocography (CTG) should not be used as the only form of surveillance in SGA
fetuses.
o Interpretation of the CTG should be based on short-term fetal heart rate variation from
computerized analysis.
o Ultrasound assessment of amniotic fluid volume should not be used as the only form of
surveillance in SGA fetuses.
o Interpretation of amniotic fluid volume should be based on the single deepest vertical
pocket.
o Biophysical profile should not be used for fetal surveillance in preterm SGA fetuses.
o In the preterm SGA fetus, middle cerebral artery (MCA) Doppler has limited accuracy to
predict acidaemia and adverse outcome and should not be used to time delivery.
o In the term SGA fetus with normal umbilical artery Doppler, an abnormal MCA Doppler
(pulsatility index <5th centile) has moderate predictive value for acidosis at birth and
should be used to time delivery.
o Ductus venosus Doppler has moderate predictive value for acidaemia and adverse
outcome.
o Ductus venosus Doppler should be used for surveillance in the preterm SGA fetus with
abnormal umbilical artery Doppler and used to time delivery.

 NURSING RESPONSIBLITIES
1. Provide adequate fluid and electrolytes and nutrition.
o Provide a high calorie formula for feeding (more than 20 calories per ounce) to promote
steady weight gain (15 to 30 grams per day growth plotted on curves shows a normal
growth rate).
o If the infant is breast feeding, add human milk fortifier to expressed breast milk.
2. Decrease metabolic demands when possible.
o Provide small frequent feedings.
o Provide gavage feedings if the infant does not have a steady weight gain.
o Provide a neutral thermal environment.
o Decrease iatrogenic stimuli.
3. Prevent hypoglycemia
o Monitor glucose screening.
o Provide early feedings.
o Provide frequent feedings (every 2 to 3 hours)
o Administer IV glucose if blood sugar does not normalize with oral feedings.
4. Maintain a neutral thermal environment.
5. Monitor serum hematocrit (normal is 45% to 65%).
o If an initial high hematocrit was obtained by heel stick capillary sample, a follow-up
sample should be done by venipuncture.
o Observe for signs, symptoms, and complications of polycythemia
  Ruddy appearance
 Cyanosis
 Lethargy, jitteriness, and seizures
 Jaundice
o Provide adequate hydration to prevent hyperviscosity
6. Assess the prenatal history for possible toxoplasmosis, rubella, cytomegalovirus, and herpes
simplex infections during pregnancy. Assess maternal and infant antibody titers. Use isolation
precautions when congenital infections are suspected.
7. Provide education and emotional support.
o Explain the possible causes of intrauterine growth retardation.
o Inform parents of the infant’s goal weight for discharge.
o Provide instruction on managing the infant at home.
 Explain how to prepare a higher calorie formula or breast feeding.
 Explain the importance of follow-up with a developmental specialist who will
screen for milestone achievements.

REFERENCES:

RNpedia(n.d.). retrieved from https://www.rnpedia.com/nursing-notes/maternal-and-child-

nursing-notes/small-gestational-age-newborn-sga/ on February 4, 2020

Embleton, N.D., et. Al,(2015). Low-Birthweight Baby: Born Too Soon or Too Small. Retrieved

from https://www.karger.com/Article/Abstract/365790 on February 4, 2020

Tidy, C.(2016). Small for Gestational Age Babies. Retrieved from

https://patient.info/doctor/small-for-gestational-age-babies on February 4, 2020

Stavis, R.L.(2019). Small-for-Gestational-Age (SGA) Infant. Retrieved from

https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/small-for-

gestational-age-sga-infant on February 4, 2020

 Large for Gestational Age

I. DEFINITION/ DESCRIPTION
 LGA newborn is one weighs more than 4,000 g, is above the 90th percentile, or is two standard
deviations above the mean.
 The LGA infant can be pre-term, term, or post-term.

II. INCIDENCE
 For U.S. Births in 2015, approximately 7% of infants had birth weight >4,000g, 1% had birth
weight greater than 4,500g, and 0.1% had birth weight greater than 5,000g. 
 Race
o Macrosomia occurs with higher frequency in newborns of Hispanic origin. Because
Hispanic women have a higher incidence of diabetes during pregnancy, part of the
preponderance of macrosomia in this ethnic group is due to the higher incidence of
diabetes in pregnancy. However, even when corrected for diabetes, Hispanic mothers
tend to have larger newborns.
 Sex
o Male infants are more likely to be macrosomic than female infants. Male infants are
generally approximately 150 - 200 g larger than female infants of the same gestational
age near term.

III. RISK FACTORS

 If a baby is too large to fit through the birth canal easily, birth can be difficult. Problems at birth
may include:
o Long time for delivery
o Difficult birth
o Injury to the baby, such as a broken collar bone or damaged nerves in the arm (brachial
plexus)
o Increased need for a cesarean section delivery
 Many large babies are born to mothers with diabetes. Poor control of blood sugar may cause
problems such as:
o Low blood sugar in the baby in the first several hours after birth
o A higher risk for birth defects
o Trouble breathing
  Babies who are large for gestational age may also be more likely to have yellowing of the skin,
eyes, and mucous membranes (jaundice).
IV. MANIFESTATION
 GA infants are large, obese, and plethoric. The 5-minute Apgar score may be low. These infants
may be listless and limp and feed poorly. Delivery complications can occur in any LGA infant.
Congenital anomalies and some metabolic and cardiac complications are specific to LGA infants
of diabetic mothers.
 Delivery complications:
o Because of the infant’s large size, vaginal delivery may be difficult and occasionally
results in birth injury, particularly including
o Shoulder dystocia
o Fracture of the clavicle or limbs
o Perinatal asphyxia
 Other complications occur when weight is > 4000 g. There is a proportional increase in morbidity
and mortality due to the following:
o Respiratory distress (and need for ventilator assistance)
o Meconium aspiration
o Hypoglycemia
o Polycythemia
 Infants of diabetic mothers (IDMs):
 IDMs are at risk of
o Hypoglycemia
o Hypocalcemia and hypomagnesaemia
o Polycythemia
o Hyperbilirubinemia
o Respiratory distress syndrome
o Certain congenital anomalies

Hypoglycemia is very likely in the first few hours after delivery because of the state of hyperinsulinism
and the sudden termination of maternal glucose when the umbilical cord is cut. Neonatal hypoglycemia
can be decreased by close prenatal control of the mother’s diabetes and early frequent feedings. Blood
glucose levels should be closely monitored by bedside testing from birth through the first 24 hours. Oral
treatment with 40% glucose gel may be tried first, but if there is persistent hypoglycemia, parenteral IV
glucose is given.

Hypocalcemia and hypomagnesemia may occur but are usually transient and asymptomatic. Good

prenatal glycemic control decreases the risk of neonatal hypocalcemia. Hypocalcemia typically does not
require treatment unless there are clinical signs of hypocalcemia or levels < 7 mg/dL in term infants.
Treatment is usually given with IV supplementation of calcium gluconate. Hypomagnesemia can
interfere with the secretion of parathyroid hormone, so hypocalcemia may not respond to treatment
until the magnesium level is corrected.

Polycythemia is slightly more common among infants of diabetic mothers. Elevated insulin levels
increase fetal metabolism and thus oxygen consumption. If the placenta is unable to meet the increased
oxygen demand, fetal hypoxemia occurs, triggering an increase in erythropoietin and thus hematocrit.
Hyperbilirubinemia occurs for several reasons. IDMs often have decreased tolerance for oral feedings
(particularly when they are preterm) in the earliest days of life, which increases the enterohepatic
circulation of bilirubin. Also, if polycythemia is present, the bilirubin load increases.

Respiratory distress syndrome (RDS) may occur because elevated insulin levels decrease surfactant
production; pulmonary maturation may thus be delayed until late in gestation. RDS may develop even if
the infant is delivered late preterm or term. Treatment of respiratory distress syndrome is discussed
elsewhere.

Transient tachypnea of the newborn is 2 to 3 times more likely in IDMs because of the delay in fetal
lung fluid clearance.

Congenital anomalies are more likely in IDMs because maternal hyperglycemia at the time of
organogenesis is detrimental. Specific anomalies include

o Congenital heart disease (hypertrophic cardiomyopathy, ventricular septal defect, transposition

of the great arteries, and aortic stenosis)
o Caudal regression syndrome
o Spina bifida
o Small left colon syndrome

Persistently elevated insulin levels can also lead to increased deposition of glycogen and fat into
cardiomyocytes. This deposition can cause transient hypertrophic cardiomyopathy, predominantly of
the septum.

V. MANAGEMENT
 LAB EXAM/ DIAGNOSTIC PROCEDURE

 Babies with this problem are often diagnosed before birth. During pregnancy, a baby’s size can
be estimated in different ways. The height of the top of a mother’s uterus can be measured
from the pubic bone. This measurement in centimeters usually links with the number of weeks
of pregnancy after the 20th week. If this measurement is high for the number of weeks, the
baby may be larger than expected. Before the baby is born, healthcare providers use the term
fetal macrosomia instead of LGA.
 Other ways to check the baby’s growth before birth include:
o Ultrasound.This test uses sound waves to create a picture of your baby and the inside of
your body. It is a more accurate method of estimating the size of your baby, but it's still
not exact. Measurements can be taken of your baby’s head, belly (abdomen), and upper
leg bone to see how fast he or she is growing.
o Weight gain during pregnancy. This can also affect your baby's size. Gaining a lot of
weight during pregnancy may cause your baby to be bigger than normal.
 Babies are weighed within the first few hours after birth. The weight is compared with the
baby's gestational age and recorded in the medical record.
  TREATMENT/ PHARMACOLOGIC MANAGEMENT

 Treatment will depend on your child’s symptoms, age, and general health.
 If ultrasound exams during pregnancy show that the baby is very large, the healthcare provider
may recommend early delivery. The mother may need a planned cesarean section.
 After birth, a baby who is large for gestational age will be carefully checked for any injuries that
happened during birth. The baby may have blood glucose testing for at least the first 12 hours to
check for low blood sugar. 

 NURSING RESPONSIBILITIES
1. If IDM, observe for potential complications 
2.  Monitor for, and manage, birth injuries and complications of birth injuries.
a. Clavicle fracture
 Confirm by x-ray.
 Assess the infant for crepitus, hematoma, or deformity over the clavicle;
decreased movement of arm on the affected side; and asymmetrical or absent.
Moro reflex.
 Limit arm motion by pinning the infant’s sleeve to the shirt.
 Manage the pain
b. Facial nerve injury
 Assess for symmetry of mouth while crying.
 Wrinkles are deeper on the unaffected side.
 The paralyzed side is smooth with a swollen appearance.
 The nasiolabial fold is absent.
 If the eye is affected, protect it with patches and artificial tears.
c. Erb-Duchenne palsy and Klumpke paralysis
 Erb-Duchenne palsy. Assess for adduction of the affected arm with internal
rotation and elbow extension. The Moro reflex is absent on the affected side.
The grasp reflex is intact.
 Klumpke paralysis. Assess for absent grasp on the affected side. The hand
appears claw-shaped.
 Management includes:
o X-ray studies of the shoulder and upper arm to rule out bony injury
o Examination of the chest to rule out phrenic nerve injury
o Delay of passive movement to maintain range of motion of the affected
joints until the nerve edema resolves (7 to 10 days)
o Splints may be useful to prevent wrist and digit contractures on the
affected side
d. Phrenic nerve palsy
 Assess for respiratory distress with diminished breath sounds.
 X-ray usually shows elevation of the diaphragm on the affected side.
  Provide pulmonary toilet to avoid pneumonia during the recovery phase (1 to 3
months).
e. Skull fracture
 Assess for soft-tissue swelling over fracture site, visible indentation in scalp,
cephalhematoma, positive skull x-ray, and CNS signs with intracranial
hemorrhage (e.g., lethargy,seizures, apnea, and hypotonia).

REFERENCES:

Stanford Children’s Health (n.d.). Large for gestational age. Retrieved from
https://www.stanfordchildrens.org/en/topic/default?id=large-for-gestational-age-90-P02383
on February 4, 2020

RNpedia(n.d.). Retrieved from https://www.rnpedia.com/nursing-notes/maternal-and-child-

nursing-notes/large-gestational-age-lga-newborn/ on February 4, 2020

Stavis, R.L.(2019). Large for Geastational age. Retrieved from

https://www.msdmanuals.com/professional/pediatrics/perinatal-problems/large-for-
gestational-age-lga-infant on February 4, 2020