A newborn who weighs less than 90% of newborns of the same gestational age at birth (below the 10th percentile) is considered small for gestational age.
Newborns may be small because of genetic disorders, their parents are small, the placenta did not function normally, or the mother has a medical disorder, has taken certain medications, has substance use disorder, or used tobacco or alcohol during the pregnancy.
Many small-for-gestational-age newborns have no symptoms and do well.
Depending on the cause of growth restriction (when a fetus does not grow as expected), development of the brain and other vital organs may be affected, resulting in long-standing and perhaps life-long problems.
Some small newborns remain small as adults.
Gestational age refers to the number of weeks of pregnancy. The gestational age is determined by counting the number of weeks between the first day of the mother's last menstrual period and the day of delivery. This time frame is often adjusted according to other information doctors receive, including the results of early ultrasound scans, which give additional information regarding the gestational age. A baby is estimated to be due (the due date) at 40 weeks of gestation.
(See also Overview of General Problems in Newborns.)
Causes of SGA Newborns
Most newborns who are moderately small for gestational age are healthy babies who just happen to be on the smaller side. However, some are small because their growth in the womb was restricted by various factors. Growth restriction is when a baby in the womb (a fetus) does not grow as expected.
Growth restriction can be classified as
Symmetric: The newborn is proportionately small, that is, its weight, length, and head size are similarly low or small.
Asymmetric: Weight, length, or head size are not equally affected (for example, head size may continue to grow as expected, but weight or length may be lower than expected).
Symmetric growth restriction is usually caused by a problem with the fetus that begins early in the pregnancy, often during the first trimester. When a problem with the fetus begins early in a pregnancy, it affects the baby's whole body.
Asymmetric growth restriction is usually caused by a problem with the placenta or with the mother that occurs in the late second or the third trimester of the pregnancy. When a problem begins later in a pregnancy, it does not affect the baby's body equally because some tissues develop sooner than others.
Not all infants whose growth was restricted in the womb are small for gestational age.
Risk factors for growth restriction include those involving the mother's underlying health and those involving the pregnancy, the fetus, or a combination.
Maternal risk factors
The risk of having a small-for-gestational-age (SGA) baby is increased for mothers who are adolescents or over 35 years of age or who have had other babies who were SGA.
Medical disorders in the mother that increase the risk of having an SGA baby include
High blood pressure (hypertension)
Long-standing diabetes
Heart disease or lung disease
Severe anemia
Abnormalities of the uterus, for example, a uterus that has 2 parts (bicornuate uterus)
Severe malnutrition
Medical disorders in the mother during the pregnancy that increase the risk of having an SGA baby include
Having more than one fetus, for example, twins or triplets (Twins grow at the same rate as single fetuses until about 32 weeks. After that, twins grow more slowly and may be SGA at birth. For triplets, slower growth begins at about 28 weeks.)
Use of assisted reproduction to conceive the pregnancy
Early separation of the placenta (placental abruption)
Use of alcohol or tobacco or of certain illicit drugs such as amphetamines, cocaine, or opioids
Use of antiseizure medications or certain cancer medications
Fetal risk factors
Genetic disorders that may include birth defects of the brain, heart, or kidneys
Certain infections in the fetus, including Zika virus, cytomegalovirus (CMV), or rubella (German measles)
Symptoms of SGA Newborns
Despite their size, small-for-gestational-age (SGA) newborns may look and act similar to newborns of similar gestational age who are typical in size.
Some SGA newborns appear thin and have less muscle mass and fat, and some have sunken facial features. The umbilical cord can appear thin and small.
Immediate complications
During pregnancy, growth-restricted fetuses are at increased risk of miscarriage or stillbirth.
At birth, SGA newborns who are born full term do not have the complications related to organ system immaturity that preterm newborns of similar size have. They are, however, at increased risk of the following problems:
Birth asphyxia: This complication is a decrease in blood flow to the baby's tissues or a decrease in oxygen in the baby's blood before, during, or just after delivery. It may result from a problem with the placenta before or during delivery.
Meconium aspiration: Growth-restricted fetuses may pass meconium (dark green fecal material that is produced in the fetus's intestine before birth) in the amniotic fluid and take forceful gasps and breathe (aspirate) the meconium-containing amniotic fluid into their lungs.
Low blood sugar (glucose) levels (hypoglycemia): This complication often occurs in the early hours and days of life because the small newborn does not have enough stored carbohydrates to use for energy and is unable to adequately process the carbohydrates it does have.
Excess red blood cells (polycythemia): SGA newborns may have a higher blood count than usual, and too many red blood cells cause the blood to become too thick, which may slow blood flow. Newborns with polycythemia have a reddish complexion and are sluggish. Polycythemia also can contribute to hypoglycemia, respiratory distress, and hyperbilirubinemia (causing jaundice, in which the skin and whites of the eyes turn yellow).
Difficulty regulating body temperature: This complication occurs because SGA newborns have less fat and body weight to keep them warm and they do not have enough carbohydrates to use for energy.
Increased risk of infection: SGA newborns may have an impaired immune system, which increases their risk of developing infections in the hospital.
Long-term complications
Infants who had asphyxia at birth may have an increased likelihood of problems during adulthood, including heart disease, high blood pressure, and stroke.
Diagnosis of SGA Newborns
Before birth, measurement of the uterus and ultrasound
After birth, assessment of gestational age and size and weight of the baby
During pregnancy, doctors measure the distance on a woman's abdomen from the top of the pubic bone to the top of the uterus (fundus). This measurement, called a fundal height measurement, corresponds roughly with the number of weeks of pregnancy. For example, the normal fundal height for a woman who is 32 weeks pregnant is about 30 to 34 centimeters. If the measurement is low for the number of weeks, the fetus may be smaller than expected.
Ultrasound can be done to assess the size of the fetus and estimate the weight of the fetus to confirm the diagnosis of small for gestational age. ultrasound may also be helpful in establishing the cause of the growth restriction and how it has affected the fetus. Depending on the findings, doctors may do genetic testing or magnetic resonance imaging (MRI) to determine the underlying cause.
After birth, small for gestational age is diagnosed by assessing the gestational age and weight of the newborn. Doctors measure the newborn's length and head circumference to categorize the growth restriction as symmetric or asymmetric. Diagnostic tests, including ultrasounds, x-rays, MRIs, tests for infection, blood tests, and genetic tests, may be needed to find the cause of the growth restriction.
Treatment of SGA Newborns
Treatment of underlying causes and complications
There is no specific treatment for small-for-gestational-age newborns, but underlying conditions and complications are treated as needed. Growth hormone injections are sometimes given to certain SGA infants who remain quite small at 2 to 4 years of age. This treatment is given for several years and is considered on a case-by-case basis.
Depending on the amount of red blood cells and the presence of symptoms, newborns with polycythemia may be given intravenous (IV) fluids. Newborns with hypoglycemia are treated with early (within 1 hour after birth) and frequent feedings or IV glucose.
All pregnant people should receive good prenatal care and should avoid alcohol, tobacco, and illicit drugs (such as cocaine and heroin) while pregnant.
Prognosis for SGA Newborns
Prognosis varies greatly depending on what caused the infant to be small for gestational age and whether complications developed.
Infants who have a moderately low birthweight usually do well unless they have an infection, genetic disorder, or birth asphyxia. Most catch up their growth during the first year of life and have a typical adult height.
Infants who are particularly small because of illness in the mother are at higher risk of complications. Some small babies remain small as adults, and others are within the typical range.
Infants whose growth was restricted because their mother used alcohol while pregnant are more likely to have long-term developmental and behavioral problems (see also Alcohol Use During Pregnancy).
The outcome for SGA infants exposed to illicit drugs during pregnancy is complicated. It is difficult to predict the prognosis because pregnant people who use illicit drugs may have other social and economic problems that affect their child's development.
