Editorial
org
Small for gestational age (SGA)
and fetal growth restriction (FGR)
Jay D. Iams, MD
D rs Zhang, Merialdi, Platt, and Kramer have provided
readers of the American Journal of Obstetrics and Gyne-
cology with a benchmark article, one that should be read and
taken to heart by all who care for pregnant women and new-
born infants. In this review, they shine a clarifying light on 3
decades of increasing confusion in the language and concepts
that are used to describe fetuses and infants who are, or are
suspected of being, small. Once upon a time, there were 3 cat-
egories that were defined by percentiles of growth that encom-
passed the entire population of newborn infants: (1) infants
with birthweights ⬍10th percentile, called small for gestational
age (SGA); (2) infants with birthweights from 10th to 90th
percentile, called appropriate for gestational age, and (3) in-
fants with birthweights of ⬎90th percentile, called large for
gestational age (LGA).
These categories were not thought of as diagnoses, just labels
that facilitated further evaluation at a time when consideration
of birthweight relative to gestational age was a new concept.
Reasons for being small or large were considered separately.
Physicians who cared for these infants memorized lists of rea-
sons that a newborn infant might be SGA or LGA, with the
understanding that some were normally small or large and oth-
ers were smaller or larger than they should have been. The
newborn concept of SGA was later applied to the fetus as in-
trauterine growth retardation, now called intrauterine or fetal
growth restriction (FGR). As this concept entered fetal care, the
definition of SGA that was population-based (⬍10th percen-
tile of all fetuses of the same gestational age) was conflated with
a standard-based (⬍10th percentile of healthy fetuses of the
same gestational age) definition of FGR that included a fetus of
any size who has not achieved its optimal growth potential,
From the Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, College of Medicine, The Ohio State
University, Columbus, OH.
Reprints not available from the author.
0002-9378/free
© 2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2009.10.890
See related article, page 522
www. AJOG.
regardless of growth percentile. The importance of this differ-
ence is the subject of the review by Dr Zhang and his coauthors.
To quote,
“A population reference is often established on the basis
of a large sample size (ideally representing the underlying
population) with a study population that includes both
low-risk and high-risk pregnancies and both normal and
abnormal perinatal outcomes ѧ a standard usually is
based on low-risk pregnancies with a normal outcome.
When the “population reference” and the “standard” are
applied to an individual fetus or infant, interpretation of
the findings differs. Use of a population reference will
yield a relative fetal size in relation to the total popula-
tion; a standard will assess a fetal size in comparison with
normally grown fetuses. Thus, a standard may have more
clinical utility than a population reference.”
Zhang et al point out that the consequences of confusing the
2 concepts are over-diagnosis of pathologic condition and con-
sequent unnecessary interventions among small normally
grown fetuses, and failure to identify and intervene on behalf of
poorly grown fetuses whose weight is estimated to be ⬎10th
percentile for age. Both are common but unacceptable and
could be reduced by clarification of the distinction. The au-
thors believe that current attempts to improve the detection
and care of these fetuses through customized fetal growth pro-
files and integration of additional markers represent improve-
ments but fall short in the United States because of the diversity
of the population. Until the improvements that they describe
become reality, I would like to propose that the conflation of
definitions be resolved by applying the term SGA to all infants
and fetuses whose weight falls at ⬍10th percentile for gesta-
tional age (population-based) and by limiting the FGR desig-
nation to infants and fetuses whose growth is suspected to be
less than optimal, recognizing that SGA infants are not all FGR
and that FGR infants are not all SGA. SGA would be based on
growth percentiles, and FGR would be based on evidence of
pathologic growth. I believe this integration of obstetric and
pediatric terminology could improve the antenatal, intrapar-
tum, and neonatal care of small babies. f
JUNE 2010 American Journal of Obstetrics & Gynecology 513