Diagnosis

Most commonly made when the birth weight (BW) is below the 10th percentile for gestational age. (SGA)
The pitfalls  does not distinguish SGA infants who are constitutionally normally small from those with
FGR, and it fails to identify infants with FGR who have BWs above the 10th percentile but who still had
abnormally poor in utero growth
To confirm the diagnosis of FGR  identifying other clinical features suggestive of poor intrauterine
growth 
- include a significant discrepancy between the actual weight and the expected optimal weight
based on maternal stature, ethnicity, and parity
- physical findings of malnourishment
o decreased skeletal muscle mass
o subcutaneous fat tissue
o excessive skin desquamation
- evidence of asymmetric growth with a low ponderal index (PI)

Differential diagnosis
Constitutionally small normal infants  no physical finding of in utero malnourishment; not at increased
risk for morbidity and mortality

Complication
At risk for the following complication in the perinatal period
- Preterm delivery
o Because the fetal risk of remaining in utero are considered to be greater that hose of
prematurity
o Preterm FGR are at increased risk for death and complications realted to prematurity
(necrotizing enterocolitis, respiratory distress syndrome, bronchopulmonary dysplasia,
and retinopathy of prematurity)
- Perinatal asphyxia, which may be accompanied by meconium aspiration or persistent pulmonary
hypertension
o May have difficult transition at delivery with the additional hypoxic stress of uterine
contractions; particularly for fetuses with FGR due to placental pathology  hypoxia
and metabolic acidosis and increases the risk of multiple organ dysfunction (such as
 hypoxic-ischemic encephalopathy, ischemic heart failure, meconium aspiration,
persistent pulmonary hypertension, and acute gastrointestinal and kidney injury)
- Impaired thermoregulation
o At risk for hypothermia; due to the SGA infants’ increased heat loss due to reduced
subcutaneous fat, and reduced heat production due to poor nutrient reserves and
depletion of catecholamies (needed for thermogenesis by brown fat)  intrauterine
stress
o Should be cared in a neutral thermal environment to avoid episodes of hypothermia
- Hypoglycemia
o The risk increases with increasing severity of growth restriction  decreasing reserves
of fat, protein, and glycogen
o The predisposition begins
 in utero as low intrauterine insulin concentrations result in decreased glycogen
synthesis and reduced glycogen stores
 after delivery, a poorly coordinated response of counterregulatory hormones
and peripheral insensitivity to these hormones
 typically occurs within the first 10 hours after birth
- Polycythemia and hyperviscosity
o More frequently in infants with FGR; increasing risk of polycythemia with the severity of
growth restriction
o Hyperviscosity was detected with a microviscometer in 18% of SGA infants
o Most had hematocrits >64%
o Increased erythropoietin production resulting from fetal hypoxia is thought to be
responsible
- Impaired immune function
o Cellular immunity can be impaired in FGR in the newborn period and through childhood
o T & B peripheral lymphocytes were decreased at birth; T lymphocyte become normal in
later childhood but the proliferative capacity was reduced
o Delayed cutaneous hypersensitivity to phytohemagglutinin was reduced in both
newborns and children
o 50% infants born to mothers with severe hypertension (common cause of FGR) have
neutropenia that may increase the risk of infection
 - Hypocalcemia
o History of preterm or birth asphyxia are at risk for early hypocalcemia which occurs in
the first 2 – 3 days after birth and increase with the severity of growth failure
- Mortality

Initial Management  supportive and is focused on preventing or addressing any associated

complications; no identified cause, further evaluation can be initiated after the infant stabilized
- Delivery room management
o Delivery should be planned and prepared to manage any infant with perinatal
depression, meconium aspiration, hypoglycemia, myocardial dysfunction, and hypoxia
o Heat loss should be avoided
 Immediate drying and placement of the infant under a radiant warmer
o Prompt resuscitation; including clearing the airway of meconium if needed, should be
instituted
o NICU
- Nursery management
o Accurate measurement of length, weight, and head circumference
o Accurate assessment of gestational age
o Thermoregulation  isolette or radiant heater
o Glucose surverillance
 Monitoring for hypoglycemia within 1 – 2 hours after birth
 Samples are obtained before feedings
 Until feedings are well established and glucose values was normalize
o Calcium monitoring
 Ionized calcium concentration should be monitored starting at 12 hours after
birth and adequate calcium intake should be provided
o Monitoring polycythemia
 Hematocrit or hemoglobin should be obtained in infants who have signs or
symptoms
 Cyanosis
 Tachypnea
 Poor feeding
  Vomiting
o Nutrition
