Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Infants with fetal (intrauterine) growth restriction

George T Mandy, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD


Infants with fetal growth restriction (FGR; also referred to as intrauterine growth restriction) who did not achieve full in utero growth potential because of genetic or environmental factors are at increased risk for significant morbidity and mortality compared with infants with normal in utero growth.

The clinical features, complications, and management of infants born with FGR are discussed here. The diagnosis, evaluation, and management of FGR during pregnancy are discussed separately. (See "Fetal growth restriction: Diagnosis" and "Fetal growth restriction: Evaluation and management".)


Several terms have been used to describe infants with low birth weights (BW) for their gestational age. These include small for gestational age (SGA) and fetal (intrauterine) growth restriction (FGR). These two terms, although related since they may include many of the same infants, are not the same.

Small for gestational age — Small for gestational age (SGA) is defined as infants with a BW below the 10th percentile for gestational age (table 1) [1]. However, this definition does not make a distinction among SGA infants who are constitutionally normally small from those who are growth-restricted and small. Constitutionally small infants are those with a normal BW below 10th percentile due to constitutional factors including maternal height, weight, ethnicity, and parity. These infants are not at increased risk for perinatal mortality or morbidity [1].

Fetal growth restriction — Fetal growth restriction (FGR) refers to the fetus who does not achieve the expected in utero growth potential due to genetic or environmental factors (table 2). It is defined as an estimated fetal weight <10th percentile (see "Fetal growth restriction: Diagnosis", section on 'Definition'). Clinically, most infants with FGR are identified because they are born SGA with a BW below the 10th percentile for gestational age (table 1). Moderate FGR is defined as BW in the 3rd to 10th percentile, and severe FGR as less than the 3rd percentile.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Battaglia FC, Lubchenco LO. A practical classification of newborn infants by weight and gestational age. J Pediatr 1967; 71:159.
  2. Tudehope D, Vento M, Bhutta Z, Pachi P. Nutritional requirements and feeding recommendations for small for gestational age infants. J Pediatr 2013; 162:S81.
  3. Lapillonne A, Braillon P, Claris O, et al. Body composition in appropriate and in small for gestational age infants. Acta Paediatr 1997; 86:196.
  4. Anderson MS, Hay WW. Intrauterine growth restriction and the small-for-gestational-age infant. In: Neonatology Pathophysiology and Management of the Newborn, 5th ed, Avery GB, Fletcher MA, MacDonald MG (Eds), Lippincott Williams and Wilkins, Philadelphia 1999. p.411.
  5. Chard T, Costeloe K, Leaf A. Evidence of growth retardation in neonates of apparently normal weight. Eur J Obstet Gynecol Reprod Biol 1992; 45:59.
  6. Miller HC, Hassanein K. Diagnosis of impaired fetal growth in newborn infants. Pediatrics 1971; 48:511.
  7. Lee AC, Kozuki N, Cousens S, et al. Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21(st) standard: analysis of CHERG datasets. BMJ 2017; 358:j3677.
  8. de Onis M, Blössner M, Villar J. Levels and patterns of intrauterine growth retardation in developing countries. Eur J Clin Nutr 1998; 52 Suppl 1:S5.
  9. Lemons JA, Bauer CR, Oh W, et al. Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics 2001; 107:E1.
  10. Bernstein IM, Horbar JD, Badger GJ, et al. Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol 2000; 182:198.
  11. Wollmann HA. Intrauterine growth restriction: definition and etiology. Horm Res 1998; 49 Suppl 2:1.
  12. Liu J, Wang XF, Wang Y, et al. The incidence rate, high-risk factors, and short- and long-term adverse outcomes of fetal growth restriction: a report from Mainland China. Medicine (Baltimore) 2014; 93:e210.
  13. Zeitlin J, El Ayoubi M, Jarreau PH, et al. Impact of fetal growth restriction on mortality and morbidity in a very preterm birth cohort. J Pediatr 2010; 157:733.
  14. Peacock JL, Lo JW, D'Costa W, et al. Respiratory morbidity at follow-up of small-for-gestational-age infants born very prematurely. Pediatr Res 2013; 73:457.
  15. De Jesus LC, Pappas A, Shankaran S, et al. Outcomes of small for gestational age infants born at <27 weeks' gestation. J Pediatr 2013; 163:55.
  16. Doctor BA, O'Riordan MA, Kirchner HL, et al. Perinatal correlates and neonatal outcomes of small for gestational age infants born at term gestation. Am J Obstet Gynecol 2001; 185:652.
  17. Kramer MS, Olivier M, McLean FH, et al. Impact of intrauterine growth retardation and body proportionality on fetal and neonatal outcome. Pediatrics 1990; 86:707.
  18. Holtrop PC. The frequency of hypoglycemia in full-term large and small for gestational age newborns. Am J Perinatol 1993; 10:150.
  19. Hawdon JM, Weddell A, Aynsley-Green A, Ward Platt MP. Hormonal and metabolic response to hypoglycaemia in small for gestational age infants. Arch Dis Child 1993; 68:269.
  20. Hakanson DO, Oh W. Hyperviscosity in the small-for-gestational age infant. Biol Neonate 1980; 37:109.
  21. Snijders RJ, Abbas A, Melby O, et al. Fetal plasma erythropoietin concentration in severe growth retardation. Am J Obstet Gynecol 1993; 168:615.
  22. Ferguson AC. Prolonged impairment of cellular immunity in children with intrauterine growth retardation. J Pediatr 1978; 93:52.
  23. Mouzinho A, Rosenfeld CR, Sanchez PJ, Risser R. Effect of maternal hypertension on neonatal neutropenia and risk of nosocomial infection. Pediatrics 1992; 90:430.
  24. Gray PH, Rodwell RL. Neonatal neutropenia associated with maternal hypertension poses a risk for nosocomial infection. Eur J Pediatr 1999; 158:71.
  25. Spinillo A, Capuzzo E, Egbe TO, et al. Pregnancies complicated by idiopathic intrauterine growth retardation. Severity of growth failure, neonatal morbidity and two-year infant neurodevelopmental outcome. J Reprod Med 1995; 40:209.
  26. Leaf A, Dorling J, Kempley S, et al. Early or delayed enteral feeding for preterm growth-restricted infants: a randomized trial. Pediatrics 2012; 129:e1260.
  27. Lapointe M, Barrington KJ, Savaria M, Janvier A. Preventing postnatal growth restriction in infants with birthweight less than 1300 g. Acta Paediatr 2016; 105:e54.
  28. Williams RL, Creasy RK, Cunningham GC, et al. Fetal growth and perinatal viability in California. Obstet Gynecol 1982; 59:624.
  29. Wennergren M, Wennergren G, Vilbergsson G. Obstetric characteristics and neonatal performance in a four-year small for gestational age population. Obstet Gynecol 1988; 72:615.
  30. Malloy MH. Size for gestational age at birth: impact on risk for sudden infant death and other causes of death, USA 2002. Arch Dis Child Fetal Neonatal Ed 2007; 92:F473.
  31. Kok JH, den Ouden AL, Verloove-Vanhorick SP, Brand R. Outcome of very preterm small for gestational age infants: the first nine years of life. Br J Obstet Gynaecol 1998; 105:162.
  32. Malin GL, Morris RK, Riley R, et al. When is birthweight at term abnormally low? A systematic review and meta-analysis of the association and predictive ability of current birthweight standards for neonatal outcomes. BJOG 2014; 121:515.
  33. Griffin IJ, Lee HC, Profit J, Tancedi DJ. The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. J Perinatol 2015; 35:503.
  34. Baer RJ, Rogers EE, Partridge JC, et al. Population-based risks of mortality and preterm morbidity by gestational age and birth weight. J Perinatol 2016; 36:1008.
  35. Ray JG, Park AL, Fell DB. Mortality in Infants Affected by Preterm Birth and Severe Small-for-Gestational Age Birth Weight. Pediatrics 2017; 140.
  36. Manning FA. Intrauterine growth retardation. In: Fetal Medicine: Principles and Practice, Appleton and Lange, Norwalk, CT 1995. p.307.
  37. Guellec I, Lapillonne A, Renolleau S, et al. Neurologic outcomes at school age in very preterm infants born with severe or mild growth restriction. Pediatrics 2011; 127:e883.
  38. Fitzhardinge PM, Steven EM. The small-for-date infant. II. Neurological and intellectual sequelae. Pediatrics 1972; 50:50.
  39. Karlberg J, Albertsson-Wikland K. Growth in full-term small-for-gestational-age infants: from birth to final height. Pediatr Res 1995; 38:733.
  40. Hediger ML, Overpeck MD, Maurer KR, et al. Growth of infants and young children born small or large for gestational age: findings from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med 1998; 152:1225.
  41. Beukers F, Rotteveel J, van Weissenbruch MM, et al. Growth throughout childhood of children born growth restricted. Arch Dis Child 2017; 102:735.
  42. Paz I, Seidman DS, Danon YL, et al. Are children born small for gestational age at increased risk of short stature? Am J Dis Child 1993; 147:337.
  43. Levine TA, Grunau RE, McAuliffe FM, et al. Early childhood neurodevelopment after intrauterine growth restriction: a systematic review. Pediatrics 2015; 135:126.
  44. Paz I, Gale R, Laor A, et al. The cognitive outcome of full-term small for gestational age infants at late adolescence. Obstet Gynecol 1995; 85:452.
  45. O'Keeffe MJ, O'Callaghan M, Williams GM, et al. Learning, cognitive, and attentional problems in adolescents born small for gestational age. Pediatrics 2003; 112:301.
  46. Bergvall N, Iliadou A, Tuvemo T, Cnattingius S. Birth characteristics and risk of low intellectual performance in early adulthood: are the associations confounded by socioeconomic factors in adolescence or familial effects? Pediatrics 2006; 117:714.
  47. Stoknes M, Andersen GL, Dahlseng MO, et al. Cerebral palsy and neonatal death in term singletons born small for gestational age. Pediatrics 2012; 130:e1629.
  48. Løhaugen GC, Østgård HF, Andreassen S, et al. Small for gestational age and intrauterine growth restriction decreases cognitive function in young adults. J Pediatr 2013; 163:447.
  49. Pylipow M, Spector LG, Puumala SE, et al. Early postnatal weight gain, intellectual performance, and body mass index at 7 years of age in term infants with intrauterine growth restriction. J Pediatr 2009; 154:201.
  50. Guellec I, Marret S, Baud O, et al. Intrauterine Growth Restriction, Head Size at Birth, and Outcome in Very Preterm Infants. J Pediatr 2015; 167:975.
  51. Korzeniewski SJ, Allred EN, Joseph RM, et al. Neurodevelopment at age 10 years of children born <28 weeks with fetal growth restriction. Pediatrics 2017; 140.
  52. McCarton CM, Wallace IF, Divon M, Vaughan HG Jr. Cognitive and neurologic development of the premature, small for gestational age infant through age 6: comparison by birth weight and gestational age. Pediatrics 1996; 98:1167.
  53. Barker DJ. Early growth and cardiovascular disease. Arch Dis Child 1999; 80:305.
  54. Barker DJ. Fetal origins of coronary heart disease. BMJ 1995; 311:171.
  55. Barker DJ, Osmond C, Simmonds SJ, Wield GA. The relation of small head circumference and thinness at birth to death from cardiovascular disease in adult life. BMJ 1993; 306:422.
  56. Kaijser M, Bonamy AK, Akre O, et al. Perinatal risk factors for ischemic heart disease: disentangling the roles of birth weight and preterm birth. Circulation 2008; 117:405.
  57. Skilton MR, Evans N, Griffiths KA, et al. Aortic wall thickness in newborns with intrauterine growth restriction. Lancet 2005; 365:1484.
  58. Skilton MR. Intrauterine risk factors for precocious atherosclerosis. Pediatrics 2008; 121:570.
  59. Bradley TJ, Potts JE, Lee SK, et al. Early changes in the biophysical properties of the aorta in pre-adolescent children born small for gestational age. J Pediatr 2010; 156:388.
  60. Napoli C, Glass CK, Witztum JL, et al. Influence of maternal hypercholesterolaemia during pregnancy on progression of early atherosclerotic lesions in childhood: Fate of Early Lesions in Children (FELIC) study. Lancet 1999; 354:1234.
  61. Norman M, Bonamy AK. Aortic wall thickening in utero. Lancet 2005; 365:1444.
  62. Spence D, Alderdice FA, Stewart MC, et al. Does intrauterine growth restriction affect quality of life in adulthood? Arch Dis Child 2007; 92:700.
  63. Huxley R, Neil A, Collins R. Unravelling the fetal origins hypothesis: is there really an inverse association between birthweight and subsequent blood pressure? Lancet 2002; 360:659.
  64. Siewert-Delle A, Ljungman S. The impact of birth weight and gestational age on blood pressure in adult life: a population-based study of 49-year-old men. Am J Hypertens 1998; 11:946.
  65. Keijzer-Veen MG, Finken MJ, Nauta J, et al. Is blood pressure increased 19 years after intrauterine growth restriction and preterm birth? A prospective follow-up study in The Netherlands. Pediatrics 2005; 116:725.
  66. Carmody JB, Charlton JR. Short-term gestation, long-term risk: prematurity and chronic kidney disease. Pediatrics 2013; 131:1168.
  67. Vikse BE, Irgens LM, Leivestad T, et al. Low birth weight increases risk for end-stage renal disease. J Am Soc Nephrol 2008; 19:151.
  68. White SL, Perkovic V, Cass A, et al. Is low birth weight an antecedent of CKD in later life? A systematic review of observational studies. Am J Kidney Dis 2009; 54:248.