Queensland Health

Maternity and Neonatal Clinical Guideline

Term small for gestational age baby

Queensland Clinical Guideline: Term small for gestational age baby

Document title: Term small for gestation age baby

Publication date: July 2016
Document number: MN16.16-V4-R21
The document supplement is integral to and should be read in conjunction
Document supplement:
with this guideline.
Amendments: Full version history is supplied in the document supplement.
Amendment date: November 2016
Replaces document: MN16.16-V3-R21
Author: Queensland Clinical Guidelines
Health professionals in Queensland public and private maternity and
Audience:
neonatal services
Review date: July 2021
Queensland Clinical Guidelines Steering Committee
Endorsed by:
Statewide Maternity and Neonatal Clinical Network (Queensland)
Email: Guidelines@health.qld.gov.au
Contact:
URL: www.health.qld.gov.au/qcg

Disclaimer

This guideline is intended as a guide and provided for information purposes only. The information has been
prepared using a multidisciplinary approach with reference to the best information and evidence available
at the time of preparation. No assurance is given that the information is entirely complete, current, or
accurate in every respect.

The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice.
Variation from the guideline, taking into account individual circumstances may be appropriate.

This guideline does not address all elements of standard practice and accepts that individual clinicians are
responsible for:

• Providing care within the context of locally available resources, expertise, and scope of practice
• Supporting consumer rights and informed decision making in partnership with healthcare practitioners
including the right to decline intervention or ongoing management
• Advising consumers of their choices in an environment that is culturally appropriate and which
enables comfortable and confidential discussion. This includes the use of interpreter services where
necessary
• Ensuring informed consent is obtained prior to delivering care
• Meeting all legislative requirements and professional standards
• Applying standard precautions, and additional precautions as necessary, when delivering care
• Documenting all care in accordance with mandatory and local requirements

Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability
(including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for
any reason associated with the use of this guideline, including the materials within or referred to throughout
this document being in any way inaccurate, out of context, incomplete or unavailable.

© State of Queensland (Queensland Health) 2016

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to
copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines,
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For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email Guidelines@health.qld.gov.au,
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Queensland Clinical Guideline: Term small for gestational age baby
Flow Chart: Term small for gestational age baby
Term small for gestational age baby
Initial care at birth:
• Resuscitate and stabilise as
required:
o Perinatal asphyxia,
meconium aspiration, PPHN
• Maintain normothermia:
o Warm draft free environment
• Skin-to-skin contact
• Feed within 30−60 minutes of
birth
• Admit to SCN if required
Newborn assessment:
• Distinguish the healthy small
baby from the FGR baby
o Obtain a detailed history
o Perform a physical
examination
o Examine the placenta
Growth assessment:
• Estimate gestation: US (earlier
dating is the most accurate),
LMP, Ballard examination
• Physical examination:
o Constitutionally small: healthy
o Growth restricted: at increased
risk of morbidity and mortality
o Plot weight, head
circumference and length on
percentile chart
Parental considerations:
• Involve parents in shared
decision making
• Facilitate parent involvement in
their baby’s care
• Ensure parents understand
importance of:
o Maintaining the baby’s
temperature and feeding
regularly to avoid
hypoglycaemia
 Provide additional feeding
support as required
 Observing for jaundice
• Explain tests and procedures,
comfort measures, equipment
• Refer to local support services
where required (e.g. social
work)
• Provide written parent
information
Queensland Clinical Guidelines: Term small for gestational age baby F16.16-1-V4-R21
ASID Australasian Society for Infectious Diseases; BGL Blood glucose level; CPAP Continuous positive airway pressure; FBC Full blood
count; FGR Fetal growth restriction; Hct Haematocrit; LMP Last menstrual period; PPHN pulmonary hypertension of the newborn; QCG
Queensland Clinical Guideline(s); SGA Small for gestational age; TORCH: Toxoplasmosis, Other (e.g. syphilis, varicella zoster, Human
immunodeficiency virus), Rubella, Cytomegalovirus, Herpes simplex); US Ultrasonography; < less than; ≥ greater than or equal to
Refer to online version, destroy printed copies after use
Yes/
Postnatal potentially Contact Retrieval Services
transfer Queensland (RSQ) on
required? 1300 799 127
No
Ongoing care: Potential associated
• Based on underlying diagnosis morbidity:
and individual presentation • Hypoglycaemia
• Feeding: • Hypothermia
o Demand feed at least 3 hourly • Polycythaemia/hyperviscosity
o If baby does not feed within a • Immunodeficiency/
four hour period: reassess with Thrombocytopaenia
a view to paediatric • Infections: TORCH
consultation • Hyperglycaemia
o Commence enteral feeds • Congenital anomalies
cautiously in babies < 2000 g • Rarely necrotising enterocolitis
with abnormal umbilical artery
Doppler flow studies
• Maintain normothermia:
o Temperature 3−4 hourly/pre-
feeds if stable Potential investigations:
o Hourly temperature if not • Placental histopathology,
stable chromosomal analysis, cord
o Pre-interventions and 30−60 blood gases
mins after interventions • FBC, Hct, platelet count
• Be alert to associated • Suspected congenital TORCH
morbidities infection:
• Consider underlying cause: o Refer to ASID guidelines
o Refer to Potential Management of perinatal
investigations infections
• Monitor BGL [refer to QCG: • Dysmorphic features:
Newborn hypoglycaemia] o Dysmorphology assessment
• Be alert for neonatal jaundice, o Chromosome studies
particularly in babies with o Refer to clinical geneticist
polycythaemia and/or not
feeding well [refer to QCG:
Neonatal jaundice]
Associated QCG guidelines:
• Routine newborn assessment
Discharge planning: • Neonatal resuscitation
• Baby healthy and physiologically • Neonatal respiratory distress
stable including CPAP
• Feeding progressing well • Neonatal stabilisation for
• A steady weight gain (e.g. ≥ 30 retrieval
grams/day) • Newborn hypoglycaemia
• Discharge plan is in place • Normal birth
• Follow-up as per baby and • Hypoxic-ischaemic
family requirements (e.g. encephalopathy (HIE)
multidisciplinary/paediatric for • Perinatal substance use
baby < 2000 g) • Neonatal jaundice
Page 3 of 21
Queensland Clinical Guideline: Term small for gestational age baby

Abbreviations
AGA Appropriate for gestational age
BGL Blood glucose level
BoBs Bacterial artificial chromosomes (BACs) on Beads
CI Confidence interval
CMV Cytomegalovirus
FBC Full blood count
FGR Fetal growth restriction
GP General Practitioner
Hct Haematocrit
HIE Hypoxic-ischaemic encephalopathy
HIV Human immunodeficiency virus
IUGR Intra-uterine growth restriction
IV Intravenous
LBW Low birth weight
QCG Queensland Clinical Guideline(s)
SD Standard deviation
SGA Small for gestational age
UA Umbilical artery
US Ultrasound
WHO World Health Organization

Definition of terms
Appropriate for • Birth weight appropriate for gestational age1
gestation age • Birth weight between the 10–90th percentile on a standardised growth chart1
(AGA)
Fetal growth • The preferred term when referring to the size of a baby caused by a pathophysiological
restriction (FGR) process occurring in-utero that inhibits fetal growth
• Estimation of fetal weight at obstetric ultrasound assessment below the 10th percentile of a
antenatal population range, with additional evidence of a pathophysiological process2,
typically Doppler abnormality
• Also known as intrauterine growth restriction (IUGR)
• FGR and SGA are related but not synonymous.2,3 FGR is included within the SGA definition
Severe FGR • Fetal growth restriction below the third percentile
Low birth weight
• Birth weight less than 2500 g regardless of gestational age4
(LBW)
Shared decision Definition adapted for the newborn and family:
making • Shared decision making involves the integration of a family’s values, goals and concerns
with the best available evidence about benefits, risks and uncertainties of treatment, in order
to achieve appropriate health care decisions for the baby. It involves clinicians and parents
(and carers) making decisions about the baby’s management together.
In partnership with their clinician, parents (and carers) are encouraged to consider available
screening, treatment, or management options and the likely benefits and harms of each, to
communicate their preferences, and help select the course of action that best fits5
Small for • For the purpose of this guideline: birth weight below the 10th percentile of a population-
gestational age specific birth weight versus gestational age plot1
(SGA) • Other guidelines may use the statistical definition of greater than two standard deviations
below the mean birth weight for gestational age1
• Antenatally, at obstetric ultrasound assessment, it is the estimated fetal weight below the
10th percentile
• The antenatal and postnatal umbrella term, with FGR referring to cases secondary to
pathology
• The preferred term when referring to the small size of a newborn baby relative to gestational
age3
• SGA is also used when the aetiology of small size is unknown
• Does not necessarily imply that fetal growth was abnormal as the baby may be
constitutionally small1
Severe SGA • Birth weight below the third percentile6
Term • Greater than or equal to 37 weeks gestation and before 42 weeks gestation

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Queensland Clinical Guideline: Term small for gestational age baby

Table of Contents
1 Introduction ..................................................................................................................................... 6
1.1 Incidence................................................................................................................................ 6
1.2 Factors associated with fetal growth ..................................................................................... 6
1.2.1 Risk factors associated with term moderate and/or severe SGA ...................................... 7
1.3 Parental considerations ......................................................................................................... 7
2 Initial newborn assessment and care ............................................................................................. 8
2.1 Rooming-in considerations .................................................................................................... 9
3 Newborn assessment and care ...................................................................................................... 9
3.1 Symmetrical and asymmetrical FGR ................................................................................... 10
3.2 Growth standards ................................................................................................................ 10
3.3 Investigations ....................................................................................................................... 11
3.4 Thermoregulation ................................................................................................................. 11
3.5 Hypoglycaemia, feeding and polycythaemia ....................................................................... 12
4 Prognosis ...................................................................................................................................... 13
5 Discharge planning ....................................................................................................................... 14
References .......................................................................................................................................... 15
Appendix A: Factors associated with term SGA babies ...................................................................... 18
Appendix B: Growth charts .................................................................................................................. 19
Acknowledgements.............................................................................................................................. 21

List of Tables
Table 1. Factors associated with term gestation moderate and severe SGA ....................................... 7
Table 2. Initial newborn assessment and care: first 2 hours post birth ................................................. 8
Table 3. Rooming-in considerations ...................................................................................................... 9
Table 4. Newborn assessment .............................................................................................................. 9
Table 5. Symmetrical and asymmetrical FGR ..................................................................................... 10
Table 6. Growth charts ........................................................................................................................ 10
Table 7. Investigations ......................................................................................................................... 11
Table 8. Thermoregulation................................................................................................................... 11
Table 9. Hypoglycaemia, feeding and polycythaemia ......................................................................... 12
Table 10. Term SGA prognosis ........................................................................................................... 13
Table 11. Discharge planning .............................................................................................................. 14

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Queensland Clinical Guideline: Term small for gestational age baby

1 Introduction
The term ‘small for gestational age’ (SGA) refers to the small size of the baby at birth, that is, when
1 1
the birth weight is below the 10th percentile. Babies who are SGA may be :
• Constitutionally small and at no greater risk than appropriate weight for gestational age
(AGA) babies, or
• Small due to fetal/intrauterine growth restriction (FGR), a pathophysiological process
occurring in-utero

7
Differentiating between FGR and SGA remains an obstetric challenge :
• Babies born SGA may not have FGR
• Babies born AGA may have been affected by growth restriction and this may not have
1
been detected antenatally
• FGR may not be detected clinically before birth
• Babies who are SGA due to FGR are more likely to have problems during the newborn
period and require specialised care, than SGA babies without FGR
• A SGA baby at term may not have a low birth weight (LBW) (i.e. less than 2500 g)

This guideline focuses on the term (greater than or equal to 37 weeks and less than 42 weeks
gestation) SGA baby. SGA babies as a group are at greater risk for perinatal morbidity and mortality
than the population of AGA babies and will include babies with undiagnosed FGR.

1.1 Incidence
An Australian study reported perinatal mortality in term SGA babies was significantly higher than in
term AGA babies. Perinatal mortality for SGA babies, which included more stillbirths than neonatal
8
deaths, was reported at :
o 3.5/1000 births at the 5th to less than 10th percentile, rising to 17.8/1000 births at less
than the 1st percentile
o 0.89/1000 births at 37 weeks rising to 4.82/1000 births at 41 weeks

9
Within Queensland, the incidence of term SGA in 2015 was :
• 5.8% within the general population, and
• 22.4% within the Aboriginal and Torres Strait Islander population
o Aboriginal and Torres Strait Islander SGA and LBW babies are disproportionately
10
represented and this extends to the number of associated admissions to neonatal
11
units

1.2 Factors associated with fetal growth

Birth weight is one of the key measurements used to reflect the intrauterine environment to which the
12
fetus was exposed. Several maternal and fetal factors both physiological and pathological may
influence fetal growth.

FGR is increasingly seen as a fetal adaptive process to a compromised intrauterine environment

which may assist the fetus to survive but may result in adverse sequelae for the baby and potentially
13,14
for the adult if prolonged. The diagnosis of reduced fetal growth rate is important. Once detected,
further obstetric assessment is required to determine the cause and guide pregnancy management.
Small size may be constitutional and reflect a normal physiological variance, however, reduced
growth rate may occur secondary to maternal, placental and/or fetal factors.

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Queensland Clinical Guideline: Term small for gestational age baby

1.2.1 Risk factors associated with term moderate and/or severe SGA
Research has generally not distinguished between preterm and term SGA risk factors, nor the
severity of the SGA. Refer to Table 1. Factors associated with term gestation moderate and severe
SGA. For other risk factors less robustly associated with term SGA babies refer to
Appendix A: Factors associated with term SGA babies.

Table 1. Factors associated with term gestation moderate and severe SGA

Odds ratio [95% Confidence Interval]*

6 6 6
Variable Moderate SGA Severe SGA
Primiparity 1.7 [1.1, 2.5] 1.9 [1.0, 3.7]
Short maternal stature 2.9 [1.9, 4.3] 2.2 [1.1, 4.6]
Antenatal smoking 1.8 [1.1, 3.1] 4.0 [1.9, 8.1]
Preeclampsia 0.3 [0.0, 2.2] 7.3 [3.1, 17.3]
Threatened preterm labour 0.9 [0.3, 2.6] 4.7 [1.9, 11.6]
Low placental weight 16.4 [10.4, 26.0] 22.0 [11.0, 44.3]
* Univariable associations with severe and moderate term SGA: results of multinomial logistic regression
6
analysis

1.3 Parental considerations

Parents of babies with SGA will require additional support, even if the baby does not have FGR:
• Involve parents in shared decision making by having regular discussions regarding their
baby’s progress
o Include investigations for the underlying cause of SGA, as these may assist with
prognosis and recurrence risk in a future pregnancy
• Facilitate and ensure parental understanding of the importance of:
o Being involved in their baby’s care
o Maintaining their baby’s temperature and feeding regularly to avoid hypoglycaemia
 Encourage skin to skin contact if the mother and baby’s condition permits
o Observing for jaundice [refer to Queensland Clinical Guideline (QCG): Neonatal
15
jaundice ]
• Explain tests and procedures, comfort measures, equipment
• Explain criteria for discharge (e.g. established feeding and gaining weight)
• Document discussions in the baby’s medical record
• Refer to local support services where required (e.g. social work, child health clinics)
• Provide written parent information on caring for SGA babies [refer to QCG parent
16
information: Small for gestational age baby ]

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Queensland Clinical Guideline: Term small for gestational age baby

2 Initial newborn assessment and care

Table 2. Initial newborn assessment and care: first 2 hours post birth

Aspect Consideration
• Uterine contractions increase hypoxic stress in the FGR baby therefore
Resuscitation perinatal asphyxia is a common morbidity
• Refer to QCG: Neonatal resuscitation
17

• The SGA baby is at greater risk of hypothermia than an AGA baby

1

• Maintain normothermia (36.5–37.5 °C), including when resuscitation is

18
required
• Provide a warm draft free environment
19
Temperature
• Dry the baby after birth with pre-warmed towels, apply a pre-warmed hat
18

• If the baby is stable: skin to skin contact (covered with a warm blanket)
18

• Overhead radiant warmer, if required:

18

o Unwrap blankets to enable radiant warmth to reach the baby

• For routine care considerations, within the first two hours of birth, refer to
20
QCG: Normal birth [Fourth stage] including information on:
o Initial assessment and care
o Skin to skin contact and breastfeeding
21
o Risk of hypoglycaemia, feed within 30−60 minutes of birth
o Observations
Routine care
o Non-urgent care
o Indications for additional newborn care
o Documentation
• Most term SGA babies are well as long as normothermia and
normoglycaemia are maintained
• Refer to Section 2.1 Rooming-in considerations
• Common morbidities associated with FGR that may require admission to a
neonatal unit for management include:
22
o Perinatal asphyxia
22
o Hypothermia
23
o Hypoglycaemia requiring intravenous (IV) therapy
o Hyperglycaemia
22
o Hypocalcaemia
22,23
o Polycythaemia/hyperviscosity
1
o Congenital anomalies
24
Indications for o Infection (TORCH and acquired)
additional care • Other associated FGR morbidities that may also require admission to a
22
neonatal unit include :
o Persistent pulmonary hypertension, meconium aspiration, pulmonary
haemorrhage
o Thrombocytopaenia, neutropenia, coagulopathy, lowered
immunoglobulin G (IgG) levels
o Necrotising enterocolitis (NEC): increased risk with absent or reversed
umbilical artery (UA) end diastolic flow on antenatal Doppler studies,
25,26 26
sepsis , congenital heart disease , hypoxic-ischaemic
26 27
encephalopathy (HIE) , formula feeding
• As required refer to QCGs [https://www.health.qld.gov.au/qcg/]:
28
o Routine newborn assessment
29
o Neonatal resuscitation
30
Associated o Establishing breastfeeding
31
Queensland o Neonatal respiratory distress including CPAP
32
Clinical o Neonatal stabilisation for retrieval
21
Guidelines (QCG) o Newborn hypoglycaemia
33
o Hypoxic-ischaemic encephalopathy
34
o Perinatal substance use: neonatal
15
o Neonatal jaundice
Placental • Examine the placenta and prepare for histopathology [refer to Section 3.3
investigations Investigations]
Inter-hospital • If advice on management and/or transfer is required, discuss with a
transfer and paediatrician or neonatologist:
consultation o Call Retrieval Services Queensland (RSQ) on 1300 799 127

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Queensland Clinical Guideline: Term small for gestational age baby

2.1 Rooming-in considerations

Table 3. Rooming-in considerations

Aspect Consideration
• SGA or LBW on its own is not a reason for neonatal unit admission
• Most babies greater than 2000 g can room-in and breastfeed if
appropriate staffing, monitoring and parental support is available
• May facilitate skin to skin contact, enhance successful breastfeeding and
35
promote mother-baby attachment
Rooming-in • Babies less than 2000 g may be able to room-in following consultation
with neonatologist/paediatrician
• Consider the additional care required for establishing breastfeeding, blood
glucose level (BGL) monitoring, potential for occasional gavage feed,
prevention of hypothermia and the potential increased length of stay
35
compared to AGA babies

3 Newborn assessment and care

Table 4. Newborn assessment

Aspect Consideration
• It is important to distinguish the healthy small baby (who may require
no/minimal support) from the growth restricted baby (who may require
investigation, ongoing management and follow-up)
• Obtain a detailed history (including pregnancy and family)
Newborn • Perform a physical examination of the baby [refer to row: Physical
assessment examination]
• Continue assessment of both mother and baby postpartum to determine,
36
where possible, cause or contributing factors for small size
• Individualise clinical management of the baby based on clinical
presentation and underlying diagnosis
• Confirm gestational age by checking the antenatal ultrasound (US) and/or
last menstrual period
• Antenatal US dating is usually much more accurate than menstrual dating
37
which is associated with overestimation of gestational age :
o The earlier US dating occurs (preferably before 12 weeks), the more
accurate the prediction of gestational age
Confirmation of
o Up to 23 weeks gestation US dating remains more accurate than a
gestational age
reliable last menstrual period
• Some dates, for instance those based on assisted reproduction
technology and/or in vitro fertilisation (IVF) procedures, may be relied
upon as they are clinically more accurate
• In the absence of menstrual or US dating or if there is doubt, the Ballard
1
Score may be performed to estimate gestational age
• Refer to QCG: Routine newborn assessment
28

• FGR may be associated with chromosomal syndromes, perinatal

38
substance use, and viral infections :
o Include a thorough assessment for associated congenital anomalies
including dysmorphic features and signs of intrauterine infection (e.g.
hepatosplenomegaly, purpuric rash)
• Uterine and UA Doppler studies may provide antenatal evidence of
Physical 2
uteroplacental insufficiency as a cause of FGR
examination
• Determining whether FGR is symmetrical or asymmetrical [refer to Table
2
5] is of less clinical importance than the results of the Doppler studies
• FGR with normal UA Doppler studies:
o Adverse perinatal morbidity (i.e. intraventricular haemorrhage,
periventricular leukomalacia, HIE, necrotising enterocolitis,
bronchopulmonary dysplasia, sepsis) and mortality have been found to
25
be uncommon

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Queensland Clinical Guideline: Term small for gestational age baby

3.1 Symmetrical and asymmetrical FGR

Table 5. Symmetrical and asymmetrical FGR

Aspect Consideration
• Usually occurs early in gestation with a proportionate decrease in length,
weight and head circumference for gestational age, with all parameters
1
less than the 10th percentile on the growth chart
Symmetrical
FGR
38 • More severe form typically detected in the second trimester ultrasound
and associated with chromosomal abnormalities, congenital
malformations and intrauterine congenital infection, fetal alcohol
1,22
syndrome, and low social-economic status
• Also known as ‘head sparing’ FGR
• Disproportionate decrease in length and weight compared to the head
1
circumference :
o The head circumference remains appropriate for gestational age
o Weight and length are decreased (often less than 10th percentile on the
growth chart for gestational age)
• Associated with uteroplacental insufficiency and extrinsic factors occurring
38
late in pregnancy (e.g. maternal hypertensive conditions, long standing
maternal diabetes, renal disease, smoking and living at a high altitude)
• May include the appearance of the following features :
38
Asymmetrical
FGR o Head disproportionately large for trunk
o Extremities appear wasted, muscle mass may be decreased especially
1
in the buttocks and thighs
o Facial appearance of an ‘old man’
o Large anterior fontanelle with wide or overlapping cranial sutures
o Thin umbilical cord with diminished Wharton’s jelly
o Scaphoid abdomen
o Skin may be loose, thin, dry, flaky and with decreased subcutaneous fat
o Tone and alertness:
 Hyperalert, jittery, hypertonic with mild to moderate FGR
 Hypotonic with severe FGR

3.2 Growth standards

Table 6. Growth charts

Aspect Consideration
• Measure and plot birth weight, head circumference and length relative to
36
gestational age
• The Fenton growth charts for preterm infants :
39

o May be used for determination of SGA

o Considered the gold standard for 22−50 weeks gestation
o Blend into the World Health Organization (WHO) growth charts used in
the Queensland Health Personal Health Record
Growth charts o Refer Appendix B: Growth charts
• There is inconsistent evidence on customised growth charts (e.g. for
maternal height, weight, ethnicity and parity variables) offering more
accurate identification of SGA babies compared to population specific
40,41,42,43
charts of the SGA baby
• Comparison of head circumference to weight and length may help to
identify symmetrical or asymmetrical FGR

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Queensland Clinical Guideline: Term small for gestational age baby

3.3 Investigations
The majority of term SGA babies are well and require normal baby care, with a focus on being kept
warm and fed, as well as the additional care of monitoring their blood sugars. Investigations to
consider to either evaluate for evidence of clinical compromise arising from growth restriction or to
determine a reason for SGA are referenced in Table 7.

Table 7. Investigations

Aspect Consideration
• Investigations to be considered at the time of birth
• To exclude uteroplacental insufficiency, infection and confined placental
Placental mosaicism:
o Histopathology
o Chromosomal analysis (G-banded karyotype)
o Cord gases as indicated
• FBC including Hct and platelet count
(to exclude polycythaemia and thrombocytopaenia respectively)
• Suspected congenital infection:
o Refer to Australasian Society of Infectious Diseases guidelines
44
Management of perinatal infections for investigations related to
toxoplasmosis, rubella, cytomegalovirus (CMV), human
Baby immunodeficiency virus (HIV), varicella zoster, syphilis
• Dysmorphic features:
o Dysmorphology assessment
o Referral to a clinical geneticist
o SNP array (single nucleotide polymorphism) plus consider FISH
(fluorescence in situ hybridization) if clinical suspicion of specific
conditions (e.g. trisomy 21,13 or 18)
• If uteroplacental insufficiency is confirmed, consider arranging testing for
Maternal antiphospholipid syndrome in the mother to guide future pregnancy
management

3.4 Thermoregulation
Table 8. Thermoregulation

Aspect Consideration
• Maintain normothermia (36.5–37.5 °C) :
16

o Dress and cover baby appropriately for the environment

o Skin to skin contact
• Monitor baby’s temperature at frequent intervals:
o Within the first hour of birth
16
o Every 3–4 hours at feed times for 24 hours:
 If less than 24 hours old
 When transferred to the postnatal floor or rooming-in from the
neonatal unit
o Pre-interventions (e.g. physical examination)
Thermoregulation o 30–60 minutes after interventions (e.g. addition of warm wraps,
commencement of overhead radiant warmer, change of incubator
temperature):
 Then hourly until stable
• If hypothermia develops consider the use of pre-warmed clothing, an
incubator, radiant warmer (unwrap blankets to enable radiant warmth to
reach the baby) or a commercial heated water bed as required
• When baby is rooming-in with parents, apply SIDS guidelines (i.e. no hat)
• Avoid hyperthermia by not over dressing the baby, monitoring equipment
16
(e.g. incubator) and the baby’s temperature
• Document baby and equipment temperature, as well as interventions

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Queensland Clinical Guideline: Term small for gestational age baby

3.5 Hypoglycaemia, feeding and polycythaemia

Table 9. Hypoglycaemia, feeding and polycythaemia

Aspect Consideration
• SGA babies are at increased risk of hypoglycaemia due to deficient
9
hepatic and cardiac muscle glycogen stores , a limited capacity for
9
gluconeogenesis , increased insulin sensitivity and polycythaemia
• If the baby is well, monitor the BGL :
18

o Prior to the second feed or within 3 hours of birth if the baby has fed
Hypoglycaemia effectively
o At 2 hours of age if the baby has not fed effectively
o Every 4–6 hours pre-feeds until monitoring ceases
o If feeding is ineffective, recheck BGL
• For management of hypoglycaemia: refer to QCG Newborn
18
hypoglycaemia
• Promote and support breastfeeding
• Refer to QCG: Establishing breastfeeding
30

• In the absence of perinatal compromise:

o Support the baby’s mother in developing a feeding plan
o Establishment of breastfeeding may necessitate additional support for
mother and/or baby
o Feed in response to feeding cues
Feeding o Offer a feed if the baby has not fed for 3 hours
o A maximum handling time of 45 minutes per feed is suggested as these
babies may tire easily
o Compared to formula fed babies, breastfed babies may take less breast
milk more often
o Midwifery support and monitoring of feeding is vital (e.g. observe and
encourage regular feeding)
• Observe and document the baby's urinary output and bowel motions
(frequency and type)
When further • If unsure of baby’s progress, consult a lactation consultant and/or the
assistance is paediatric team as required
required • With ineffective feeding:
o Express after each feed
o Supplementary feeds may be required:
 Expressed breast milk is preferred
30
o Skin to skin contact may promote breastfeeding behaviours
• If the baby does not feed within a 4 hour period, reassess with a view to
paediatric consultation
• If no evidence of milk transfer (i.e. with non-nutritive sucking), a feeding
volume guide is 60 mL/kg/day on Day 1, with subsequent daily stepwise
increments of 30 mL/kg/day
• Consider insertion of an enteral tube to administer feeds in the event of
continued ineffective feeding: discuss with the mother prior to the
intervention
• If enteral feeding is not possible, commence IV 10% Glucose IV at
60 mL/kg/day
• When commencing feeds in babies who have had absent or reversed UA
end diastolic flow on antenatal Doppler studies:
o Monitor for signs of feed intolerance (vomiting, increasing/large residual
gastric aspirate if tube feeding)
• For babies less than 2000 g, ensure a low tolerance for commencing IV
35
fluids whilst waiting for colostrum or breast milk to become available
• Increased risk of neonatal jaundice and hypoglycaemia
• If the Hct is greater than 70% and the baby has symptoms of
Polycythaemia
polycythaemia, discuss management with a tertiary neonatologist
• Refer to QCG: Neonatal jaundice
15

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Queensland Clinical Guideline: Term small for gestational age baby

4 Prognosis
Table 10. Term SGA prognosis

Aspect Consideration
• Although there is conflicting evidence on the impact of being born SGA at
term (including in babies who had normal Doppler studies), most term
45-48
SGA babies are at low risk for serious long term outcomes
• Prognosis related to FGR can principally be determined by :
1

Prognosis o The cause of aberrant growth

17
o Timing and duration of growth restriction
17
o Severity and symmetry of growth restriction
33
o Presence and degree of perinatal asphyxia and its complications
o Postnatal course
o Socioeconomic status of the baby’s family
• Neurodevelopmental outcomes (from systematic reviews):
o Noted weak but significant association with childhood learning
45
difficulties
o Children between 1 month and 12 years of age showed those born
SGA at 36–41 weeks gestation scored on average 0.5 standard
deviation (SD) lower than AGA children across a range of composite
neurodevelopmental domains (cognitive, behavioural, language, motor,
17
hearing, vision or sleep outcomes) :
 Individually, the domains of cognitive (0.52 SD) and behavioural
(0.47 SD) development predominantly scored lower
 Children with evidence of fetal circulatory redistribution (preferential
perfusion of the brain) have more associated neurodevelopmental
impairments than babies born AGA or SGA without US evidence of
17
FGR
• Whilst an increased prognosis of metabolic syndrome has been
49
associated with FGR irrespective of gestation , composite outcome
Long term analysis for conditions associated with metabolic syndrome (obesity,
morbidity hypertension, hypercholesterolaemia, coronary heart disease, and type 2
45
diabetes) has shown a non-significant association with term SGA
• When individual morbidities are considered, there is :
45

o An association with:
 Adult obesity [OR: 1.98 (95% CI: 1.23, 3.20)]
 End stage renal disease (childhood/adulthood) [OR: 1.95 (95% CI:
1.46, 2.61)]
o For term birth weight less than 2500 g a weak association with adult
outcomes of:
 Hypertension [OR: 1.38 (95% CI: 1.14, 1.69)]
 Diabetes mellitus or impaired glucose tolerance [OR: 1.93 (95% CI:
1.06, 3.53)]
 Cardiovascular mortality [OR: 1.53 (95% CI: 1.03, 2.29)]
o A non-significant association with childhood:
 Obesity
 Hypertension
45,50,51
o Conflicting evidence on the association with childhood asthma
Symmetrical FGR • Remain smaller and relatively underweight throughout life
• Have a higher risk of adverse neurological outcome which may include :
36

o Learning deficits
o Behavioural problems
Asymmetrical • Usually have an accelerated velocity of growth (‘catch up growth’) in the
1
FGR first six months particularly if growth restriction is due to maternal factors
and normal development:
o Increased linear growth and lean body mass is preferred to increased
52
fat mass, central adiposity and insulin resistance

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Queensland Clinical Guideline: Term small for gestational age baby

5 Discharge planning
Table 11. Discharge planning

Aspect Consideration
• Evaluate each mother and baby individually to determine the optimal time
53
for discharge
• Discussion of discharge plans with the parents and multidisciplinary team,
including the Lactation Consultant in a timely manner prior to discharge
• Weight is not the only criterion for discharge although there needs to be
35

caution in babies weighing less than 2000 g

Criteria for
• For babies less than 2000 g, discharge may be considered providing :
35
discharge
o Baby is healthy
o Physiologically stability (temperature maintained in open cot)
o Feeding is progressing well
o Parents are able to sufficiently care for baby
o A steady weight gain (i.e. greater than or equal to 30 g/day)
o An appropriate follow-up plan is in place
• Prior to discharge provide parent(s) with education and information
1
regarding :
o Nutritional/feeding requirements
Parents o Baby’s expected growth and development (regular assessment of
growth and development by Child Health services or the General
Practitioner (GP) is recommended during the first year)
• Consider/offer rooming-in as required
• Babies who are SGA have a higher risk of readmission after discharge
• Close follow-up and coordination of post discharge care help to reduce
readmission
• Include a hard copy of the full discharge summary and plan, highlighting
the type and timing of follow-up care, within the Personal Health Record
• Refer to:
o GP: provide a hard or soft copy of discharge summary
Follow-up o Child Health Service:
 Early feeding and support drop-in clinics
o Aboriginal and Torres Strait Islander Health services, where applicable
o Specialist Lactation Service where concerns persist and/or monitoring
is required (e.g. if needing supplementary feeds)
o Specialised multidisciplinary clinic or paediatrician for babies who were
less than 2000 g or with co-existing medical conditions
o Other community support services as required e.g. Australian
Breastfeeding Association

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Queensland Clinical Guideline: Term small for gestational age baby

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Queensland Clinical Guideline: Term small for gestational age baby

Appendix A: Factors associated with term SGA babies

The table below includes published factors associated with SGA babies at term. More robust factors
can be found in Section 1.2.1 Risk factors associated with term moderate and/or severe SGA.

Factors associated with term SGA babies

• Greater than or less than 35 years
6

• Primiparity
6,54

• Spacing less than 36 months

55

• Short maternal stature

6,55 6
(less than or equal to 157 cm )
• Weight:
6
o Underweight pre-pregnancy BMI / weight less than or equal to 55kg pre-
55
pregnancy
6 56
o Obesity , particularly with weight loss in pregnancy
54 52
o Inadequate weight gain / weight gain less than 6kg
• Greater severity of intimate partner violence in low income women
57

• Less than 4 antenatal visits /inadequate or late commencement of antenatal

54
58,55,59,60
Maternal care
• Previous SGA baby
• Multiple pregnancy
• Smoking
6,58,60,61,55

• Peridontal disease
62,63

• Hypertensive disorders of pregnancy (e.g. preeclampsia)

6,58

• Chronic hypertension
58

• Threatened preterm labour :

6
6 64
o Possibly due to an early intrauterine insult (e.g. central nervous system )
• Previous preterm birth
60

• Anaemia
55

• Pollutant exposures (e.g. proximity to power plants)

65

• Infection: CMV
66

• Female gender
67
Fetal
• Congenital anomaly
60

• Low placental weight

6

• Insufficient placental perfusion :

68

o Doppler assessment 37−41 weeks in low risk pregnancies: UA PI greater

Placental 69
than 1.2 and uterine artery RI greater than 0.5
• Placental infarction
54

• Chronic villitis
54

• Lower social-economic status /family income

55 6

• Illicit perinatal substance dependency or abuse , alcohol consumption

60 6
Conflicting
• Gestational hypertension
6,54,55,60
evidence
• Infection (e.g. HIV
70,71
)
• Education less than high school
6

• Diabetes , gestational diabetes

6 6

• Social support
6

• Maternal anxiety
6
Insufficient
• Maternal depressive symptoms
6
evidence
• High exercise
6

• Micronutrient deficiency
6

• Low dietary energy (calorie) intake

6

Abbreviations: BMI Body mass index; PI Pulsatility index; RI Resistive index

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Queensland Clinical Guideline: Term small for gestational age baby

Appendix B: Growth charts

Growth chart for girls

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Queensland Clinical Guideline: Term small for gestational age baby

Growth chart for boys

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Queensland Clinical Guideline: Term small for gestational age baby

Acknowledgements
Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and
other stakeholders who participated throughout the guideline development process particularly:

Working Party Clinical Lead

Dr Linda McLaughlin, Staff Specialist, Grantley Stable Neonatal Unit, Royal Brisbane and Womens’
Hospital

Queensland Clinical Guidelines Program Officer

Ms Lyndel Gray, Clinical Nurse Consultant

Working Party Members

Ms Lyn Ahearn, Baby Friendly Hospital Initiative Co-ordinator, Gold Coast University Hospital
Mrs Seija Argyros, Neonatal Nurse Practitioner, Royal Brisbane and Women’s Hospital
Mrs Maxine Ballinger, Clinical Nurse Consultant, Special Care Nursery, Rockhampton Hospital
Mrs Anne Barnes, Midwife, Goondiwindi Hospital
Dr Leanne Chapman, Advanced Trainee, Obstetrics & Gynaecology, Logan Hospital
Dr Lindsay Cochrane, Staff Specialist, Obstetrics, Caboolture Hospital
Dr Paul Conaghan, Senior Staff Specialist, Obstetrics, Mater Health Services
Mrs Kelly Cooper, Midwife, Caboolture Hospital
Dr Mark Davies, Neonatologist, Royal Brisbane and Women’s Hospital
Dr Wendy Dutton, Director of Obstetrics and Gynaecology, Redland Hospital
Ms Tonya Gibbs, Nurse Educator, Nambour Hospital
Dr Shivanand Hebbandi, Paediatrician, Redland Hospital
Ms Louise Homan, Midwife, Nurse Unit Manager, Cairns Hospital
Ms Karen Hose, Neonatal Nurse Practitioner, Royal Brisbane and Women’s Hospital
Mrs Sharon Kiggins, Clinical Midwifery Specialist, Campbelltown Hospital
Ms Cathy Krause, Clinical Nurse and Midwife, St Vincent’s Hospital
Associate Professor Kassam Mahomed, Obstetrician, Ipswich Hospital
Dr Bruce Maybloom, General Practitioner, Brisbane
Dr Lee Minuzzo, Senior Staff Specialist, Obstetrician, Royal Brisbane and Women’s Hospital
Mrs Megan Murphy, Clinical Nurse Consultant, Neonatal Intensive Care Unit, The Townsville
Hospital
Dr Scott Petersen, Staff Specialist, Obstetrician, Mater Health Services
Ms Marian Rigney, Neonatal Nurse Unit Manager, Logan-Bayside Network
Mrs Erika Rossouw, Clinical Nurse, Neonatal Unit, Gold Coast University Hospital
Ms Heather Scanlan, Midwife, Cairns Hospital
Dr Renuka Sekar, Staff Specialist, Maternal Fetal Medicine, Royal Brisbane and Women’s Hospital
Ms Alecia Staines, Consumer Representative, Maternity Consumer Network
Dr Mohan Swaminathan, Senior Medical Officer, Paediatrics & Neonatology, Cairns Hospital
Mrs Angela Swift, Clinical Midwife Consultant, Mossman Multi-Purpose Health Service
Mrs Donna Traves, Obstetric Sonographer, Royal Brisbane and Women’s Hospital
Professor David Tudehope, Professorial Researcher, Mater Research Institute and University of
Queensland
Mrs Deanna Ward, Clinical Educator, Midwifery and Neonatal Services, Mater Health Services North
Queensland
Professor Joan Webster, Nursing Director, Research, Royal Brisbane and Women’s Hospital

Queensland Clinical Guidelines Team

Associate Professor Rebecca Kimble, Director
Ms Jacinta Lee, Manager
Ms Lyndel Gray, Clinical Nurse Consultant
Ms Stephanie Sutherns, Clinical Nurse Consultant
Dr Brent Knack, Program Officer
Steering Committee

Funding
This clinical guideline was funded by Healthcare Improvement Unit, Queensland Health.

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