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: [email protected] 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, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected], phone (07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479.

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Flow Chart: Term small for gestational age baby

Term small for gestational age baby

Initial care at birth: • Resuscitate and stabilise as required: Yes/ Postnatal Perinatal asphyxia, potentially Contact Retrieval Services o transfer meconium aspiration, PPHN Queensland (RSQ) on required? • Maintain normothermia: 1300 799 127 o Warm draft free environment • Skin-to-skin contact • Feed within 30−60 minutes of No birth • Admit to SCN if required Newborn assessment: Ongoing care: Potential associated • Distinguish the healthy small • Based on underlying diagnosis morbidity: baby from the FGR baby and individual presentation • Hypoglycaemia o Obtain a detailed history • Feeding: • Hypothermia o Perform a physical o Demand feed at least 3 hourly • Polycythaemia/hyperviscosity examination o If baby does not feed within a • Immunodeficiency/ o Examine the placenta 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 Growth assessment: • Rarely necrotising enterocolitis with abnormal umbilical artery • Estimate gestation: US (earlier Doppler flow studies dating is the most accurate), • Maintain normothermia: LMP, Ballard examination Temperature 3−4 hourly/pre- • Physical examination: o feeds if stable Constitutionally small: healthy Potential investigations: o Hourly temperature if not Growth restricted: at increased o • Placental histopathology, o stable risk of morbidity and mortality chromosomal analysis, cord Pre-interventions and 30−60 Plot weight, head o blood gases o mins after interventions circumference and length on • FBC, Hct, platelet count • Be alert to associated percentile chart • 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: Parental considerations: Newborn hypoglycaemia] Dysmorphology assessment • Involve parents in shared • Be alert for neonatal jaundice, o o Chromosome studies decision making particularly in babies with Refer to clinical geneticist • Facilitate parent involvement in polycythaemia and/or not o their baby’s care feeding well [refer to QCG: • Ensure parents understand Neonatal jaundice] importance of: o Maintaining the baby’s temperature and feeding Associated QCG guidelines: regularly to avoid • Routine newborn assessment hypoglycaemia Discharge planning: • Neonatal resuscitation . Provide additional feeding • Baby healthy and physiologically • Neonatal respiratory distress support as required stable including CPAP . Observing for jaundice • Feeding progressing well • Neonatal stabilisation for • Explain tests and procedures, • A steady weight gain (e.g. ≥ 30 retrieval comfort measures, equipment grams/day) • Newborn hypoglycaemia • Refer to local support services • Discharge plan is in place • Normal birth where required (e.g. social • Follow-up as per baby and • Hypoxic-ischaemic work) family requirements (e.g. encephalopathy (HIE) • Provide written parent multidisciplinary/paediatric for • Perinatal substance use information baby < 2000 g) • Neonatal jaundice

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

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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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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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1 Introduction The term ‘small for gestational age’ (SGA) refers to the small size of the baby at birth, that is, when the birth weight is below the 10th percentile.1 Babies who are SGA may be1: • 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

Differentiating between FGR and SGA remains an obstetric challenge7: • Babies born SGA may not have FGR • Babies born AGA may have been affected by growth restriction and this may not have been detected antenatally1 • 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 deaths, was reported at8: 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

Within Queensland, the incidence of term SGA in 2015 was9: • 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 represented10 and this extends to the number of associated admissions to neonatal units11

1.2 Factors associated with fetal growth Birth weight is one of the key measurements used to reflect the intrauterine environment to which the fetus was exposed.12 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 for the adult if prolonged.13,14 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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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]* Variable6 Moderate SGA6 Severe SGA6 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 analysis6

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 jaundice15] • 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 information: Small for gestational age baby16]

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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 resuscitation17 • The SGA baby is at greater risk of hypothermia than an AGA baby1 • Maintain normothermia (36.5–37.5 °C), including when resuscitation is required18 • Provide a warm draft free environment19 Temperature 18 • Dry the baby after birth with pre-warmed towels, apply a pre-warmed hat • 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 QCG: Normal birth [Fourth stage]20 including information on: o Initial assessment and care Skin to skin contact and breastfeeding o 21 o Risk of hypoglycaemia, feed within 30−60 minutes of birth Observations Routine care o 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 Hypothermia22 o 23 o Hypoglycaemia requiring intravenous (IV) therapy o Hyperglycaemia Hypocalcaemia22 o 22,23 o Polycythaemia/hyperviscosity Congenital anomalies1 o 24 Indications for o Infection (TORCH and acquired) additional care • Other associated FGR morbidities that may also require admission to a neonatal unit include22: 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, sepsis25,26, congenital heart disease26, hypoxic-ischaemic encephalopathy (HIE)26, formula feeding27 • As required refer to QCGs [https://www.health.qld.gov.au/qcg/]: 28 o Routine newborn assessment Neonatal resuscitation29 o 30 Associated o Establishing breastfeeding Queensland Neonatal respiratory distress including CPAP31 o 32 Clinical o Neonatal stabilisation for retrieval Guidelines (QCG) Newborn hypoglycaemia21 o 33 o Hypoxic-ischaemic encephalopathy Perinatal substance use: neonatal34 o 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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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 promote mother-baby attachment35 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 compared to AGA babies35 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, where possible, cause or contributing factors for small size36 • 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 which is associated with overestimation of gestational age37: o The earlier US dating occurs (preferably before 12 weeks), the more accurate the prediction of gestational age Confirmation of Up to 23 weeks gestation US dating remains more accurate than a gestational age o 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 Score may be performed to estimate gestational age1 • Refer to QCG: Routine newborn assessment28 • FGR may be associated with chromosomal syndromes, perinatal substance use, and viral infections38: 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 5] is of less clinical importance than the results of the Doppler studies2 • 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 be uncommon25

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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 less than the 10th percentile on the growth chart1 Symmetrical 38 • More severe form typically detected in the second trimester ultrasound FGR and associated with chromosomal abnormalities, congenital malformations and intrauterine congenital infection, fetal alcohol syndrome, and low social-economic status1,22 • Also known as ‘head sparing’ FGR • Disproportionate decrease in length and weight compared to the head circumference1: 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 late in pregnancy38 (e.g. maternal hypertensive conditions, long standing maternal diabetes, renal disease, smoking and living at a high altitude) • 38 Asymmetrical May include the appearance of the following features : FGR o Head disproportionately large for trunk o Extremities appear wasted, muscle mass may be decreased especially in the buttocks and thighs1 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 gestational age36 • The Fenton growth charts for preterm infants39: 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 charts of the SGA baby40,41,42,43 • Comparison of head circumference to weight and length may help to identify symmetrical or asymmetrical FGR

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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 mosaicism: Placental 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 Management of perinatal infections44 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: Within the first hour of birth o 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 (e.g. incubator) and the baby’s temperature16 • Document baby and equipment temperature, as well as interventions

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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 hepatic and cardiac muscle glycogen stores9, a limited capacity for gluconeogenesis9, increased insulin sensitivity and polycythaemia • If the baby is well, monitor the BGL18: 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 hypoglycaemia18 • Promote and support breastfeeding • Refer to QCG: Establishing breastfeeding30 • 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 Offer a feed if the baby has not fed for 3 hours Feeding o 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 fluids whilst waiting for colostrum or breast milk to become available35 • 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 jaundice15

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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 SGA babies are at low risk for serious long term outcomes45-48 • Prognosis related to FGR can principally be determined by1: The cause of aberrant growth Prognosis o 17 o Timing and duration of growth restriction Severity and symmetry of growth restriction17 o 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 difficulties45 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, hearing, vision or sleep outcomes)17: . 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 FGR17 • Whilst an increased prognosis of metabolic syndrome has been associated with FGR irrespective of gestation49, composite outcome Long term analysis for conditions associated with metabolic syndrome (obesity, morbidity hypertension, hypercholesterolaemia, coronary heart disease, and type 2 diabetes) has shown a non-significant association with term SGA45 • When individual morbidities are considered, there is45: 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 include36: 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 fat mass, central adiposity and insulin resistance52

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5 Discharge planning

Table 11. Discharge planning

Aspect Consideration • Evaluate each mother and baby individually to determine the optimal time for discharge53 • 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 discharge35 although there needs to be caution in babies weighing less than 2000 g Criteria for • 35 discharge For babies less than 2000 g, discharge may be considered providing : 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 regarding1: 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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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 years6 • Primiparity6,54 • Spacing less than 36 months55 • Short maternal stature6,55 (less than or equal to 157 cm6) • Weight: 6 o Underweight pre-pregnancy BMI / weight less than or equal to 55kg pre- pregnancy55 Obesity6, particularly with weight loss in pregnancy56 o 54 52 o Inadequate weight gain / weight gain less than 6kg • Greater severity of intimate partner violence in low income women57 • Less than 4 antenatal visits54/inadequate or late commencement of antenatal 58,55,59,60 Maternal care • Previous SGA baby • Multiple pregnancy • Smoking6,58,60,61,55 • Peridontal disease62,63 • Hypertensive disorders of pregnancy (e.g. preeclampsia)6,58 • Chronic hypertension58 • Threatened preterm labour6: 6 64 o Possibly due to an early intrauterine insult (e.g. central nervous system ) • Previous preterm birth60 • Anaemia55 • Pollutant exposures (e.g. proximity to power plants)65 • Infection: CMV66 Fetal • Female gender67 • Congenital anomaly60 • Low placental weight6 • Insufficient placental perfusion68: Doppler assessment 37−41 weeks in low risk pregnancies: UA PI greater Placental o 69 than 1.2 and uterine artery RI greater than 0.5 • Placental infarction54 • Chronic villitis54 • Lower social-economic status55/family income6 Conflicting • Illicit perinatal substance dependency or abuse60, alcohol consumption6 evidence • Gestational hypertension6,54,55,60 • Infection (e.g. HIV70,71) • Education less than high school6 • Diabetes6, gestational diabetes6 • Social support6 Insufficient • Maternal anxiety6 evidence • Maternal depressive symptoms6 • High exercise6 • Micronutrient deficiency6 • Low dietary energy (calorie) intake6 Abbreviations: BMI Body mass index; PI Pulsatility index; RI Resistive index

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Appendix B: Growth charts Growth chart for girls

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Growth chart for boys

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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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