Small for Gestational Age (SGA)
This site is for Small for Gestational age information. Small for Gestational Age, otherwise called SGA, is a very challenging diagnosis. It is often overlooked or misinterpreted. If you have any questions-please contact us at the information provided below.
Between 3% and 10% of live births each year are described as "small for gestational age" (SGA). In addition, older children who are of short stature and underweight may be labeled Small for Gestational Age by their physicians. There are many variances in the definition of Small for Gestational Age, but generally, SGA describes a child whose birth weight and/or length is/was less than the 3rd percentile (with age adjusted for prematurity). In addition, when ultrasound evidence demonstrated poor fetal growth while in-utero, an infant is also described as being "IUGR" (intrauterine growth retardation). These definitions are descriptive terms and are not specific diagnoses.
Between 3% and 10% of live births each year are described as "small for gestational age" (SGA). In addition, older children who are of short stature and underweight may be labeled Small for Gestational Age by their physicians. There are many variances in the definition of Small for Gestational Age, but generally, SGA describes a child whose birth weight and/or length is/was less than the 3rd percentile (with age adjusted for prematurity). In addition, when ultrasound evidence demonstrated poor fetal growth while in-utero, an infant is also described as being "IUGR" (intrauterine growth retardation). These definitions are descriptive terms and are not specific diagnoses.
Introduction
What are Typical Small for Gestational Age Characteristics?
Clearly, the typical Small for Gestational Age child is shorter and thinner than his or her peers. But the range of other characteristics can vary. A list of common characteristics and more information on SGA is listed below: Characteristics Seen in Almost all Short Small for Gestational Age Children
An infant with SGA is generally born with normal intelligence. Learning disabilities and ADD may be increased in incidence in SGA. Autism and similar disorders like pervasive developmental disorder (PDD) may also be increased. It is unclear whether these problems just appear to be increased in SGA, are innate to SGA, or are related to SGA through early malnutrition and hypoglycemia, both of which are preventable.
Does a Delayed Bone Age Mean My Child Will Have Catch-Up Growth Later?
Although most if not all Small for Gestational Age children have a bone age that is relatively delayed compared to their chronological age, studies have shown bone age to be an unreliable predictor of adult height in SGA children. One possible reason is that many SGA children experience a rapid acceleration of their bone age just prior to the onset of, and during, puberty. Within a span of just 12-18 months, an Small for Gestational Age child's previously delayed bone age can quickly surpass his chronological age, negating any "extra growing time" that usually is present with delayed bone age. It is therefore important to monitor an SGA child's bone age, to ensure that it does not begin to advance. For the older SGA child, bone ages are also used to determine if any incremental height remains for the child (as long as the bone plates are open and not fused).
How Can I Help My Small for Gestational Age Child Grow?
Simplistically, there are two aspects of the SGA child's growth -- weight and height. Particular attention should be paid to weight gain during the first 2 to 3 years of life, as many children born Small for Gestational Age may struggle to gain weight (although ironically, some children born Small for Gestational Age may gain excessive weight during childhood). As previously discussed, a pediatric GI doctor can help diagnose and treat, or rule out, any GI medical issues that may impede an SGA child's ability to gain weight. Reflux (often silent) and delayed gastric emptying appear to be the most common of these GI problems. A nutritionist can also help provide advice on simple additives and other means of adding calories to a child's diet. There are also medications like the antihistamine "cyproheptadine" (brand name: Periactin) which can act to increase an SGA child's appetite. Please contact MAGIC for more in-depth literature on this topic. The second growth aspect is length/height. More than 90% of children born Small for Gestational Age catch-up to normal height by 2 to 3 years of age. Among those who do not, inadequate caloric intake may contribute to growth failure. If optimum caloric intake can be attained, some "catch-up" in weight and height growth curves may occur. If a child is still significantly short after this period, and the child is 2 to 3 years old or older, then the family may consider growth hormone therapy in order to increase the child's height growth velocity. It is important to note two things. First, research has not found any means except growth hormone therapy to stimulate catch-up growth, maintain a normal height during childhood, and increase a Small for Gestational Age child's adult height. The United States F.D.A. approved growth hormone therapy as "…long-term treatment of children who were born SGA and who have not achieved catch-up growth by the age of 2." Second, most SGA children are not GH deficient according to standard testing measurements. Studies are ongoing, but it appears that many of these short SGA children do not respond normally to growth hormone and thus require more growth hormone than the typical child. Instead of being growth hormone "deficient", experts now consider SGA children to be growth hormone "insufficient."
Deciding About Growth Hormone Therapy
The decision to begin growth hormone therapy for an Small for Gestational Age child can be an easy decision for some parents, and a difficult one for others. Not all parents choose this treatment for their child. We at MAGIC will support you in whatever choice you make. However, remember that growth hormone therapy is the only treatment currently available to increase the Small for Gestational Age child's height. Your doctor will help you in this decision process, and many factors must be considered. Factors discussed may include potential incremental height for your child (based on the parents' height), whether your child can benefit from the possible added muscle mass and strength, your child's age, bone age, other health issues of your child, and insurance coverage or the possible pharmaceutical company assistance. Growth hormone therapy requires a commitment. However, the initial commitment can be for a trial period of at least 6 months to determine growth response. The injection is a simple subcutaneous (top layers of skin) injection every night. Most children and parents who have chosen this treatment think it has turned out far better and far easier than they expected. If you are interested in talking with other families who have chosen or declined growth hormone therapy, MAGIC can connect you.
Are There any Other Health Issues Associated with Being Born SGA?
Multiple studies, short-term and longitudinal, have found an increased risk of health problems such as insulin resistance, cardiovascular disease, hypertension, obesity, and type 2 diabetes among adults who were born SGA or with low-birth weight. Explanations for these risks vary from intrauterine nutrition to genetic causes. In addition, some correlations have been found between persistent short stature and psychosocial difficulties and/or behavioral problems. Clearly, a great deal of research still needs to be done to narrow down and clarify the exact risks of being born Small for Gestational Age and identify which children are at risk. Until then, children and adults born SGA should be monitored carefully by their physicians in light of these possible risks.
Coping
Coping with the time-consuming special attention and services necessary to care for an SGA child can be overwhelming, especially if you try to face it alone. Good physicians may have no experience with routine needs of Small for Gestational Age children. Day-to-day challenges such as feeding, formulas, fitting clothes, school issues and peer pressures can be less stressful if you are in contact with other families who "have been there". Making connections between families with similar issues and facilitating sharing of information and experience is a major goal of the MAGIC Foundation's RSS/SGA Division. We can put you in touch with other people who have had, and have solved, problems similar to yours.
Treatment
The treatment of Small for Gestational Age children's problems should be approached in a systematic and timely fashion. The major problems that require intervention in the various age periods are all different, but most all these problems can be solved or dealt with successfully if you get the help you need. It is beyond the scope of this brochure to go into specifics on various treatment protocols. Feel free to contact MAGIC for more in-depth information. Most importantly, be your child's #1 advocate, trust your parental gut instinct, and love your beautiful Small for Gestational Age child. We at MAGIC will be here to help you in whatever way you need.
Contributing Medical Specialists:
Peter A. Lee, M.D. Ph.D.
Prof. of Pediatrics, Chief of Pediatric Endocrinology
Penn State University, Milton S. Hershey Medical Center
College of Medicine, Division of Pediatric Endocrinology
Madeleine D. Harbison, M.D.
Asst. Prof. of Pediatrics,
Div. of Pediatric Endocrinology
Weill Medical College of Cornell University
New York Presbyterian Hospital
To contact other parents affected by Small for Gestational Age, read additional information or personal stories, please contact us (The MAGIC Foundation) at the information below. We are a parent organized and run group because we have lived through this very challenging issue.
Clearly, the typical Small for Gestational Age child is shorter and thinner than his or her peers. But the range of other characteristics can vary. A list of common characteristics and more information on SGA is listed below: Characteristics Seen in Almost all Short Small for Gestational Age Children
- low birth weight; probably low birth length
- inadequate catch-up growth in first 2 years
- persistently low weight-for-height proportion
- lack of muscle mass and/or poor muscle tone
- lack of interest in eating
- fasting hypoglycemia & mild metabolic acidosis
- generalized intestinal movement abnormalities:
- esophageal reflux (may be silent with no spitting up)
- delayed stomach emptying
- constipation
- blue sclera (bluish tinge in white of eye)
- late closure of the anterior fontanel (soft spot on the skull)
- frequent ear infections or chronic fluid in ears
- congenital absence of the second premolars
- delay of gross and fine motor development
- delay of speech and oral motor development
- delayed bone age early, later fast advancement
- early pubic hair and underarm odor (adrenarche)
- early puberty or rarely true precocious puberty
- classical or neurosecretory growth hormone deficiency
- possible attention deficit disorder (ADD) or specific learning disabilities
- possible kidney abnormalities
- Make sure your child is measured carefully & frequently. KEEP YOUR OWN RECORDS. Find an endocrinologist who knows how to treat SGA children's growth failure and discuss the options.
- Find a pediatrician who is willing to learn from experts about SGA children, and will coordinate care and opin- ions with consulting specialists.
- Have your child evaluated by a pediatric gastroenterolo- gist if your child struggles to gain weight. She/he may consider a test for slow gastric emptying and reflux (the latter preferably with a pH probe test).
- Get adequate calories into your child. Insufficient nutri- tion & low blood sugar damage the developing brain and compound the growth failure.
- Take necessary measures to prevent hypoglycemia in young SGA children. Pay special attention to the night when everyone is asleep, anytime your child is ill or not eating normally, and when your child is unusually active or stressed.
- Know clues that hypoglycemia (or the spilling of ketones) may be occurring:
- waking to feed at night past early infanc
- excessive sweating
- extreme crankiness improved by feeding
- difficulty waking up in the morningketones in the urine
- Prevent hypoglycemia (primarily in the underweight SGA child) by:
- feeding frequently during the day & night
- keeping snacks with you at all time
- adding glucose polymer in infant's, & cornstarch in child's, bed- & night-time feeding
- keeping glucose gel with you at all times
- making prior arrangements with your doctor and local ER to start IV glucose if feeding is impossible
- having urine ketone sticks at home (over the counter)
- Monitor skeletal maturity (bone age x-ray) annually
- Treat your child according to his age not his size. Arrange safe, age-appropriate activities; buy age- appropriate clothes; and expect age-appropriate behavior and responsibility.
- Watch your child's psychosocial and motor development. All states have developmental evaluation & intervention services for children less than 3. These programs are based on the child's needs not parental income. For children over 3 years, the school district becomes responsible for providing these services. Take advantage of this; intervention can make a world of difference for your child!
- Seek appropriate consultation for recurrent ear infections, or any other medical issues. But remember:
- Only emergency surgery should be done until the child is gaining weight well.
- A young underweight SGA child should NEVER be fasted or kept NPO for more than 4 hours for ANY reason without glucose-running IV.
- For surgery, IV glucose should be given during the procedure and continued in the recovery room until the child can eat again.
An infant with SGA is generally born with normal intelligence. Learning disabilities and ADD may be increased in incidence in SGA. Autism and similar disorders like pervasive developmental disorder (PDD) may also be increased. It is unclear whether these problems just appear to be increased in SGA, are innate to SGA, or are related to SGA through early malnutrition and hypoglycemia, both of which are preventable.
Does a Delayed Bone Age Mean My Child Will Have Catch-Up Growth Later?
Although most if not all Small for Gestational Age children have a bone age that is relatively delayed compared to their chronological age, studies have shown bone age to be an unreliable predictor of adult height in SGA children. One possible reason is that many SGA children experience a rapid acceleration of their bone age just prior to the onset of, and during, puberty. Within a span of just 12-18 months, an Small for Gestational Age child's previously delayed bone age can quickly surpass his chronological age, negating any "extra growing time" that usually is present with delayed bone age. It is therefore important to monitor an SGA child's bone age, to ensure that it does not begin to advance. For the older SGA child, bone ages are also used to determine if any incremental height remains for the child (as long as the bone plates are open and not fused).
How Can I Help My Small for Gestational Age Child Grow?
Simplistically, there are two aspects of the SGA child's growth -- weight and height. Particular attention should be paid to weight gain during the first 2 to 3 years of life, as many children born Small for Gestational Age may struggle to gain weight (although ironically, some children born Small for Gestational Age may gain excessive weight during childhood). As previously discussed, a pediatric GI doctor can help diagnose and treat, or rule out, any GI medical issues that may impede an SGA child's ability to gain weight. Reflux (often silent) and delayed gastric emptying appear to be the most common of these GI problems. A nutritionist can also help provide advice on simple additives and other means of adding calories to a child's diet. There are also medications like the antihistamine "cyproheptadine" (brand name: Periactin) which can act to increase an SGA child's appetite. Please contact MAGIC for more in-depth literature on this topic. The second growth aspect is length/height. More than 90% of children born Small for Gestational Age catch-up to normal height by 2 to 3 years of age. Among those who do not, inadequate caloric intake may contribute to growth failure. If optimum caloric intake can be attained, some "catch-up" in weight and height growth curves may occur. If a child is still significantly short after this period, and the child is 2 to 3 years old or older, then the family may consider growth hormone therapy in order to increase the child's height growth velocity. It is important to note two things. First, research has not found any means except growth hormone therapy to stimulate catch-up growth, maintain a normal height during childhood, and increase a Small for Gestational Age child's adult height. The United States F.D.A. approved growth hormone therapy as "…long-term treatment of children who were born SGA and who have not achieved catch-up growth by the age of 2." Second, most SGA children are not GH deficient according to standard testing measurements. Studies are ongoing, but it appears that many of these short SGA children do not respond normally to growth hormone and thus require more growth hormone than the typical child. Instead of being growth hormone "deficient", experts now consider SGA children to be growth hormone "insufficient."
Deciding About Growth Hormone Therapy
The decision to begin growth hormone therapy for an Small for Gestational Age child can be an easy decision for some parents, and a difficult one for others. Not all parents choose this treatment for their child. We at MAGIC will support you in whatever choice you make. However, remember that growth hormone therapy is the only treatment currently available to increase the Small for Gestational Age child's height. Your doctor will help you in this decision process, and many factors must be considered. Factors discussed may include potential incremental height for your child (based on the parents' height), whether your child can benefit from the possible added muscle mass and strength, your child's age, bone age, other health issues of your child, and insurance coverage or the possible pharmaceutical company assistance. Growth hormone therapy requires a commitment. However, the initial commitment can be for a trial period of at least 6 months to determine growth response. The injection is a simple subcutaneous (top layers of skin) injection every night. Most children and parents who have chosen this treatment think it has turned out far better and far easier than they expected. If you are interested in talking with other families who have chosen or declined growth hormone therapy, MAGIC can connect you.
Are There any Other Health Issues Associated with Being Born SGA?
Multiple studies, short-term and longitudinal, have found an increased risk of health problems such as insulin resistance, cardiovascular disease, hypertension, obesity, and type 2 diabetes among adults who were born SGA or with low-birth weight. Explanations for these risks vary from intrauterine nutrition to genetic causes. In addition, some correlations have been found between persistent short stature and psychosocial difficulties and/or behavioral problems. Clearly, a great deal of research still needs to be done to narrow down and clarify the exact risks of being born Small for Gestational Age and identify which children are at risk. Until then, children and adults born SGA should be monitored carefully by their physicians in light of these possible risks.
Coping
Coping with the time-consuming special attention and services necessary to care for an SGA child can be overwhelming, especially if you try to face it alone. Good physicians may have no experience with routine needs of Small for Gestational Age children. Day-to-day challenges such as feeding, formulas, fitting clothes, school issues and peer pressures can be less stressful if you are in contact with other families who "have been there". Making connections between families with similar issues and facilitating sharing of information and experience is a major goal of the MAGIC Foundation's RSS/SGA Division. We can put you in touch with other people who have had, and have solved, problems similar to yours.
Treatment
The treatment of Small for Gestational Age children's problems should be approached in a systematic and timely fashion. The major problems that require intervention in the various age periods are all different, but most all these problems can be solved or dealt with successfully if you get the help you need. It is beyond the scope of this brochure to go into specifics on various treatment protocols. Feel free to contact MAGIC for more in-depth information. Most importantly, be your child's #1 advocate, trust your parental gut instinct, and love your beautiful Small for Gestational Age child. We at MAGIC will be here to help you in whatever way you need.
Contributing Medical Specialists:
Peter A. Lee, M.D. Ph.D.
Prof. of Pediatrics, Chief of Pediatric Endocrinology
Penn State University, Milton S. Hershey Medical Center
College of Medicine, Division of Pediatric Endocrinology
Madeleine D. Harbison, M.D.
Asst. Prof. of Pediatrics,
Div. of Pediatric Endocrinology
Weill Medical College of Cornell University
New York Presbyterian Hospital
To contact other parents affected by Small for Gestational Age, read additional information or personal stories, please contact us (The MAGIC Foundation) at the information below. We are a parent organized and run group because we have lived through this very challenging issue.
www.magicfoundation.org
Ph: (708) 383-0808 (M-F 9-4 central time)
6645 W. North Avenue
Oak Park, IL 60302
Email: ContactUs@magicfoundation.org
And finally- Trust your parental instincts- no one knows your child like you do! No one will fight for your child if you don't! Remember MAGIC's Motto: "Children have a short time to grow and a lifetime to live with the results." (C)
This information is provided as an educational tool for parents seeking information about their children's medical issues. Always defer to your personal / local medical professionals prior to making decisions about healthcare.
LEGAL NOTE:The information in this article is copywritten and legally protected against unauthorized reproduction in any complete or partial form. This article was prepared specifically for The MAGIC Foundation. Any type of reproduction is strictly prohibited pending the foundation and author's written authorization. Privacy and enforcement of our authors, families and materials is taken very seriously. Failure to comply with the legal posting of this notice, will be met with legal action.
Copyright 20014
Ph: (708) 383-0808 (M-F 9-4 central time)
6645 W. North Avenue
Oak Park, IL 60302
Email: ContactUs@magicfoundation.org
And finally- Trust your parental instincts- no one knows your child like you do! No one will fight for your child if you don't! Remember MAGIC's Motto: "Children have a short time to grow and a lifetime to live with the results." (C)
This information is provided as an educational tool for parents seeking information about their children's medical issues. Always defer to your personal / local medical professionals prior to making decisions about healthcare.
LEGAL NOTE:The information in this article is copywritten and legally protected against unauthorized reproduction in any complete or partial form. This article was prepared specifically for The MAGIC Foundation. Any type of reproduction is strictly prohibited pending the foundation and author's written authorization. Privacy and enforcement of our authors, families and materials is taken very seriously. Failure to comply with the legal posting of this notice, will be met with legal action.
Copyright 20014
