What is the management plan for a newborn with intrauterine growth restriction (IUGR)?

Management of a Child with IUGR

Immediate Postnatal Assessment and Monitoring

Newborns with IUGR require immediate evaluation for acute metabolic, thermal, and hematological complications that can be life-threatening in the early neonatal period. 1

Initial Stabilization

• Ensure a pediatric team attends the delivery, as IUGR infants have high risk of meconium aspiration, low Apgar scores, and metabolic disorders 2
• Monitor for and treat hypoglycemia (most common acute complication), hypothermia, polycythemia, and hypocalcemia in the first 24-48 hours 1
• Assess for perinatal asphyxia given the reduced ability of growth-restricted fetuses to tolerate labor and high risk of acidosis 2, 3

Diagnostic Evaluation

• Perform detailed physical examination to identify congenital anomalies, as up to 20% of early-onset IUGR cases are associated with fetal or chromosomal abnormalities 4
• Consider chromosomal microarray analysis if IUGR was diagnosed prenatally before 32 weeks without clear etiology, or if malformations are present 5, 4
• Evaluate for intrauterine infections (cytomegalovirus, toxoplasmosis) if clinically indicated by maternal history or infant findings 5

Short-Term Neonatal Management

Metabolic Monitoring

• Implement frequent glucose monitoring (every 2-4 hours initially) as IUGR infants have limited glycogen stores and are prone to hypoglycemia 1
• Monitor electrolytes and calcium levels closely in the first days of life 1
• Assess hematocrit for polycythemia, which increases risk of hyperviscosity syndrome 1

Nutritional Support

• Initiate early and aggressive nutritional support to prevent further growth failure while avoiding excessive catch-up growth 1
• Balance optimal catch-up growth to promote normal development while preventing onset of cardiovascular and metabolic disorders long-term 1
• Monitor feeding tolerance carefully, as IUGR infants may have increased risk of necrotizing enterocolitis

Thermal Regulation

• Provide strict temperature control as IUGR infants have reduced subcutaneous fat and increased surface area-to-body mass ratio, making them vulnerable to hypothermia 1

Long-Term Follow-Up and Monitoring

Growth Surveillance

• Monitor physical growth parameters (weight, length, head circumference) at regular intervals through childhood 1
• Track growth velocity to ensure adequate catch-up growth without excessive acceleration that predisposes to metabolic syndrome 1

Developmental Assessment

• Implement neurodevelopmental screening and monitoring as IUGR is associated with increased risk of neurodevelopmental impairment 1
• Assess developmental milestones at routine well-child visits with lower threshold for early intervention referral

Metabolic and Cardiovascular Screening

• Screen for metabolic syndrome components including insulin resistance, dyslipidemia, and hypertension starting in childhood 6, 1
• Monitor blood pressure regularly, as IUGR infants have increased risk of systolic hypertension in childhood and adulthood 6
• Assess for obesity and insulin resistance during childhood, as IUGR predisposes to type 2 diabetes in adulthood 6, 1

Endocrine Monitoring

• Evaluate for endocrine abnormalities including growth hormone deficiency and thyroid dysfunction during follow-up 1

Critical Pitfalls to Avoid

• Do not assume all small infants are constitutionally small—IUGR carries significant morbidity and mortality risk requiring heightened surveillance 7, 6
• Do not allow excessive rapid catch-up growth in the first 2 years, as this programming increases cardiovascular and metabolic disease risk 1
• Do not discontinue monitoring after the neonatal period—long-term health consequences emerge throughout childhood and adulthood, requiring ongoing surveillance 6, 1
• Do not overlook the need for multidisciplinary care involving neonatology, pediatrics, nutrition, and developmental specialists 1