The Challenge of Enteral Feeding of

Small for Gestational Age Infants

Dr. dr. Rinawati Rohsiswatmo SpA(K)
dr. Audesia Alvianita
 SMALL FOR GESTATIONAL INFANT VS
INTRA-UTERINE GROWTH RESTRICTION
SGA
• Well-nourished, healthy and short
baby
• Simetrical, normal amniotic fluid
index, normal placental blood flow

IUGR
• Fetus is unable to achieve its
genetically determined potential
size.
• Asimetrical, Abnormal amniotic
fluid, Abnormal placental blood
flow
1. Ester, W., Bannink, E., Van Dijk, M., Willemsen, R., Van Der Kaay, D., De Ridder, M., & Hokken-Koelega, A. (2008).
Subclassification of small for gestational age children with persistent short stature: Growth patterns and response to GH treatment.
Hormone Research, 69(2), 89–98. https://doi.org/10.1159/000111812
2. https://emedicine.medscape.com/article/261226-overview
3. Wibawa, Aria (2019). Analisis Profil Janin, bahan Metabolik dan Sistem Transpor Plasenta, Pengaruh Intervensi Nutrisi Model 5J,
dan hasil Luaran Neonatal pada PJT. Fakultas Kedokteran Universitas Indonesia
 SMALL FOR GESTATIONAL INFANT

Lingkar abdomen • Mean abdominal

90th circumference
intrauterine is between
10th 10th – 20th percentile &
consistent
• Simetrical, normal
amniotic fluid index,
normal placental blood
flow
• No fetal distress

Wibawa, Aria (2019). Analisis Profil Janin, bahan Metabolik dan Sistem Transpor Plasenta, Pengaruh Intervensi Nutrisi Model 5J, dan hasil Luaran Neonatal pada PJT. Fakultas Kedokteran Universitas Indonesia
 INTRA-UTERINE GROWTH RESTRICTION

1. Using serial examination, the growth deviates negatively to 10th percentile in 2 weeks
2. No rise for abdominal circumference in 2 weeks
3. Abnormality of amniotic fluid index
4. Abnormality of placental blood flow (absent or reverse end diastolic umbilical artery)
5. CPR < 1.0

Wibawa, Aria (2019). Analisis Profil Janin, bahan Metabolik dan Sistem Transpor Plasenta, Pengaruh Intervensi Nutrisi Model 5J, dan hasil Luaran Neonatal pada PJT. Fakultas Kedokteran Universitas Indonesia
 OUR BURDEN: Prevalence of SGA
(+IUGR??) Baby

2012
Lee, A. C. C., Kozuki, N., Cousens, S., Stevens, G. A., Blencowe, H., Silveira, M. F., … Katz, J. (2017). Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-
21 st standard: Analysis of CHERG datasets. BMJ (Online), 358, 1–11. https://doi.org/10.1136/bmj.j3677
 SMALL FOR GESTATIONAL INFANT (+IUGR)
Most common causes
Placental  plancental
Constitutional  genetic
infarction, tumor (hydatiform
predisposition, ethnicity
mole, chorioangioma), TTTS

Maternal  young maternal Fetal  chromosomal

age, pregnancy-induced abnormalities (Trisomy 21),
hypertension, chronic congenital anomalies (heart
hypoxemia, malnutrition, defects), chronic congenital
chronic illness infection (CMV, rubella, syphilis)

1.Department of Heath and Human Services SGoV, Australia,. Neonatal ehand- book: Small for gestational age infants. Available at: http://www.health.vic
.gov.au/neonatalhandbook/conditions/small-for-gestational-age-infants .htm. Accessed 14 November 2015
2.Belkacemi L, Nelson DM, Desai M, Ross MG. Maternal undernutrition influ- ences placental-fetal development. Biol Reprod 2010; 83: 325-31.
WHAT IS OUR
CHALLENGE?
 How slow we can wait
How fast we can go
TOO LONG  Undernutrition  Stunting
While many children born SGA
achieve sufficient growth to
normalize their stature by 2
years of age, approximately
10–15% maintain a height <–2
standard deviation scores and
continue to be short
throughout adolescence and
adulthood

TOO FAST  Overnutrition  Metabolic Syndrome

Ester, W., Bannink, E., Van Dijk, M., Willemsen, R., Van Der Kaay, D., De Ridder, M., & Hokken-Koelega, A. (2008). Subclassification of small for gestational age children with persistent short stature: Growth patterns and response to GH
treatment. Hormone Research, 69(2), 89–98. https://doi.org/10.1159/000111812
 NUTRITION STRATEGIES FOR CATCH-UP
GROWTH
Assessing growth differences for term SGA
infants
- Clinically significant catch-up growth  weight or length gain of greater
than 0.67 standard deviation score during the first 2 years of age

- Accelerated growth especially within the first 3-6 months

- Begins with an increased rate of subcutaneous fat deposition

- Height, weight, and head circumference catch-up not occur at identical

rates
1. Ong KK, Ahmed ML, Emmett PM, Preece MA, Dunger DB. Association between postnatal catch-up growth and obesity in childhood: prospective cohort study. BMJ 2000; 320: 967-71.
2. Taal HR, Vd Heijden AJ, Steegers EA, Hofman A, Jaddoe VW. Small and large size for gestational age at birth, infant growth, and childhood overweight. Obesity (Silver Spring) 2013; 21: 1261-8.
 1-3 mo : 25-30 g/day

3-6 mo : 20 g/day

6-12 mo: 10-15 g/day

Catch-up growth  min. 50%

percentile before 7 months of
age (corrective age)
NUTRITION STRATEGIES FOR CATCH-UP
GROWTH

Lei, Xiaoping, et al. "The optimal postnatal growth trajectory for term small for gestational age babies: a prospective cohort study." The Journal of pediatrics 166.1 (2015): 54-58.
 Weight growth trajectory in term SGA
infants

Lei, X., Chen, Y., Ye, J., Ouyang, F., Jiang, F., & Zhang, J. (2015). The optimal postnatal growth trajectory for term small for gestational age babies: A prospective cohort study. Journal of Pediatrics, 166(1), 54-58.e3.
https://doi.org/10.1016/j.jpeds.2014.09.025
CMH EXPERIENCE
Assessing growth differences for preterm
SGA infants
Optimal growth in CMH:

1.At least maintain linear growth

2.Achieve minimum weight growth of 15-20 g/kg/day until

34 weeks, followed by 25-30 g/day, length 0.9 cm/week,
Head circumference 0.9 cm/week

3.Achieve between 10th - 50th percentile before 7 months

13
Nutritional requirements of the preterm
infants
EPSGHAN 2018
UPDATE

2.5 - 3.5

(parenteral amino acid

intakes above 3.5 g/kg/d
should only be administered
as part of clinical trials)

Enteral feeding of Preterm Infants-Neonatal Feeding Clinical Guidelines , NHS Royal Cornwall Hospital, 2018
Nutritional requirements of the preterm
infants
EPSGHAN 2018
UPDATE
 CONCLUSION

SGA remains a
problem in Physiologically Research needed to
Indonesia & should different than devise specific guideline
preterm infants for SGA
be differentiate
from IUGR
Q&A Session