Comparisons of mortality and pre-discharge respiratory morbidities in small for gestational age and appropriate-for gestational age premature infants - An Indian Experience

Document Type: Original Article


KEM Hospital, Pune, India


Background: There is an assumption that fetus with restricted growth with an inappropriate intrauterine environment lies under stress. Although small-for-gestational-age (SGA) infants have higher mortality, difference in the outcome of SGA and appropriate-for-gestational-age (AGA) infants regarding respiratory morbidity is controversial. It seems that respiratory morbidities in SGA neonates is different from neonates with AGA. In this study, we intend to compare the mortality and  respiratory morbidity rates between the preterm small for gestational age (SGA) and appropriate for age (AGA) neonates of less than 34 weeks of gestation.
Methods: This analytical cross-sectional study was conducted on 498 preterm neonates with gestational age of < 34 weeks, admitted to the Neonatal Intensive Care Unit. These neonates were categorized into two groups of SGA (n=210) and AGA (n=286). The data analysis was performed, using Student’s t-test and Mann-Whitney U test for parametric variables and Chi-square and Fisher’s exact tests for nonparametric data.
Results: According to the results of the study, the two groups were significantly different in terms of their birth weight (P<0.001), pregnancy-induced hypertension (P<0.001), and antenatal steroid usage (P=0.011). Furthermore, respiratory distress syndrome (RDS) was found to be more prevalent in the premature AGA neonates than the SGA ones (P=0.011). In addition, surfactant usage was significantly less in the SGA group (P=0.0006). Bronchopulmonary dysplasia (BPD) developed in 14% and 9% of the premature AGA and SGA neonates, respectively (P=0.094). However, there was no significant difference between the two groups regarding the mortality rate, intra-ventricular hemorrhage, and necrotizing enterocolitis. Among the survived neonates, mean length of hospital stay was significantly higher in the premature SGA newborns born within 26-36 weeks of gestation than their AGA counterparts.
Conclusion: As the findings of the current study demonstrated, the mortality rate was similar in the SGA and AGA groups; however, the respiratory morbidities such as RDS and BPD were more prevalent in the AGA neonates.


  1. Gilbert WM, Danielsen B. Pregnancy outcomes associated with intrauterine growth restriction. Am J Obstet Gynecol. 2003; 188(6):1596–9.
  2. Bartels DB, Kreienbrock L, Dammann O, Wenzlaff P, Poets CF. Population based study on the outcome of small for gestational age newborns. Arch Dis Child Fetal Neonatal Ed. 2005; 90(1):F53–9.
  3. Gortner L, Wauer RR, Stock GJ, Reiter HL, Reiss I, Jorch G, et al. Neonatal outcome in small for gestational age infants: do they really better? J Perinat Med. 1999; 27(6):484–9.
  4. Simchen MJ, Beiner ME, Strauss-Liviathan N, Dulitzky M, Kuint J, Mashiach S, et al. Neonatal outcome in growth-restricted versus appropriately grown preterm infants. Am J Perinatol. 2000; 17(4):187–92.
  5. Spinillo A, Capuzzo E, Piazzi G, Baltaro F, Stronati M, Ometto A. Significance of low birthweight for gestational age among very preterm infants. Br J Obstet Gynaecol. 1997; 104(6):668–73.
  6. Piper JM, Xenakis EM, McFarland M, Elliott BD, Berkus MD, Langer O. Do growth-retarded premature infants have different rates of perinatal morbidity and mortality than appropriately grown premature infants? Obstet Gynecol. 1996; 87(2):169–74.
  7. Kristensen S, Salihu HM, Keith LG, Kirby RS, Fowler KB, Pass MAB. SGA subtypes and mortality risk among singleton births. Early Hum Dev. 2007; 83(2):99–105.
  8. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991; 119(3):417–23.
  9. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013; 13:59.
10. Kopelman AE, Mathew OP. Common respiratory disorders of the newborn. Pediatr Rev. 1995; 16(6):209–17.

11. Mathai SS, Raju U, Kanitkar M. Management of respiratory distress in the newborn. Med J Armed Forces India. 2007; 63(3):269–72.

12. Birenbaum HJ, Dentry A, Cirelli J, Helou S, Pane MA, Starr K, et al. Reduction in the incidence of chronic lung disease in very low birth weight infants: results of a quality improvement process in a tertiary level neonatal intensive care unit. Pediatrics. 2009; 123(1):44–50.

13. Levesque BM, Kalish LA, LaPierre J, Welch M, Porter V. Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs. Pediatrics. 2011; 128(1):e218–26.

14. Dunn MS, Jefferies AL. Recommendations for neonatal surfactant therapy–addendum. Paediatr Child Health. 2012; 17(3):137–8.

15. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med. 2001; 163(7):1723–9.

16. Gluck L, Kulovich MV. Lecithin-sphingomyelin ratios in amniotic fluid in normal and abnormal pregnancy. Am J Obstet Gynecol. 1973; 115(4):539–46.

17. Yoon JJ, Kohl S, Harper RG. The relationship between maternal hypertensive disease of pregnancy and the incidence of idiopathic respiratory distress syndrome. Pediatrics. 1980; 65(4):735–9.

18. Ferdynus C, Quantin C, Abrahamowicz M, Platt R, Burguet A, Sagot P, et al. Can birth weight standards based on healthy populations improve the identification of small-for-gestational-age newborns at risk of adverse neonatal outcomes? Pediatrics. 2009; 123(2):723–30.

19. Yu HJ, Kim ES, Kim JK, Yoo HS, Ahn SY, Chang YS, et al. Outcomes of small for gestational age micropremies depending on how young or how small they are. Korean J Pediatr. 2011; 54(6):246–52.

20. Bardin C, Zelkowitz P, Papageorgiou A. Outcome of small-for-gestational age and appropriate-for-gestational age infants born before 27 weeks of gestation. Pediatrics. 1997; 100(2):E4.

21. Tyson JE, Kennedy K, Broyles S, Rosenfeld CR. The small for gestational age infant: accelerated or delayed pulmonary maturation? Increased or decreased survival? Pediatrics. 1995; 95(4):534–8.

22. Procianoy RS, Garcia-Prats JA, Adams JM, Silvers A, Rudolph AJ. Hyaline membrane disease and intraventricular haemorrhage in small for gestational age infants. Arch Dis Child. 1980; 55(7):502-5.

23. Schiff E, Friedman SA, Mercer BM, Sibai BM. Fetal lung maturity is not accelerated in preeclamptic pregnancies. Am J Obstet Gynecol. 1993; 169(5):1096–101.

24. Owen J, Baker SL, Hauth JC, Goldenberg RL, Davis RO, Copper RL. Is indicated or spontaneous preterm delivery more advantageous for the fetus? Am J Obstet Gynecol. 1990; 163(3):868–72.

25. Thompson PJ, Greenough A, Gamsu HR, Nicolaides KH. Ventilatory requirements for respiratory distress syndrome in small-for-gestational-age infants. Eur J Pediatr. 1992; 151(7):528–31.

26. Kulovich MV, Gluck L. The lung profile. II. Complicated pregnancy. Am J Obstet Gynecol. 1979; 135(1):64–70.

27. Gross TL, Sokol RJ, Wilson MV, Kuhnert PM, Hirsch V. Amniotic fluid phosphatidylglycerol: a potentially useful predictor of intrauterine growth retardation. Am J Obstet Gynecol. 1981; 140(3):277–81.

28. Lee YA, Dhanireddy R. Association of prolonged rupture of membranes (Prom) with bronchopulmonary dysplasia (BPD) in extremely low birth weight (ELBW) infants in the post-surfactant ERA 1287. Pediatr Res. 1998; 43(S4):220.

29. Hartling L, Liang Y, Lacaze-Masmonteil T. Chorioamnionitis as a risk factor for bronchopulmonary dysplasia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2012; 97(1):F8–17.