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Large-for-Gestational-Age (LGA) Infant

By Robert L. Stavis, PhD, MD, Clinical Director, Neonatal ICUs; Associate Professor, Department of Pediatrics, Main Line Health, Bryn Mawr, PA; Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children; Thomas Jefferson University Hospital

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Infants whose weight is > the 90th percentile for gestational age are classified as large for gestational age (LGA). Macrosomia is birth weight > 4000 g in a term infant. The predominant cause is maternal diabetes. Complications include birth trauma, hypoglycemia, hyperviscosity, and hyperbilirubinemia.

Gestational age is the time elapsed since the beginning of the woman's last menstrual period; it is usually counted in weeks and days. Gestational age is not the actual embryologic age of the fetus.

The Fenton growth charts provide a more precise assessment of growth vs gestational age (see Figure: Fenton Growth Chart for Preterm Boys and see Figure: Fenton Growth Chart for Preterm Girls).

Fenton Growth Chart for Preterm Boys

Fenton T, Kim J: A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatrics13:59, 2013; used with permission. Available at

Fenton Growth Chart for Preterm Girls

Fenton T, Kim J: A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatrics13:59, 2013; used with permission. Available at


Other than genetically determined size, maternal diabetes mellitus is the major cause of large-for-gestational-age (LGA) infants. The macrosomia results from the anabolic effects of high fetal insulin levels produced in response to excessive maternal blood glucose during gestation and sometimes increased caloric intake by the mother to compensate for glucose lost in urine. The less well controlled the mother’s diabetes during pregnancy, the more severe is the fetal macrosomia.

Rare causes of macrosomia are Beckwith-Wiedemann syndrome (characterized by macrosomia, omphalocele, macroglossia, and hypoglycemia) and Sotos, Marshall, and Weaver syndromes.

Symptoms, Signs, and Treatment

LGA infants are large, obese, and plethoric. The 5-min Apgar score may be low. These infants may be listless and limp and feed poorly. Delivery complications can occur in any LGA infant. Congenital anomalies and some metabolic and cardiac complications are specific to LGA infants of diabetic mothers.

Delivery complications:

Because of the infant’s large size, vaginal delivery may be difficult and occasionally results in birth injury, particularly including

Other complications occur when weight is > 4000 g. There is a proportional increase in morbidity and mortality due to the following:

Infants of diabetic mothers (IDMs):

IDMs are at risk of

Hypoglycemia is very likely in the first few hours after delivery because of the state of hyperinsulinism and the sudden termination of maternal glucose when the umbilical cord is cut. Neonatal hypoglycemia can be decreased by close prenatal control of the mother’s diabetes and early frequent feedings. Blood glucose levels should be closely monitored by bedside testing from birth through the first 24 h. Oral treatment with 40% glucose gel may be tried first, but if there is persistent hypoglycemia, parenteral IV glucose is given.

Hypocalcemia and hypomagnesemia may occur but are usually transient and asymptomatic. Good prenatal glycemic control decreases the risk of neonatal hypocalcemia. Hypocalcemia typically does not require treatment unless there are clinical signs of hypocalcemia or levels < 7 mg/dL in term infants. Treatment is usually given with IV supplementation of calcium gluconate. Hypomagnesemia can interfere with the secretion of parathyroid hormone, so hypocalcemia may not respond to treatment until the magnesium level is corrected.

Polycythemia is slightly more common among infants of diabetic mothers. Elevated insulin levels increase fetal metabolism and thus oxygen consumption. If the placenta is unable to meet the increased oxygen demand, fetal hypoxemia occurs, triggering an increase in erythropoietin and thus Hct.

Hyperbilirubinemia occurs for several reasons. IDMs have decreased tolerance for oral feedings (particularly when they are preterm) in the earliest days of life, which increases the enterohepatic circulation of bilirubin. Also, if polycythemia is present, the bilirubin load increases.

Respiratory distress syndrome (RDS) may occur because elevated insulin levels decrease surfactant production; pulmonary maturation may thus be delayed until late in gestation. RDS may develop even if the infant is delivered late preterm or term. The lecithin/sphingomyelin ratio, and especially the presence of phosphatidyl glycerol, in amniotic fluid obtained by amniocentesis can evaluate fetal lung maturity and help determine the optimal time for safe delivery. Lung maturity can be assumed only if phosphatidyl glycerol is present. Good prenatal glycemic control decreases the risk of RDS. Treatment of respiratory distress syndrome is discussed elsewhere. Transient tachypnea of the newborn is 2 to 3 times more likely in IDMs because of the delay in fetal lung fluid clearance.

Congenital anomalies are more likely in IDMs because maternal hyperglycemia at the time of organogenesis is detrimental. Specific anomalies include

  • Congenital heart disease (hypertrophic cardiomyopathy, ventricular septal defect, transposition of the great arteries, and aortic stenosis)

  • Caudal regression syndrome

  • Small left colon syndrome

Persistently elevated insulin levels can also lead to increased deposition of glycogen and fat into cardiomyocytes. This deposition can cause transient hypertrophic cardiomyopathy, predominantly of the septum.

Key Points

  • Maternal diabetes mellitus is the major cause of LGA infants.

  • Large size itself increases risk of birth injury (eg, clavicle or extremity long bone fracture) and perinatal asphyxia.

  • Infants of diabetic mothers also may have metabolic complications immediately after delivery, including hypoglycemia, hypocalcemia, and polycythemia.

  • Infants of diabetic mothers are also at risk of respiratory distress syndrome and congenital anomalies.

  • Good control of maternal glucose levels minimizes risk of complications.

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