Lifelong cognitive and motor outcomes after being born small for gestational age or with fetal growth restriction

Table 1 Overview of research on cognitive and neuromotor outcomes in individuals born small for gestational age or with fetal growth restriction

Ref.	Study type	Fetal growth	Term or preterm	Participants	Assessment	Findings
Jöud et al[47], 2020	Retrospective cohort, Sweden	-	Term: ≥ 37 weeks. Late preterm: 32-36 weeks. Very preterm: < 32 weeks	206618 term, 7355 late preterm and 1244 very preterm	CP diagnosis	Term infants-SGA is associated with moderate-to-severe disability. Very preterm infants-SGA is not associated with moderate-to-severe disability. SGA was not a risk factor for CP
Wilcox et al[49], 2021	Retrospective, United States and Norway	26 birth weight-percentile	Term: > 37 weeks	3836034 United States and 292279 Norway participants	CP diagnosis	Birth weight alone is only marginally better than chance at predicting CP. Gestational age is a predictor of CP risk
Kobezda and Rehm[54], 2022	Retrospective cohort, United Kingdom	SGA: Birth weight < 10%	-	87318 participants, 130 with CP	CP diagnosis, birth	Low birth weight and reduced gestational age had a significant effect on CP incidence. Low Apgar scores at 1 minute and 5 minutes, admission to neonatal intensive care unit and male sex were significant risk factors for CP. SGA as a covariate was not statistically significant
Ahmed et al[51], 2023	Longitudinal cohort, Canada	SGA: Birth weight < 10%	Exterm preterm: < 28. Very preterm: 28-31. Late preterm: 32-36. Term: ≥ 37 weeks	2110177 participants, 5317 of with CP	CP diagnosis, 0-5 years	SGA CP rates almost double AGA. CP rates declined across gestational age and birth weight categories
Eves et al[28], 2020	Retrospective cohort, Germany	SGA: ≤ 10%. Very preterm/very low birth weight: < 32 weeks and/or < 1500 g	Very preterm: < 32 weeks. Term: > 32 weeks	217 very preterm/very low birth weight 197 term	Griffiths Mental Development Scale: 5-20 months. Columbia Mental Maturity Scale, Active Vocabulary Test and Beery-Buktenica Developmental Test of Visual-Motor Integration: 4 years. German version of the Kaufmann Assessment Battery for Children: 6 years and 8 years. German version of Wechsler Adult Intelligence Scale: 26 years	Being born SGA is associated with lower IQ throughout development, independent of being born very preterm/very low birth weight and the growth reference range used
Chen et al[35], 2022	Prospective cohort, China	SGA: Birth weight < 10%	Term: ≥ 37 < 42 weeks	41 SGA, 121 AGA	Age and Staging Questionnaire-3: Communication, gross motor, fine motor, problem-solving and personal-social 6 months. Faeces collected on days 1, 3, 5 and 7 after birth	Gut microbial diversity of SGA infants was significantly lower in the first week of life compared to AGA infants, and differences in the populations of specific organisms may be associated with neurodevelopmental outcomes at 6 months of age
Lach et al[17], 2022	Retrospective cohort, United States	SGA: < 10% body weight	Preterm	37 very low birth weight: 29 AGA, 8 SGA	Capute Scales Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale, Peabody Development Motor Scales, 1 year	No significant differences were observed in neurodevelopmental outcomes between SGA and AGA infants at four serial evaluations. SGA infants exhibited a significant catch-up growth
Murki et al[15], 2020	Cross-sectional, India	SGA: Birth weight < 10%	Preterm: < 35 weeks	59 SGA, 119 AGA	Developmental Assessment Scale for Indian Infants: Developmental assessment. Neurological/neurosensory examination: Tone abnormalities and need for hearing/visual aids 12-18 months	More infants in the SGA group had statistically significant higher incidence of motor and mental development delay, as well as a higher risk of underweight and stunting
Della Gatta et al[32], 2023	Retrospective cohort, Italy	FGR diagnosed via doppler ultrasound and < 1500 g body weight	Very preterm: < 32 weeks	48 FGR: 14 early and transient, 12 early and persistent, 22 later-absent and end diastolic flow	Revised Griffiths Mental Development Scales: Locomotor, personal-social, hearing-language, eye and hand coordinator, and performance 12 months and 24 months	Infants exposed to persistent absent and end diastolic flow from 20-24 weeks gestation face the greatest risk of adverse neurodevelopmental outcomes. Those with transient early absent and end diastolic flow also showed performance-specific developmental delays
Athalye-Jape et al[24], 2022	Retrospective cohort, Australia	SGA: Birth weight < 10%	Participants ≥ 22 weeks	35 SGA, 6 AGA	Griffiths Mental Developmental Scale: 12 months and 36 months. Bayley Scales of Infant and Toddler Development: 24 months. Wechsler Preschool and Primary Scale of Intelligence: 5 years	SGA individuals had increased moderate-severe disability compared to AGA, primarily involving cognitive impairments. Cases of CP were detected
Uberos et al[34], 2022	Retrospective cohort, Spain	SGA: Birth weight < 10%. Very low birth weight: < 1500 g. FGR: Reduced rate of weight increase, resulting in SGA	-	64 FGR, 62 SGA	Mild motor disorder (motor coordination disorders including fine and gross motor abilities). monoparesis/hemiparesis, tetraparesis/CP diagnosis. Reviewed at 13 months, 24 months, 36 months and 48 months	Mild motor disorder was present in 10% FGR and SGA cases compared toa 32% in AGA. Postnatal energy restriction was significantly associated with motor disorders, CP and sensory disorders in very low birth weight. FGR was associated with behavioural disorders and poorer cognitive development
Cho et al[16], 2021	Retrospective cohort, South Korea	SGA: Birth weight < 10%	Preterm: < 32 weeks	90 SGA	Bayley Scales of Infant and Toddler Development (version III): 18-24 months	Growth failure was associated with worse neurodevelopmental outcomes. Failure to achieve catch-up head circumference by 4 months was associated with neurodevelopmental impairment
Bae et al[19], 2021	Retrospective cohort, Korea	SGA: Birth weight < 3%	Preterm: 26-32 weeks	182 all < 1500 g, 25 with neurodevelopmental impairment	Bayley Scales of Infant and Toddler Development (version III), CP, Gross Motor Function Classification System. Sensory impairments 18-24 months	Very-low birth weight and SGA were associated with neurodevelopmental impairment. Only one case of CP was reported
Sacchi et al[29], 2021	Randomized controlled trial, United Kingdom	FGR: Prenatal evaluation and birth weight < 10%. AGA birth weight > 10%	Preterm: ≤ 33 weeks	49 FGR, 265 AGA	Bayley Scales of Infant and Toddler Development (version III). Modified-Checklisy for Autism in Toddlers, mean 22 months	Very preterm infants born with FGR scored lower in cognitive and motor domains than their preterm AGA peers. Autism spectrum disorders were more prevalent. Volumetric differences in grey matter were observed in different brain regions
Morsing et al[31], 2021	Retrospective cohort, Sweden	FGR: Estimated fetal weight > 2SD below mean of Swedish reference curve	Preterm: < 30 weeks	139 FGR, 945 controls	CP diagnosis, Gross Motor Function Classification System, > 2 years	Long-term rate of neurodevelopmental impairment is higher in FGR than controls, especially in infants born before 26 weeks
Lim et al[18], 2023	Retrospective cohort, Korea	-	Preterm < 32	136 dichorionic, 38 monochorionic (no twin-to-twin transfusion), 30 monochorionic (twin-to-twin transfusion)	CP diagnosis. Bayley Scales of Infant and Toddler Development: 2 years	Monochorionic twins with twin-to-twin transfusion syndrome displayed higher incidence of cerebral palsy and motor impairments. Greater discordance was associated with impaired neurodevelopmental outcome
Delorme et al[33], 2020	Retrospective cohort, France	FGR estimated fetal weight < 10% or growth arrest	Very preterm: 22-31 weeks	484 FGR	Ages and Stages Questionnaire: Communication, gross motor, fine motor, problem solving and personal/social, 2 years	Among children delivered preterm due to FGR and/or maternal hypertensive disorder, prenatal absent or reversed end-diastolic flow was associated with higher incidence of severe or moderate neuromotor and/or sensory disability
Gardella et al[30], 2021	Prospective cohort, Italy	FGR: Abdominal circumference and/or birth weight at < 3% and/or absent/reverse umbilical artery doppler. Very low birth weight: ≤ 1500 g	Preterm: ≤ 34 weeks	198 FGR preterm very low birth weight	Griffith’s Mental Development Scales-Extended Revised: General quotient and 5 subareas (locomotor, personal-social, hearing and speech, eye-hand coordination, and performance), 2 years	In preterm infants with FGR, placental fetal vascular malperfusion is a significant predictor of adverse neurodevelopmental outcomes. This occurs in the absence of brain lesions
Lucaccioni et al[43], 2022	Prospective cohort, Italy	FGR: Estimated fetal weight < 3% or abdominal circumference < 3%	Term: > 32 weeks	38 FGR, 20 AGA	Griffiths Mental Development Scales: Neurological assessment, 2 years	Neurological development was within the normal range for both AGA and FGR. However, late onset-FGR showed statistically significant lower scores
Palazzo et al[20], 2024	Retrospective cohort, Italy	SGA: Weight Z scores < -1.282, AGA: Weight Z scores ≥ -1.282 and ≤ 1.282 at birth	Preterm: < 32 weeks	Hypoglycemia 44 SGA/129 AGA. Normoglycemia 105 SGA/469 AGA	Bayley Scales of Infant and Toddler Development (version III), COG scale, 2 years	Hypoglycemia within the first 6 hours of life was not associated with cognitive impairment
Naz et al[27], 2023	Prospective cohort, Pakistan	SGA: Birth weight ≤ 10%	Preterm: < 37 weeks. Term: > 37 weeks	33 SGA (10% preterm), 147 AGA (27% preterm)	Neurodevelopment assessed with Malawi Developmental Assessment Tool: Fine motor, gross motor, social and language, 2-4 years	SGA was associated with poor performance on overall neurodevelopment, largely due to fine motor deficits. The scores in domains such as gross motor, language and social were lower among SGA, without reaching statistical significance
Tamai et al[37], 2020	Population-based cohort, Japan	Severely SGA, moderately SGA, mildly SGA, AGA: 10%-90%	Term: 37-41 weeks	36321 participants	Questionnaire used has not been officially validated or taken from an established scale, 2.5 years and 5.5 years	The risk of neurodevelopmental delay increased with the severity of SGA. The association between birth weight for gestational age and neurodevelopmental outcomes follows a U-shaped curve, with children born AGA and mildly large for gestational age exhibiting the lowest risk
Yoneda et al[23], 2021	Retrospective cohort, Japan	SGA: Birth weight < 10%	Preterm 23-33 weeks	165 participants	CP diagnosis. Bayley Scales of Infant and Toddler Development (version III). Low score Kyoto scale of psychological development, < 3 years	Delivery week, low birth weight, SGA rate and head circumference were associated with poor neurodevelopment in preterm children. SGA was not an independent risk factor in multivariate analysis
Kono et al[48], 2022	Retrospective cohort, Japen	SGA: Birth weight < 10%	Preterm singletons	683 hypertensive-AGA, 1719 hyper-SGA, 7790 no hyper-AGA	CP diagnosis, 3 years	The outcomes of preterm very low birth weight infants born to mothers with hypertensive disorders of pregnancy are influenced by both FGR status and the gestational age at birth
Suenaga et al[21], 2024	Retrospective cohort, Japan	SGA: Birth weight < 10%. AGA: 10%-90%	Preterm: 22-27 weeks	434 SGA, 1716 AGA	CP diagnosis. Developmental quotient, 3 years	SGA born at 26-27 weeks had higher prevalence of CP. The prevalence of developmental quotient < 70 was higher in SGA infants born at 24-25 weeks
Richter et al[44], 2020	Prospective cohort, Germany	FGR: Fetal abdominal circumference or fetal weight < 10%	Preterm and term	26 FGR participants	Wechsler Preschool and Primary Scale of Intelligence, IQChild Behaviour Checklist, Behaviour. Behaviour Rating Inventory of Executive Function: Executive function, 4 years	Fetal brain-sparing was associated with better total and internalizing behaviour and executive functioning. Postnatal cerebral oxygen saturation was associated with better total and internalizing behaviour and executive functioning, but lower IQ
Zhang et al[36], 2025	Longitudinal, China	SGA: Birth weight < 10%. Severe SGA: Birth weight < 3%	Term	319 SGA	Age and Staging Questionnaire-3 Ages and Stages Questionnaires: Social-Emotional, 4 years	Children of mothers who maintained appropriate weight gain during pregnancy scored higher in personal and social domains, while those born to mothers with inappropriate weight gain exhibited difficulties in problem-solving and social functioning
Hubert et al[22], 2020	Cohort, Poland	SGA: Birth weight < 10%	Preterm: 27.8 ± 2.4 weeks	15 SGA and 74 AGA, all very-low birth weight < 1500 g	CP diagnosis, mean 4 years	SGA was an independent risk factor for neurodevelopmental delay in preterm children, but did not result in a higher incidence of CP
Aubert et al[52], 2023	Retrospective population-based cohort, 11 countries	SGA: Birth weight < 10%	Very preterm: < 32 weeks	100 with CP, 224 moderate disability, 366 controls	CP diagnosis. Movement Assessment Battery for Children, 2nd edition, 5 years	SGA < 3% was associated with an increased risk of moderate disability in univariate analysis. When adjusted for neonatal factors, this association was no longer significant. SGA was not identified as a risk factor for CP
Esih et al[50], 2022	Retrospective observational case-control, Slovenia	SGA: Birth weight < 10%	Preterm and term, ≥ 22 weeks	254 CP and 762 controls	CP diagnosis, > 5 years	The risk of CP escalates progressively as birth weight percentiles fall below the 50%. The increased risk is consistent across both term and preterm infants
Chen et al[45], 2021	Retrospective cohort, Taiwan	SGA: Birth weight < 10% large for gestational age: Birth weight > 90%	Preterm and term	850710 no hypertension 7920 chronic hypertension 18603 pregnancy hypertension/preeclampsia	Diagnoses of autism spectrum disorder, attention-deficit/hyperactivity disorder, developmental delay, intellectual disability, CP, 5-6 years	In utero exposure to chronic hypertension or pregnancy induced hypertension/preeclampsia could increase the risk of neurodevelopmental disorders, including CP. The co-occurrence of FGR further increases the risk. Neurodevelopmental disorders are not motor specific, although risk increases when CP is reported
Tojo et al[55], 2025	Prospective cohort, Japan	SGA: Birth weight < 10%	Preterm: ≤ 35 weeks	3500 participants	Developmental Coordination Disorder Questionnaire Japanese version, 5-6 years	SGA exhibited lower scores in coordination. In particular, in the subscale ‘control during movement’
Olga et al[46], 2023	Prospective cohort, United Kingdom	FGR: Fetal weight < 10% and indicators of placental dysfunction. Healthy SGA: Fetal weight ≤ 10%. Healthy AGA: Fetal weight ≥ 10% and ≤ 90%	Term: > 37 weeks	250 FGR, 949 AGA with markers of placental dysfunction, 126 healthy SGA, 1429 healthy AGA	National Pupil Database: Educational outcomes, 5 years, 6 years and 7 years	FGR was associated with poorer educational attainment in mid-childhood when compared to AGA with no markers of placental dysfunction. Healthy SGA children showed no significant difference in educational attainment compared to healthy AGA individuals
Ferguson et al[39], 2021	Prospective cohort, Netherlands	SGA: < 10%	Term and preterm	656 SGA participants, 19% preterm. Subdivided: 64 consistent small, 418 moderate decreases in weight, 174 large decreases in weight	Snijders-Oomen Nonverbal Intelligence Test-Revised: Non-verbal IQ. Child Behaviour Checklist: Emotional and behavioural problems, 6 years	Low birth weight group had lower non-verbal IQ scores, and slightly more attention-deficit hyperactivity disorder symptoms. Moderate decreased weight group had lower non-verbal IQ scores, but no difference in attention-deficit hyperactivity disorder symptoms. Large decrease in weight had no difference in non-verbal IQ and attention-deficit hyperactivity disorder symptoms compared to non-SGA children
Nguyen et al[41], 2024	Randomized controlled trial, Vietnam	SGA: Birth weight < 10%	Preterm: < 37 weeks. Term: > 37 weeks	1243-993 AGA, 147-122 preterm, 180-147 SGA	Wechsler Intelligence Scale for Children–Fourth Edition, 6-7 years and 10-11 years. Academinc achievement Vietnamise tool, 10-11 years	SGA infants showed lower cognitive scores at 6-7 years and 0-11 years old. SGA infants had poorer academic scores at 10-11 years old
Bufteac Gincota et al[53], 2021	Retrospective case-control, Moldova	SGA: Birth weight < 10%	Preterm: < 32 weeks. Term: > 32 weeks	351 CP and 417 non-CP children	CP diagnosis, 7 years	SGA was associated with higher odds of developing CP. This association was not statistically significant in multivariate analysis
Doyle et al[25], 2023	Retrospective cohort, Australia	SGA: < 10%	Extremely preterm: < 28 weeks	499 participants	IQ, CP diagnosis, blindness, deafness. Wide Range Achievement Test: Reading, spelling, arithmetic/maths. Movement Assessment Battery for Children: Motor performance. General Executive Composite of Behaviour Rating Inventory of Executive Function, 8 years	SGA status was linked to lower IQ, academic performance and motor function. Associations with spelling and executive function were inconsistent. Across four growth curves, SGA status showed low sensitivity and diagnostic accuracy for predicting mortality and neurodevelopmental disability
Reichman et al[40], 2023	Retrospective cohort, United States	SGA: < 10% of sex-specific birth weight < 5%	Term: 37-41 weeks	2144 participants	Peabody Vocabulary Test, Woodcock-Johnson, Passage Comprehension Test, Woodcock-Johnson Applied Problems Test, 9 years	SGA was associated with low cognitive scores and children were predisposed to suboptimal cognitive development
Burger et al[42], 2023	Population-based cohort, Netherlands	Birth weight centiles	Term: 36-42 weeks	Participants 266400	Standardized test from Central Institute of Test Development Netherlands for school performance, 12 years	School performance and attendance to higher secondary education correlated positively with birth weight centile
Cortese et al[38], 2021	Prospective population, Norway	Birth weight assessed in categories of 0.5 kg	Term: 39-41 weeks	1833502 participants	National Insurance Scheme: Neurodevelopmental diagnoses (including intellectual impairment, autism spectrum disorder, behavioural disorders, epilepsy and schizophrenia), mean 24 years, maximum 47 years	With weights below 3.5 kg, the risk of intellectual impairment, schizophrenia, autism spectrum disorder and attention-deficit hyperactivity disorder increased. An elevated risk of CP was observed in heavier infants
Weider et al[26], 2022	Prospective cohort, Norway	SGA: < 10%, AGA: > 10%. Very low birth weight: < 1500 g	Preterm and term	53 very low birth weight, 63 term SGA, 81 AGA term	Wechsler Abbreviated Scale of intelligence, logical memory subtest from Wechsler Memory Scale, Trail making Test and Verbal Fluency Test, Grooved Pegboard Test, and Cambridge Neuropsychological Test Automated Battery: Cognitive measures. Mini-International Neuropsychiatric Interview: Psychiatric diagnoses 26 years	Very low birth weight adults scored below SGA and AGA groups on neurocognitive measures, including IQ, psychomotor speed, verbal fluency, visual learning and memory, attention, social cognition, working memory and fine motor speed. They also displayed lower spatial memory and increased occurrence of anxiety disorders, attention problems and autistic traits. The SGA group consistently scored significantly lower than the AGA group on performance IQ and psychomotor speed

AGA: Appropriate for gestational age; CP: Cerebral palsy; FGR: Fetal growth restriction; SGA: Small for gestational age.

Table 2 Cognitive outcome trends in small for gestational age/fetal growth restriction

	Ref.	Population	Age at assessment	Cognitive impairment	Sensorial impairment	Social/behavioural impairment
Preterm	Lach et al[17]	SGA	1 year	3
	Della Gatta et al[32]	Early-onset-FGR	1-2 years	1		3
	Murki et al[15]	SGA	1-1.5 year	1
	Cho et al[16]	SGA	1.5-2 years	1
	Bae et al[19]	SGA cov	1.5-2 years	1
	Lim et al[18]	Birth weight	2 years	3	3
	Palazzo et al[20]	SGA	2 years	1
	Sacchi et al[29]	FGR	2 years	1
	Morsing et al[31]	FGR	2 years	1	1
	Delorme et al[33]	FGR	2 years	3	1	3
	Gardella et al[30]	FGR	2 years	1	1	1
	Suenaga et al[21]	SGA	3 years	1	1
	Yoneda et al[23]	SGA cov	< 3 years	2
	Hubert et al[22]	SGA	4 years	1	1	3
	Uberos et al[34]	SGA-FGR	4 years	3	3	1
	Athalye-Jape et al[24]	SGA	5 years	3	1
	Doyle et al[25]	SGA	8 years	1
	Weider et al[26]	SGA	26 years	1	1
Term	Chen et al[35]	SGA	0.5 years
	Lucaccioni et al[43]	LO-FGR	2 years	1
	Naz et al[27]	SGA	2-4 years		3	3
	Zhang et al[36]	SGA	4 years
	Richter et al[44]	4FGR	4 years	1		1
	Tamai et al[37]	SGA	2.5-5.5 years
	Chen et al[45]	4FGR/4SGA cov	5-6 years	1
	Ferguson et al[39]	SGA	6 years	1
	Olga et al[46]	LO-FGR	5-7 years	1
	Reichman et al[40]	SGA	9 years	1
	Nguyen et al[41]	SGA	6-11 years	1
	Burger et al[42]	Birth weight	12 years	1
	Eves et al[28]	4SGA	5 months - 26 years	1
	Weider et al[26]	SGA	26 years	1	1
	Cortese et al[38]	Birth weight	0-47 years	1	1

¹Statistically significant associations between small for gestational age or fetal growth restriction compared to controls.

²Trends toward significance.

³No statistically significant associations between small for gestational age or fetal growth restriction compared to controls.

⁴Preterm within the groups, but not accounted separately. Cognitive includes IQ, educational attainment, language and problem solving. Sensorial includes hearing and blindness. Social includes communication.

cov: Covariate; FGR: Fetal growth restriction; LO-FGR: Late onset-fetal growth restriction; SGA: Small for gestational age.

Table 3 Neuromotor outcome trends in small for gestational age/fetal growth restriction

	Ref.	Population	Age at assessment	Motor impairment	Cerebral palsy
Preterm	Jöud et al[47]	SGA			1
	Ahmed et al[51]	SGA cov	0-5 years		1
	Lach et al[17]	SGA	1 year	3
	Murki et al[15]	SGA	1-1.5 years	1
	Lim et al[18]	SGA	2 years	1	1
	Bae et al[19]	SGA	2 years	3	3
	Morsing et al[31]	EO-FGR	> 2 years		3
	Della Gatta et al[32]	EO-FGR	2 years	3
	Delorme et al[33]	FGR	2 years	1	2
	Gardella et al[30]	FGR	2 years	3
	Kono et al[48]	SGA	3 years		1
	Suenaga et al[21]	SGA	3 years		1
	Hubert et al[22]	SGA	4 years		3
	Uberos et al[34]	SGA-FGR	4 years	3	3
	Aubert et al[52]	SGA cov	5 years	1	3
	Athalye-Jape et al[24]	SGA	5 years		3
	Tojo et al[55]	SGA	5-6 years	1
	Doyle et al[25]	SGA	8 years	1
	Weider et al[26]	SGA	26 years	1
Term	Jöud et al[47]	SGA			1
	Wilcox et al[49]	4SGA			3
	Kobezda and Rehm[54]	4SGA cov	Birth		1
	Chen et al[35]	SGA	0.5 years
	Naz et al[27]	4SGA	2-4 years	1
	Tamai et al[37]	SGA	2.5-5.5 years
	Zhang et al[36]	SGA	4 years
	Esih et al[50]	4SGA	> 5 years		1
	Chen et al[45]	4FGR/4SGA cov	5-6 years		1
	Bufteac Gincota et al[53]	SGA cov	7 years		1
	Weider et al[26]	SGA	26 years	3
	Cortese et al[38]	Birth weight	0-47 years		1

¹Statistically significant associations between small for gestational age or fetal growth restriction compared to controls.

²Trends toward significance.

³No statistically significant associations between small for gestational age or fetal growth restriction compared to controls.

⁴The cohort includes preterm.

cov: Covariate; EO-FGR: Early-onset-fetal growth restriction; FGR: Fetal growth restriction; SGA: Small for gestational age.