Fetal growth restriction (FGR) refers to the inability of a fetus to achieve its genetically determined growth potential in the womb. It significantly contributes to morbidity and mortality during the perinatal period and has also been linked to adverse lifelong consequences.
Of particular concern is the potential impact of suboptimal intrauterine environments on fetal neurodevelopment, which could explain the previously observed associations between low birth weight and poorer educational outcomes in childhood. However, studying the relationship between FGR and long-term outcomes poses several challenges.
One of the challenges in assessing the impact of FGR is that babies classified as small-for-gestational-age (SGA) encompass actual cases of FGR and healthy infants who are constitutionally small. Relying solely on observed birth weight to analyze associations may fail to identify the actual effects of FGR accurately. Identifying genuine cases of FGR requires the integration of ultrasonic estimates of fetal size with other antenatal indicators of placental dysfunction.
Another complicating factor is the response to an antenatal diagnosis of suspected FGR, which typically involves intensified fetal monitoring and intervention, such as early-term delivery (at 37 to 38 weeks gestational age). While intervention may improve outcomes by reducing the fetus’s exposure to a hostile intrauterine environment, early-term delivery has been associated with poorer educational outcomes. This raises the possibility that the diminished educational performance observed in SGA babies could be attributed to the interventions rather than the FGR itself.
New research published in PLOS Medicine suggests that fetuses with evidence of antenatal Fetal Growth Restriction (FGR) are more likely to have lower educational attainment during mid-childhood. The study, conducted over multiple assessments between the ages of 5 and 7, revealed a consistent association between FGR and educational performance across the early school years.
While the association was not statistically significant at age 5, potentially due to assessment limitations or a higher percentage of children not meeting expected standards at that stage, the overall effect estimate remained similar across all ages studied. By age 7, a clear difference emerged between children with FGR and their peers, with FGR-affected children more likely to struggle in reading, writing, and mathematics.
The findings suggest that a suboptimal intrauterine environment caused by placental insufficiencies, such as reduced oxygen levels, inadequate nutrient supply, or chronic pro-inflammatory response, is associated with poorer future educational outcomes.
Fetal neural development, which relies on precise transcriptional and epigenetic mechanisms, may be vulnerable to disruption caused by placental dysfunction, particularly in conditions like preeclampsia. Previous research has also indicated lower cognitive, linguistic, and communication skills and lower social adjustment and emotional readiness for school in children affected by FGR.
One key strength of the study was the blinded approach to imaging and biochemical data, ensuring that attending clinicians were not influenced by the results, thereby avoiding potential biases. Additionally, the study design accounted for the complexity surrounding early-term delivery in cases of FGR, which could have confounding effects on outcomes. The results indicate that the association between FGR and poor educational attainment is independent of iatrogenic harm from earlier delivery and cannot be solely attributed to the timing of birth.
These findings have important implications for clinicians considering interventions for suspected FGR near term. Early-term delivery is sometimes recommended to mitigate the risk of stillbirth and other complications associated with FGR.
However, clinicians may need to reconsider intervention strategies if the association between FGR and poor educational outcomes is primarily due to earlier delivery rather than the disease process itself. The study’s data suggest that late FGR is an independent predictor of poor educational outcomes, highlighting the need for improved screening and diagnostic methods to target interventions specifically for actual FGR cases.
The research underscores the importance of advancing discovery science methods to identify new predictors of FGR and conducting interventional trials better to understand interventions’ short- and long-term consequences.
By deepening our understanding of FGR and developing enhanced screening and diagnostic techniques, providing more targeted antenatal care and improving neurodevelopmental outcomes for affected fetuses may be possible. Further studies are warranted to continue investigating the complex relationship between FGR and educational outcomes, ultimately striving to improve the prospects of children affected by FGR.
