Extrauterine growth restriction (EGR) is an identifiable marker of severe nutritional deficit during the first weeks of life. Infants with EGR have growth values at or below the 10th percentile of intrauterine growth expectation based on estimated gestational age. Although all preterm sick infants are at risk for EGR, risk is greatest for those infants <1500 g at birth. As estimated gestational age and birthweight decrease, the incidence of extrauterine growth restriction increases. The duration of initial weight loss also increases as birthweight decreases, compounding the difficulty of attaining appropriate growth. To decrease the incidence and consequences of nutritional deficit, NICU caregivers should learn more about EGR, implement assessment protocols to identify EGR, seek opportunities to decrease energy needs of at-risk infants, and work toward enhancing nutritional status of VLBW infants through innovative nutritional management.