Educational Performance of Children Born Prematurely

Grade 7 school performance of children born preterm: a retrospective Canadian Cohort study

IMPORTANCE

Data on the middle school outcomes of preterm children are limited and have methodologic issues.

OBJECTIVE

To study the association between preterm birth and grade 7 school performance.

METHODS

A retrospective population-based cohort study of children born in Manitoba, Canada between 1994 and 2006 using their grade 7 school performance data. A secondary sibling cohort was created comprising children born preterm and their full-term siblings. Primary exposure was preterm birth categorized as <28, 28-33 and 34-36 weeks gestation. The two co-primary grade 7 outcome measures were: not meeting the mathematics competencies, and not meeting the student engagement competencies. Multivariable logistic regression models tested the association between preterm birth and both co-primary outcomes; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

7653 preterm (gestational age median [IQR]: 35 weeks [34,36]) and 110,313 term (40 [39,40]) were included. 43% of < 28 weeks, 18% of 28-33 weeks and 17% of 34-36 weeks had the mathematics co-primary outcome compared to 13% of term children. The corresponding % for the student engagement outcome were 42%, 24%, 24% and 24% respectively. Preterm birth was associated with the mathematics (<28 weeks: 5.48, 3.89-7.70; 28-33 weeks: 1.47, 1.27-1.70; 34-36 weeks: 1.26, 1.16-1.35) and student engagement outcomes (<28 weeks: 2.49, 1.76-3.51; 28-33 weeks: 1.21, 1.06-1.39; 34-36 weeks: 1.09, 1.01-1.16). However, there was no difference in outcomes among the sibling cohort.

CONCLUSIONS AND RELEVANCE

Children born preterm had lower grade 7 performance compared to children born term in this population-based cohort. Screening and supports for them in their middle school years are warranted.

Developmental trajectories of late preterm infants and predictors of academic performance

BACKGROUND

The trajectories of late preterm development from infancy to kindergarten reading and math, and predictors of academic resilience and risk are unknown.

METHODS

Sample included 1200 late preterm infants (LPIs) from the Early Childhood Longitudinal Study, Birth Cohort. Objective measurements of development at 9 and 24 months (Bayley-SFR) and reading and math academic achievement at preschool and kindergarten were standardized; trajectories of late preterm development from 9 months to kindergarten reading and math were identified using latent class growth analysis. Multinomial logistic regression [aOR, 95% CI] identified predictors of academic resilience and risk.

RESULTS

Four trajectory groups were observed for reading and three for math. More optimal trajectories (in reading and math) and academic resilience were associated with experiencing sensitive parenting and preschool attendance. Suboptimal (at-risk) trajectories (in reading or math) and an increased odds of academic risk were associated with

CONCLUSIONS

LPI trajectories varied from infancy to kindergarten. More sensitive parenting and preschool attendance predicted academic resilience, and should be encouraged. Select risk factors (prenatal smoking, twin/multiple gestation, male sex,

IMPACT

Late preterm infants (LPIs) have developmental risks compared to full terms. LPI trajectories of early reading and math varied from infancy to kindergarten. We identified predictors of academic resilience and risk, which can help inform anticipatory guidance provided to LPIs prior to kindergarten. Promotive factors (sensitive parenting and preschool enrollment) predicted academic resilience. Select maternal and neonatal characteristics ( Collapse

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MESH Headings

• Infant
• Humans
• Male
• Infant, Newborn
• Child, Preschool
• Infant, Premature
• Longitudinal Studies
• Child Development
• Academic Success
• Parenting

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Grants

• K08 HD078506 NICHD NIH HHS

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Affiliation(s)

Prachi E Shah Division of Developmental Behavioral Pediatrics, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA.
Julie Poehlmann Department of Human Development and Family Studies, University of Wisconsin, Madison, WI, USA
Heidi M Weeks Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
Maria Spinelli Department of Neurosciences, Imaging and Clinical Sciences, University G. D'Annunzio Chieti-Pescara, Chieti, Italy
Blair Richards Michigan Institute for Clinical & Health Research (MICHR), University of Michigan, Ann Arbor, MI, USA
Joohee Suh Research Foundation for Mental Hygiene, New York, NY, USA
Niko Kaciroti Department of Biostatistics, School of Public of Health, University of Michigan, Ann Arbor, MI, USA

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Do Bayley-III Composite Scores at 18-22 Months Corrected Age Predict Full-Scale IQ at 6-7 Years in Children Born Extremely Preterm?

OBJECTIVE

To determine the ability of the Bayley-III cognitive and language composite scores at 18-22 months corrected age to predict WISC-IV Full Scale IQ (FSIQ) at 6-7 years in infants born extremely preterm.

STUDY DESIGN

Children in this study were part of the Neuroimaging and Neurodevelopmental Outcome cohort, a secondary study to the SUPPORT trial and born 240/7-276/7 weeks gestational age. Bayley-III cognitive and language scores and WISC-IV FSIQ were compared with pairwise Pearson correlation coefficients and adjusted for medical and socioeconomic variables using linear mixed effect regression models.

RESULTS

Bayley-III cognitive (r = 0.33) and language scores (r = 0.44) were mildly correlated with WISC-IV FSIQ score. Of the children with Bayley-III cognitive scores of <70, 67% also had FSIQ of <70. There was less consistency for children with Bayley-III scores in the 85-100 range; 43% had an FSIQ of <85 and 10% an FSIQ of <70. Among those with Bayley-III language scores >100, approximately 1 in 5 had an FSIQ of <85. A cut point of 92 for the cognitive composite score resulted in sensitivity (0.60), specificity (0.64). A cut point of 88 for the language composite score produced sensitivity (0.61), specificity (0.70).

CONCLUSIONS

Findings indicate the Bayley-III cognitive and language scores correlate with later IQ, but may fail to predict delay or misclassify children who are not delayed at school age. The Bayley-III can be a useful tool to help identify children born extremely preterm who have below average cognitive scores and may be at the greatest risk for ongoing cognitive difficulties.

TRIAL REGISTRATION

Extended Follow-up at School Age for the SUPPORT Neuroimaging and Neurodevelopmental Outcomes (NEURO) Cohort: NCT00233324.

Preterm birth and educational disadvantage: Heterogeneous effects

Although preterm birth is the leading cause of perinatal morbidity and mortality in advanced economies, evidence about the consequences of prematurity in later life is limited. Using Swedish registers for cohorts born 1982-94 (N  =  1,087,750), we examine the effects of preterm birth on school grades at age 16 using sibling fixed effects models. We further examine how school grades are affected by degree of prematurity and the compensating roles of family socio-economic resources and characteristics of school districts. Our results show that the negative effects of preterm birth are observed mostly among children born extremely preterm (<28 weeks); children born moderately preterm (32-<37 weeks) suffer no ill effects. We do not find any evidence for a moderating effect of parental socio-economic resources. Children born extremely preterm and in the top decile of school districts achieve as good grades as children born at full term in an average school district.Supplementary material for this article is available at: http://dx.doi.org/10.1080/00324728.2022.2080247.

A Narrative Review of the Association between Prematurity and Attention-Deficit/Hyperactivity Disorder and Accompanying Inequities across the Life-Course

Preterm birth is associated with an increased risk of neurodevelopmental and neurobehavioral impairments including attention-deficit/hyperactivity disorder (ADHD), the most common neurobehavioral disorder of childhood. In this narrative review, we examine the known associations between prematurity and ADHD and highlight the impact of both prematurity and ADHD on multiple domains across the pediatric life-course. We develop a framework for understanding the health services journey of individuals with ADHD to access appropriate services and treatments for ADHD, the "ADHD Care Cascade". We then discuss the many racial and ethnic inequities that affect the risk of preterm birth as well as the steps along the "ADHD Care Cascade". By using a life-course approach, we highlight the ways in which inequities are layered over time to magnify the neurodevelopmental impact of preterm birth on the most vulnerable children across the life-course.

Timing of parenteral nutrition initiation in critically ill children: a randomized clinical trial

BACKGROUND

The optimal timing of parenteral nutrition (PN) initiation in critically ill children remains controversial.

PURPOSE

To identify the optimal timing of PN initiation in critically ill children.

METHODS

This randomized clinical trial was conducted in the pediatric intensive care unit (PICU) of Menoufia University Hospital. A total of 140 patients were randomized to receive early or late PN. The early PN group consisted of 71 well-nourished and malnourished patients who received PN on the first day of PICU admission. Malnourished (42%) and well-nourished children randomized to the late PN group (42%) started PN on the fourth versus seventh day after admission, respectively. Mechanical ventilation (MV) was the primary outcome, while PICU length of stay and mortality were secondary outcomes.

RESULTS

Patients who received early PN started enteral feeding significantly earlier (median, 6 days; interquartile range, 2-20 days) than those not provided early PN (median, 12 days; interquartile range, 3-30 days; P<0.001) and had a significantly lower risk of feeding intolerance (5.6% vs.18.8%, P=0.035). The median time required to obtain full calories enterally was shorter in the early versus late PN group (P=0.004). Furthermore, patients in the early versus late PN group had a significantly shorter median PICU stay (P<0.001) and were less likely to require MV (P=0.018).

CONCLUSION

Patients who received early PN had a lower MV need and duration than those who received later PN and had more favorable clinical outcomes in terms of morbidity.

Association between urinary 2-hydroxyethyl mercapturic acid and dyslexia among school-aged children

Ethylene oxide is commonly used in industrial synthesis and medical disinfection. It is a known human carcinogen and has neurotoxicity. However, the association between ethylene oxide exposure and neurodevelopmental disorders remains unclear. This study aimed to evaluate the association between urinary concentrations of 2-hydroxyethyl mercapturic acid (HEMA; metabolite of ethylene oxide) and dyslexia among school-aged children. A total of 355 dyslexic children and 390 controls from three cities in China were enrolled in this case-control study from November 2017 to December 2020. Urinary HEMA was detected in 100% of the urine samples, suggesting widespread exposure to ethylene oxide in the children. Notably, the children with dyslexia had higher concentrations of urinary HEMA compared to the controls (geometric mean: 2.92 vs. 2.47 ng/mL) (P = 0.004). In the multivariable-adjusted model, urinary concentrations of HEMA were significantly associated with dyslexia risk. The individuals within the highest HEMA concentration demonstrated a 1.97-fold increased odds of dyslexia compared to those within the lowest quartile (95% confidence interval: 1.20-3.23). Thus, these findings suggested the possible link between HEMA levels and the risk of dyslexia. Further studies are warranted to validate this finding and illustrate the underlying mechanism.

Gestational age and socio-demographic factors associated with school performance at the age of 12 years, a population-based study

BACKGROUND

Gestational age is positively associated with cognitive development, but socio-demographic factors also influence school performance. Previous studies suggested possible interaction, putting children with low socio-economic status (SES) at increased risk of the negative effects of prematurity.

OBJECTIVES

To investigate the association between gestational age in weeks, socio-demographic characteristics, and school performance at the age of 12 years among children in regular primary education.

METHODS

Population-based cohort study among liveborn singletons (N = 860,332) born in the Netherlands in 1999-2006 at 25-42 weeks' gestation, with school performance from 2011 to 2019. Regression analyses were conducted investigating the association of gestational age and sociodemographic factors with school performance and possible interaction.

RESULTS

School performance increased with gestational age up to 40 weeks. This pattern was evident across socio-demographic strata. Children born at 25 weeks had -0.57 SD (95% confidence interval -0.79, -0.35) lower school performance z-scores and lower secondary school level compared to 40 weeks. Low maternal education, low maternal age, and non-European origin were strongly associated with lower school performance. Being born third or later and low socioeconomic status (SES) were also associated with lower school performance, but differences were smaller than among other factors. When born preterm, children from mothers with low education level, low or high age, low SES or children born third or later were at higher risk for lower school performance compared to children of mothers with intermediate education level, aged 25-29 years, with intermediate SES or first borns (evidence of interaction).

CONCLUSIONS

Higher gestational age is associated with better school performance at the age of 12 years along the entire spectrum of gestational age, beyond the cut-off of preterm birth and across socio-demographic differences. Children in socially or economically disadvantaged situations might be more vulnerable to the negative impact of preterm birth. Other important factors in school performance are maternal education, maternal age, ethnicity, birth order and SES. Results should be interpreted with caution due to differential loss to follow-up.

Neuroimaging of brain connectivity related to reading outcomes in children born preterm: A critical narrative review

Premature children are at high risk for delays in language and reading, which can lead to poor school achievement. Neuroimaging studies have assessed structural and functional connectivity by diffusion MRI, functional MRI, and magnetoencephalography, in order to better define the "reading network" in children born preterm. Findings point to differences in structural and functional connectivity compared to children born at term. It is not entirely clear whether this discrepancy is due to delayed development or alternative mechanisms for reading, which may have developed to compensate for brain injury in the perinatal period. This narrative review critically appraises the existing literature evaluating the neural basis of reading in preterm children, summarizes the current findings, and suggests future directions in the field.

School Readiness Among Children Born Preterm in Manitoba, Canada

Importance

Children born preterm may experience learning challenges at school. However, there is a paucity of data on the school readiness of these children as they prepare to begin grade 1.

Objective

To examine the association between prematurity and school readiness in a population-based cohort of children.

Design, Setting, and Participants

This cohort study was conducted in the province of Manitoba, Canada, and involved 2 cohorts of children in kindergarten at the time of data collection. The population-based cohort included children born between January 1, 2000, and December 31, 2011, whose school readiness was assessed in kindergarten using the Early Development Instrument (EDI) data. The sibling cohort comprised children born preterm and their closest-in-age siblings born full term. Data were analyzed between March 12 and September 28, 2021.

Exposures

Preterm birth, defined as gestational age (GA) less than 37 weeks.

Main Outcomes and Measures

The primary outcome was vulnerability in the EDI, defined as a score below the tenth percentile of the Canadian population norms for any 1 or more of the 5 EDI domains (physical health and well-being, social competence, emotional maturity, language and cognitive development, and communication skills and general knowledge). Logistic regression models were used to identify the factors associated with vulnerability in the EDI. P values were adjusted for multiplicity using the Simes false discovery method.

Results

Of 86 829 eligible children, 63 277 were included, of whom 4352 were preterm (mean [SD] GA, 34 [2] weeks; 2315 boys [53%]) and 58 925 were full term (mean [SD] GA, 39 (1) weeks; 29 885 boys [51%]). Overall, 35% of children (1536 of 4352) born preterm were vulnerable in the EDI compared with 28% of children (16 449 of 58 925) born full term (adjusted odds ratio [AOR], 1.32; 95% CI, 1.23-1.41; P < .001]). Compared with children born full term, those born preterm had a higher percentage of vulnerability in each of the 5 EDI domains. In the population-based cohort, prematurity (34-36 weeks' GA: AOR, 1.23 [95% CI, 1.14-1.33]; <34 weeks' GA: AOR, 1.72 [95% CI, 1.48-1.99]), male sex (AOR, 2.24; 95% CI, 2.16-2.33), small for gestational age (AOR, 1.31; 95% CI, 1.23-1.40), and various maternal medical and sociodemographic factors were associated with EDI vulnerability. In the sibling cohort, EDI outcomes were similar for both children born preterm and their siblings born full term except for the communication skills and general knowledge domain (AOR, 1.39; 95% CI, 1.07-1.80) and Multiple Challenge Index (AOR, 1.43; 95% CI, 1.06-1.92), whereas male sex (AOR, 2.19; 95% CI, 1.62-2.96) and maternal age at delivery (AOR, 1.53; 95% CI, 1.38-1.70) were associated with EDI vulnerability.

Conclusions and Relevance

Results of this study suggest that, in a population-based cohort, children born preterm had a lower school-readiness rate than children born full term, but this difference was not observed in the sibling cohort. Child and maternal factors were associated with lack of school readiness among this population-based cohort.

School Readiness in Children Born <30 Weeks' Gestation at Risk for Developmental Coordination Disorder: A Prospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether school readiness differs between children born <30 weeks' gestation who are classified as at risk for developmental coordination disorder (DCD) and those who are not.

METHODS

This study was a prospective cohort study of children born <30 weeks' gestation. Children were classified as at risk for DCD at a corrected age of 4 to 5 years if they scored <16th centile on the Movement Assessment Battery for Children-Second Edition (MABC-2), had a full scale IQ score of ≥80 on the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV), and had no cerebral palsy. Children were assessed on 4 school readiness domains: (1) health/physical development [Physical Health domain of Pediatric Quality of Life Inventory (PedsQL), Pediatric Evaluation of Disability Inventory Computer Adaptive Test, and Little Developmental Coordination Disorder Questionnaire], (2) social-emotional development (Strengths and Difficulties Questionnaire and PedsQL psychosocial domains), (3) cognitive skills/general knowledge (WPPSI-IV), and (4) language skills (WPPSI-IV).

RESULTS

Of 123 children assessed, 16 were ineligible (IQ < 80 or cerebral palsy: n = 15; incomplete MABC-2: n = 1); 28 of 107 (26%) eligible children were at risk for DCD. Children at risk for DCD had poorer performance on all school readiness domains, with group differences of more than 0.4 SD in health/physical development, social-emotional development, and language skills and up to 0.8 SD for cognitive skills/general knowledge compared with those not at risk of DCD.

CONCLUSION

Being at risk for DCD in children born <30 weeks' gestation is associated with challenges in multiple school readiness domains, not only the health/physical domain.

Scaffolding Parenting and Health Development for Preterm Flourishing Across the Life Course

Advances in obstetrics and neonatal medicine have resulted in improved survival rates for preterm infants. Remarkably, >75% extremely (<28 weeks) preterm infants who leave the NICU do not experience major neurodevelopmental disabilities, although >50% experience more minor challenges in communication, perception, cognition, attention, regulatory, and executive function that can adversely impact educational and social function resulting in physical, behavioral, and social health issues in adulthood. Even late premature (32-36 weeks) infants have more neurodevelopmental challenges than term infants. Although early intervention and educational programs can mitigate risks of prematurity for children's developmental trajectories, restrictive eligibility requirement and limitations on frequency and intensity mean that many premature infants must "fail first" to trigger services. Social challenges, including lack of family resources, unsafe neighborhoods, structural racism, and parental substance use, may compound biological vulnerabilities, yet existing services are ill-equipped to respond. An intervention system for premature infants designed according to Life Course Health Development principles would instead focus on health optimization from the start; support emerging developmental capabilities such as self-regulation and formation of reciprocal secure early relationships; be tailored to each child's unique neurodevelopmental profile and social circumstances; and be vertically, horizontally, and longitudinally integrated across levels (individual, family, community), domains (health, education), and time. Recognizing the increased demands placed on parents, it would include parental mental health supports and provision of trauma-informed care. This developmental scaffolding would incorporate parenting, health, and developmental interventions, with the aim of improved health trajectories across the whole of the life course.

Gestational Age, Newborn Metabolic Markers and Academic Achievement

BACKGROUND

Gestational age is associated with greater school achievement and variation in newborn metabolic markers. Whether metabolic markers are related to gestational age differences in achievement is unknown. This study examines whether newborn metabolic markers are associated with gestational age differences in performance on standardized school tests.

METHODS

This retrospective cohort study linked birth certificates of children born in Iowa between 2002 and 2010 to newborn screening records and school tests between 2009 and 2018. The analytical sample includes up to 229,679 children and 973,247 child-grade observations. Regression models estimate the associations between gestational age and 37 newborn metabolic markers with national percentile ranking (NPR) scores on math, reading comprehension, and science tests.

RESULTS

An additional gestational week is associated with 0.6 (95% CI: 0.6, 0.7), 0.5 (95% CI: 0.4, 0.5), and 0.4 (95% CI: 0.4, 0.5) higher NPRs on math, reading, and science, respectively. Compared to full term children (37-44 weeks), preterm children (32-36 weeks) have 2.2 (95% CI: -2.6, -1.8), 1.5 (95% CI: -1.9, -1.1), and 1.0 (95% CI: -1.4, -0.7) lower NPRs on math, reading comprehension, and science. Very preterm children (20-31 weeks) have 8.3 (95% CI: -9.4, -7.2), 5.2 (95% CI: -6.2, -4.0), and 4.7 (95% CI: -5.6, -3.8) lower NPRs than full term children on math, reading, and science. Metabolic markers are associated with 27%, 36%, and 45% of gestational age differences in math, reading, and science scores, respectively, and over half of the difference in test scores between preterm or very preterm and full term children.

CONCLUSIONS

Newborn metabolic markers are strongly related to gestational age differences in school test scores, suggesting that early metabolic differences are important markers of long-term child development.

Functional Hyperconnectivity during a Stories Listening Task in Magnetoencephalography Is Associated with Language Gains for Children Born Extremely Preterm

Extreme prematurity (EPT, <28 weeks gestation) is associated with language problems. We previously reported hyperconnectivity in EPT children versus term children (TC) using magnetoencephalography (MEG). Here, we aim to ascertain whether functional hyperconnectivity is a marker of language resiliency for EPT children, validating our earlier work with a distinct sample of contemporary well-performing EPT and preterm children with history of language delay (EPT-HLD). A total of 58 children (17 EPT, 9 EPT-HLD, and 32 TC) participated in stories listening during MEG and functional magnetic resonance imaging (fMRI) at 4–6 years. We compared connectivity in EPT and EPT-HLD, investigating relationships with language over time. We measured fMRI activation during stories listening and parcellated the activation map to obtain “nodes” for MEG connectivity analysis. There were no significant group differences in age, sex, race, ethnicity, parental education, income, language scores, or language representation on fMRI. MEG functional connectivity (weighted phase lag index) was significantly different between groups. Preterm children had increased connectivity, replicating our earlier work. EPT and EPT-HLD had hyperconnectivity versus TC at 24–26 Hz, with EPT-HLD exhibiting greatest connectivity. Network strength correlated with change in standardized scores from 2 years to 4–6 years of age, suggesting hyperconnectivity is a marker of advancing language development.

Gestational Age at Birth and Risk of Developmental Delay: The Upstate KIDS Study

OBJECTIVE

The aim of this study is to model the association between gestational age at birth and early child development through 3 years of age.

STUDY DESIGN

Development of 5,868 children in Upstate KIDS (New York State; 2008-2014) was assessed at 7 time points using the Ages and Stages Questionnaire (ASQ). The ASQ was implemented using gestational age corrected dates of birth at 4, 8, 12, 18, 24, 30, and 36 months. Whether children were eligible for developmental services from the Early Intervention Program was determined through linkage. Gestational age was based on vital records. Statistical models adjusted for covariates including sociodemographic factors, maternal smoking, and plurality.

RESULTS

Compared with gestational age of 39 weeks, adjusted odds ratios (aOR) and 95% confidence intervals of failing the ASQ for children delivered at <32, 32-34, 35-36, 37, 38, and 40 weeks of gestational age were 5.32 (3.42-8.28), 2.43 (1.60-3.69), 1.38 (1.00-1.90), 1.37 (0.98-1.90), 1.29 (0.99-1.67), 0.73 (0.55-0.96), and 0.51 (0.32-0.82). Similar risks of being eligible for Early Intervention Program services were observed (aOR: 4.19, 2.10, 1.29, 1.20, 1.01, 1.00 [ref], 0.92, and 0.78 respectively for <32, 32-34, 37, 38, 39 [ref], 40, and 41 weeks).

CONCLUSION

Gestational age was inversely associated with developmental delays for all gestational ages. Evidence from our study is potentially informative for low-risk deliveries at 39 weeks, but it is notable that deliveries at 40 weeks exhibited further lower risk.

Extremely preterm children demonstrate hyperconnectivity during verb generation: A multimodal approach

Children born extremely preterm (EPT, <28 weeks gestation) are at risk for delays in development, including language. We use fMRI-constrained magnetoencephalography (MEG) during a verb generation task to assess the extent and functional connectivity (phase locking value, or PLV) of language networks in a large cohort of EPT children and their term comparisons (TC). 73 participants, aged 4 to 6 years, were enrolled (42 TC, 31 EPT). There were no significant group differences in age, sex, race, ethnicity, parental education, or family income. There were significant group differences in expressive language scores (p < 0.05). Language representation was not significantly different between groups on fMRI, with task-specific activation involving bilateral temporal and left inferior frontal cortex. There were group differences in functional connectivity seen in MEG. To identify a possible subnetwork contributing to focal spectral differences in connectivity, we ran Network Based Statistics analyses. For both beta (20-25 Hz) and gamma (61-70 Hz) bands, we observed a subnetwork showing hyperconnectivity in the EPT group (p < 0.05). Network strength was computed for the beta and gamma subnetworks and assessed for correlation with language performance. For the EPT group exclusively, strength of the subnetwork identified in the gamma frequency band was positively correlated with expressive language scores (r = 0.318, p < 0.05). Thus, hyperconnectivity is positively related to language for EPT children and might represent a marker for resiliency in this population.

Extremely Preterm Children Demonstrate Interhemispheric Hyperconnectivity During Verb Generation: a Multimodal Approach

Children born extremely preterm (EPT, <28 weeks gestation) are at risk for delays in development, including language. We use fMRI-constrained magnetoencephalography (MEG) during a verb generation task to assess the extent and functional connectivity (phase locking value, or PLV) of language networks in a large cohort of EPT children and their term comparisons (TC). 73 participants, aged 4 to 6 years, were enrolled (42 TC, 31 EPT). There were no significant group differences in age, sex, race, ethnicity, parental education, or family income. There were significant group differences in expressive language scores (p<0.05). Language representation was not significantly different between groups on fMRI, with task-specific activation involving bilateral temporal and left inferior frontal cortex. There were group differences in functional connectivity seen in MEG. To identify a possible subnetwork contributing to focal spectral differences in connectivity, we ran Network Based Statistics analyses. For both beta (20-25 Hz) and gamma (61-70 Hz) bands, we observed a subnetwork showing hyperconnectivity in the EPT group (p<0.05). Network strength was computed for the beta and gamma subnetworks and assessed for correlation with language performance. For the EPT group, exclusively, strength of the subnetwork identified in the gamma frequency band was positively correlated with expressive language scores (r=0.318, p<0.05). Thus, interhemispheric hyperconnectivity is positively related to language for EPT children and might represent a marker for resiliency in this population.

Extremely preterm children exhibit altered cortical thickness in language areas

Children born extremely preterm (< 28 weeks gestation, EPT) are at increased risk for language and other neurocognitive deficits compared to term controls (TC). Prior studies have reported both increases and decreases in cortical thickness in EPT across the cerebrum. These studies have not formally normalized for intracranial volume (ICV), which is especially important as EPT children often have smaller stature, head size, and ICV. We previously reported increased interhemispheric functional and structural connectivity in a well-controlled group of school-aged EPT children with no known brain injury or neurological deficits. Functional and structural hyperconnectivity between left and right temporoparietal regions was positively related with language scores in EPT, which may be reflected in measures of cortical thickness. To characterize possible language network cortical thickness effects, 15 EPT children and 15 TC underwent standardized assessments of language and structural magnetic resonance imaging at 4 to 6 years of age. Images were subjected to volumetric and cortical thickness analyses using FreeSurfer. Whole-brain analyses of cortical thickness were conducted both with and without normalization by ICV. Non-normalized results showed thinner temporal cortex for EPT, while ICV-normalized results showed thicker cortical regions in the right temporal lobe (FDRq = 0.05). Only ICV-normalized results were significantly related to language scores, with right temporal cortical thickness being positively correlated with performance.

Language, Motor, and Cognitive Outcomes of Toddlers Who Were Born Preterm

Purpose The purpose of this study was to examine the language, motor, and cognitive abilities of children born preterm in four categories: (a) healthy preterm infants, (b) infants of diabetic mothers, (c) infants with respiratory distress syndrome, and (d) infants with chronic lung disease when the children were 30 months, uncorrected age. Comorbidity of language, motor, and cognitive skills was examined, along with predictor variables. Method A total of 148 children who were born preterm participated and were assessed using bivariate tests and logistic regression on standardized assessment scores. Results Controlling for the children's gestational age (GA), overall language ability was significantly lower in the infants of diabetic mothers group compared to the healthy preterm infant group, and expressive language skills were significantly lower for the chronic lung disease group than the respiratory distress syndrome group. The children with language delays on at least one measure were significantly more likely to have cognitive, motor, or both delays. Lower maternal education was a significant predictor for language and cognitive delays, and younger GA was a significant predictor for language, motor, and cognitive delays. Conclusion Assessment of the preterm infant from a biosystems approach allows the speech-language pathologist to take into consideration maternal education, diagnosis at preterm birth, and GA, which were found to impact the language, motor, and cognitive outcomes of children born preterm. Our findings further reinforce the concept of the whole child in that children born preterm who display language delays should be screened for co-occurring motor and/or cognitive delays.

Rewiring the extremely preterm brain: Altered structural connectivity relates to language function

Children born preterm are at increased risk for cognitive impairment, with higher-order functions such as language being especially vulnerable. Previously, we and others have reported increased interhemispheric functional connectivity in children born extremely preterm; the finding appears at odds with literature showing decreased integrity of the corpus callosum, the primary commissural bundle, in preterm children. We address the apparent discrepancy by obtaining advanced measures of structural connectivity in twelve school-aged children born extremely preterm (<28 weeks) and ten term controls. We hypothesize increased extracallosal structural connectivity might support the functional hyperconnectivity we had previously observed. Participants were aged four to six years at time of study and groups did not differ in age, sex, race, ethnicity, or socioeconomic status. Whole-brain and language-network-specific (functionally-constrained) connectometry analyses were performed. At the whole-brain level, preterm children had decreased connectivity in the corpus callosum and increased connectivity in the cerebellum versus controls. Functionally-constrained analyses revealed significantly increased extracallosal connectivity between bilateral temporal regions in preterm children (FDRq <0.05). Connectivity within these extracallosal pathways was positively correlated with performance on standardized language assessments in children born preterm (FDRq <0.001), but unrelated to performance in controls. This is the first study to identify anatomical substrates for increased interhemispheric functional connectivity in children born preterm; increased reliance on an extracallosal pathway may represent a biomarker for resiliency following extremely preterm birth.

Small-for-Gestational Age Birth Confers Similar Educational Performance through Middle School

OBJECTIVE

To estimate the association between small for gestational age (SGA) at birth and educational performance on standardized testing and disability prevalence in elementary and middle school.

STUDY DESIGN

Through linked birth certificates and school records, surviving infants born at 23-41 weeks of gestation who entered Florida's public schools 1998-2009 were identified. Twenty-three SGA definitions (3rd-25th percentile) were derived. Outcomes were scores on Florida Comprehensive Assessment Test (FCAT) and students' disability classification in grades 3 through 8. A "sibling cohort" subsample included families with at least 2 siblings from the same mother in the study period. Multivariable models estimated independent relationships between SGA and outcomes.

RESULTS

Birth certificates for 80.2% of singleton infants were matched to Florida public school records (N = 1 254 390). Unadjusted mean FCAT scores were 0.236 SD lower among <10th percentile SGA infants compared with non-SGA infants; this difference declined to -0.086 SD after adjusting for maternal and infant characteristics. When siblings discordant in SGA status were compared within individual families, the association declined to -0.056 SD. For SGA <10th percentile infants, the observed prevalence of school-age disability was 15.0%, 7.7%, and 6.3% for unadjusted, demographics-adjusted, and sibling analyses, respectively. No inflection or discontinuity was detected across SGA definitions from 3rd to 25th percentile in either outcome, and the associations were qualitatively similar.

CONCLUSIONS

The associations between SGA birth and students' standardized test scores and well-being were quantitatively small but persisted through elementary and middle school. The observed deficits were largely mitigated by demographic and familial factors.

School performance is age appropriate with support services in very preterm children at 11 years of age

Aim

This Finnish regional birth‐cohort study compared the school performance of very preterm and full‐term children when they reached 11 years of age.

Methods

Teachers rated the educational abilities of 123 preterm children and 133 full‐term controls at the age of 11 years as well as the support services they received. The children were all born in the Turku University Hospital between 2001 and 2005. In the preterm group, neurosensory impairments were confirmed at two years of corrected age, and full‐scale intelligence quotient (IQ) was assessed at 11 years of age using the Wechsler Intelligence Scale, Fourth Edition.

Results

Educational abilities, including academic skills and classroom functioning, did not differ between the two groups after excluding the children with a full‐scale IQ < 70. However, 40% of the preterm group and 26% of the controls had received at least one support service (p <0.02). The 13 preterm children with a full‐scale IQ <70 and the 10 with neurosensory impairment received more support services. Boys in both groups displayed more classroom‐functioning problems than girls.

Conclusion

A full‐scale IQ ≥ 70 and age‐appropriate educational abilities do not exclude a significant need for support services in very preterm children at the age of 11 years.

Do premature and postterm birth increase the risk of epilepsy? An updated meta-analysis

BACKGROUND

Many studies have reported that premature birth is associated with a higher incidence of epilepsy, and postterm birth also increases the risk of epilepsy. The effects of different gestational ages (GAs) on epilepsy have become a research hotspot, but the findings of these studies remain controversial, and no systematic review has been performed until now.

OBJECTIVE

The aim of this study was to evaluate the impact of different GAs on the incidence of epilepsy.

DATA SOURCES

The main databases, including PubMed, Medline, Embase, Cochrane Library, and Web of Science, were searched using the terms "preterm/premature/early/postterm/postmature/late/delayed delivery/birth", "gestational age", and "epilepsy/seizure" for eligible studies published up to April 1, 2019. The search was limited to English-language articles.

STUDY SELECTION

Observational studies investigating the association between epilepsy and premature or postterm birth were included in this meta-analysis. We only selected studies that had clearly reported GA and the occurrence of epilepsy.

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted the data. The quality of the included studies was examined in accordance with the Newcastle-Ottawa criteria, and the heterogeneity and publication bias were tested. We used sensitivity and subgroup analyses to determine the source of heterogeneity. A logistic randomized-effects model was used to assess the collected data when I² ≥ 50%.

MAIN OUTCOMES

The primary outcome was the odds ratio (OR) of epilepsy.

RESULTS

The research included eleven eligible studies with a total of 4,513,577 participants. Studies involving premature birth showed that the risk of epilepsy was 2.16 times higher in the premature birth group (<37 weeks) than in the full-term birth group (≥37 weeks) (OR [99% confidence interval [CI]] = 2.16 [1.80, 2.58]; P < 0.001). Those born before 32 weeks were associated with an increased occurrence of epilepsy when compared with those born at 32-36 weeks (OR [99% CI] = 2.73 [1.90, 3.94]; P < 0.001). However, the difference in the incidence of epilepsy between postterm children (41 weeks or more) and full-term children (37-40 weeks) was not statistically significant (OR [99% CI] = 1.05 [0.98, 1.12]; P = 0.067).

CONCLUSIONS

Preterm birth was closely associated with a higher risk of epilepsy throughout childhood that persisted into adulthood, and the association became stronger as GA decreased, while there was no significant difference in the risk of developing epilepsy between postterm and full-term offspring.

Association of Socioeconomic Status and Brain Injury With Neurodevelopmental Outcomes of Very Preterm Children

IMPORTANCE

Studies of socioeconomic status and neurodevelopmental outcome in very preterm neonates have not sensitively accounted for brain injury.

OBJECTIVE

To determine the association of brain injury and maternal education with motor and cognitive outcomes at age 4.5 years in very preterm neonates.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of preterm neonates (24-32 weeks' gestation) recruited August 16, 2006, to September 9, 2013, at British Columbia Women's Hospital in Vancouver, Canada. Analysis of 4.5-year outcome was performed in 2018.

MAIN OUTCOMES AND MEASURES

At age 4.5 years, full-scale IQ assessed using the Wechsler Primary and Preschool Scale of Intelligence, Fourth Edition, and motor outcome by the percentile score on the Movement Assessment Battery for Children, Second Edition.

RESULTS

Of 226 survivors, neurodevelopmental outcome was assessed in 170 (80 [47.1%] female). Based on the best model to assess full-scale IQ accounting for gestational age, standardized β coefficients demonstrated the effect size of maternal education (standardized β = 0.21) was similar to that of white matter injury volume (standardized β = 0.23) and intraventricular hemorrhage (standardized β = 0.23). The observed and predicted cognitive scores in preterm children born to mothers with postgraduate education did not differ in those with and without brain injury. The best-performing model to assess for motor outcome accounting for gestational age included being small for gestational age, severe intraventricular hemorrhage, white matter injury volume, and chronic lung disease.

CONCLUSIONS AND RELEVANCE

At preschool age, cognitive outcome was comparably associated with maternal education and neonatal brain injury. The association of brain injury with poorer cognition was attenuated in children born to mothers of higher education level, suggesting opportunities to promote optimal outcomes.

Resilience in Extremely Preterm/Extremely Low Birth Weight Kindergarten Children

OBJECTIVES

Research on developmental outcomes of preterm birth has traditionally focused on adverse effects. This study investigated the prevalence and correlates of resilience in 146 extremely preterm/extremely low birth weight (EPT/ELBW) children (gestational age &lt;28 weeks and/or birth weight &lt;1000 g) attending kindergarten and 111 term-born normal birth weight (NBW) controls.

METHODS

Adaptive competence (i.e., "resilience" in the EPT/ELBW group) was defined by scores within grade expectations on achievement tests and the absence of clinically elevated parent ratings of child behavior problems. The "adaptive" children who met these criteria were compared to the "maladaptive" children who did not on child and family characteristics. Additional analyses were conducted to assess the conjoint effects of group (ELBW vs. NBW) and family factors on adaptive competence.

RESULTS

A substantial minority of the EPT/ELBW group (45%) were competent compared to a majority of NBW controls (73%), odds ratio (95% confidence interval)=0.26 (0.15, 0.45), p&lt;.001. Adaptive competence was associated with higher cognitive skills, more favorable ratings of behavior and learning not used to define adaptive competence, and more advantaged family environments in both groups, as well as with a lower rate of earlier neurodevelopmental impairment in the EPT/ELBW group. Higher socioeconomic status and more favorable proximal home environments were associated with competence independent of group, and group differences in competence persisted across the next two school years.

CONCLUSIONS

The findings document resilience in kindergarten children with extreme prematurity and highlight the role of environmental factors as potential influences on outcome. (JINS, 2019, 25, 362-374).

Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates

BACKGROUND

Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates.

METHODS

Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age.

RESULTS

Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age.

CONCLUSIONS

The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.

Long-Term Functioning and Participation Across the Life Course for Preterm Neonatal Intensive Care Unit Graduates

To understand the trajectories of risk and resilience in the vulnerable preterm and neonatal brain, clinicians must go beyond survival and critically examine on a population basis the functional outcomes of children, adolescents, and adults across their life course. Evaluations must go well beyond Bayley assessments and counts of neonatal morbidities, such as bronchopulmonary dysplasia, retinopathy of prematurity, sonographic brain injury, sepsis, and necrotizing enterocolitis. Proactively providing support to families and developmental and educational supports to children can optimize academic functioning and participation in adult learning, physical and behavioral health activities, community living, relationships, and employment.

The impact of prematurity and maternal socioeconomic status and education level on achievement-test scores up to 8th grade

BACKGROUND

The relative influence of prematurity vs. maternal social factors (socioeconomic status and education level) on academic performance has rarely been examined.

OBJECTIVE

To examine the impact of prematurity and maternal social factors on academic performance from 3rd through 8th grade.

METHODS

We conducted a retrospective cohort study of infants born in 1998 at the University of Arkansas for Medical Sciences. The study sample included 58 extremely low gestational age newborns (ELGANs, 23‒<28 weeks), 171 preterm (≥28‒<34 weeks), 228 late preterm (≥34‒<37 weeks), and 967 term ((≥37‒<42 weeks) infants. Neonatal and maternal variables were collected including maternal insurance status (proxy measure for socioeconomic status) and education level. The primary outcomes were literacy and mathematics achievement-test scores from 3rd through 8th grade. Linear mixed models were used to identify significant predictors of academic performance. All two-way interactions between grade level, gestational-age (GA) groups, and social factors were tested for statistical significance.

RESULTS

Prematurity, social factors, gender, race, gravidity, and Apgar score at one minute were critical determinants of academic performance. Favorable social factors were associated with a significant increase in both literacy and mathematic scores, while prematurity was associated with a significant decrease in mathematic scores. Examination of GA categories and social factors interaction suggested that the impact of social factors on test scores was similar for all GA groups. Furthermore, the impact of social factors varied from grade to grade for literacy, while the influence of either GA groups or social factors was constant across grades for mathematics. For example, an ELGAN with favorable social factors had a predicted literacy score 104.1 (P <.001), 98.2 (P <.001), and 76.4 (P <.01) points higher than an otherwise similar disadvantaged term infant at grades 3, 5, and 8, respectively. The difference in their predicted mathematic scores was 33.4 points for all grades (P <.05).

CONCLUSION

While there were significant deficits in academic performance for ELGANs compared to PT, LPT, and term infants, the deficit could be offset by higher SES and better-educated mothers. These favorable social factors were critical to a child's academic achievement. The role of socioeconomic factors should be incorporated in discussions on outcome with families of preterm infants.

Extremely preterm children exhibit increased interhemispheric connectivity for language: findings from fMRI-constrained MEG analysis

Children born extremely preterm are at significant risk for cognitive impairment, including language deficits. The relationship between preterm birth and neurological changes that underlie cognitive deficits is poorly understood. We use a stories-listening task in fMRI and MEG to characterize language network representation and connectivity in children born extremely preterm (n = 15, <28 weeks gestation, ages 4-6 years), and in a group of typically developing control participants (n = 15, term birth, 4-6 years). Participants completed a brief neuropsychological assessment. Conventional fMRI analyses revealed no significant differences in language network representation across groups (p > .05, corrected). The whole-group fMRI activation map was parcellated to define the language network as a set of discrete nodes, and the timecourse of neuronal activity at each position was estimated using linearly constrained minimum variance beamformer in MEG. Virtual timecourses were subjected to connectivity and network-based analyses. We observed significantly increased beta-band functional connectivity in extremely preterm compared to controls (p < .05). Specifically, we observed an increase in connectivity between left and right perisylvian cortex. Subsequent effective connectivity analyses revealed that hyperconnectivity in preterms was due to significantly increased information flux originating from the right hemisphere (p < 0.05). The total strength and density of the language network were not related to language or nonverbal performance, suggesting that the observed hyperconnectivity is a "pure" effect of prematurity. Although our extremely preterm children exhibited typical language network architecture, we observed significantly altered network dynamics, indicating reliance on an alternative neural strategy for the language task.