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Background: Early childhood education offers opportunities for stimulation in multiple developmental domains and its positive impact on long-term outcomes and wellbeing for children is well documented. Few studies have explored early education in children born very preterm (VPT; <32 weeks of gestation) who are at higher risk of neurodevelopmental disorders and poor educational outcomes than their term-born peers. The purpose of the study is to describe and compare the educational environment of children born VPT in European countries at 5 years of age according to the degree of perinatal risk., Methods: Data originated from the population-based Screening to Improve Health In very Preterm infants (SHIPS) cohort of children born VPT in 2011/2012 in 19 regions from 11 European countries. Perinatal data were collected from medical records and the 5-year follow-up was conducted using parental questionnaires. Outcomes at 5 years were participation in early education (any, type, intensity of participation) and receipt of special educational support, which were harmonized across countries., Results: Out of 6,759 eligible children, 3,687 (54.6%) were followed up at 5 years (mean gestational age 29.3 weeks). At 5 years, almost all children (98.6%) were in an educational program, but type (preschool/primary), attendance (full-time/part-time) and use and type of school support/services differed by country. In some countries, children with high perinatal risk were more likely to be in full-time education than those with low risk (e.g. Estonia: 97.9% vs. 87.1%), while the inverse pattern was observed elsewhere (e.g. Poland: 78.5% vs. 92.8%). Overall, 22.8% of children received special educational support (country range: 12.4-34.4%) with more support received by children with higher perinatal risk. Large variations between countries remained after adjustment for socio-demographic characteristics., Conclusions: There are marked variations in approaches to early education for children born VPT in Europe, raising opportunities to explore its impact on their neurodevelopment and well-being., (© 2024. The Author(s).)

Background: Children born extremely preterm (EP) are at increased risk of neurocognitive and behavioural morbidity. Here, we investigate whether behavioural outcomes have changed over time concomitant with increasing survival following EP birth., Methods: Comparison of outcomes at 11 years of age for two prospective national cohorts of children born EP in 1995 (EPICure) and 2006 (EPICure2), assessed alongside term-born children. Behavioural outcomes were assessed using the parent-completed Strengths and Difficulties Questionnaire (SDQ), DuPaul Attention-Deficit/Hyperactivity Disorder Rating Scale (ADHD-RS), and Social Communication Questionnaire (SCQ)., Results: In EPICure, 176 EP and 153 term-born children were assessed (mean age: 10.9 years); in EPICure2, 112 EP and 143 term-born children were assessed (mean age: 11.8 years). In both cohorts, EP children had higher mean scores and more clinically significant difficulties than term-born children on almost all measures. Comparing outcomes for EP children in the two cohorts, there were no significant differences in mean scores or in the proportion of children with clinically significant difficulties after adjustment for confounders. Using term-born children as reference, EP children in EPICure2 had significantly higher SDQ total difficulties and ADHD-RS hyperactivity impulsivity z-scores than EP children in EPICure., Conclusions: Behavioural outcomes have not improved for EP children born in 2006 compared with those born in 1995. Relative to term-born peers, EP children born in 2006 had worse outcomes than those born in 1995. There is an ongoing need for long-term clinical follow-up and psychological support for children born EP., (© 2023. The Author(s).)

Aim: Adults born preterm have increased risk of mental health problems and other neurodevelopmental conditions. We aimed to investigate associations of mental health with pain and tiredness in adults born very preterm (VP; <32 weeks) or very low birthweight (VLBW; <1500 g) and at term, and whether these associations are influenced by physical activity., Methods: As part of an EU Horizon 2020 project, individual participant data from six prospective cohort studies were harmonised for 617 VP/VLBW and 1122 term-born participants. Mental health was assessed by the Achenbach System of Empirically Based Assessment Adult Self-Report. Pain and tiredness were harmonised based on specific items from self-reported questionnaires. Associations between mental health and pain or tiredness were explored by linear regression., Results: An increase in the mental health scales internalising, externalising and total problems was associated with increased pain and tiredness in the preterm and term group alike. Results were maintained when adjusting for physical activity., Conclusion: The findings indicate that associations between mental health, pain and tiredness in adults are independent of gestation or birthweight. Future research should explore other potential mechanisms that may underlie the increased risk of mental health problems in the preterm population., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Objective: To investigate whether extrauterine growth restriction (EUGR) during the neonatal hospitalisation by sex among extremely preterm (EPT) infants is associated with cerebral palsy (CP) and cognitive and motor abilities at 5 years of age., Study Design: Population-based cohort of births <28 weeks of gestation with data from obstetric and neonatal records and parental questionnaires and clinical assessments at 5 years of age., Setting: 11 European countries., Patients: 957 EPT infants born in 2011-2012., Main Outcomes: EUGR at discharge from the neonatal unit was defined as (1) the difference between Z-scores at birth and discharge with <-2 SD as severe, -2 to -1 SD as moderate using Fenton's growth charts (Fenton) and (2) average weight-gain velocity using Patel's formula in grams (g) per kilogram per day (Patel) with <11.2 g (first quartile) as severe, 11.2-12.5 g (median) as moderate. Five-year outcomes were: a CP diagnosis, intelligence quotient (IQ) using the Wechsler Preschool and Primary Scales of Intelligence tests and motor function using the Movement Assessment Battery for Children, second edition., Results: 40.1% and 33.9% children were classified as having moderate and severe EUGR, respectively, by Fenton and 23.8% and 26.3% by Patel. Among children without CP, those with severe EUGR had lower IQ than children without EUGR (-3.9 points, 95% Confidence Interval (CI)=-7.2 to -0.6 for Fenton and -5.0 points, 95% CI=-8.2 to -1.8 for Patel), with no interaction by sex. No significant associations were observed between motor function and CP., Conclusions: Severe EUGR among EPT infants was associated with decreased IQ at 5 years of age., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Meta-analyses of the voluminous scientific literature on the impact of very preterm (VPT, <32 weeks' gestation) birth on cognition find a marked deficit in intelligence quotient (IQ) among children born VPT relative to term-born peers, but with unexplained between-study heterogeneity in effect size., Objectives: To conduct an umbrella review to describe the design and methodology of primary studies and to assess whether methodological heterogeneity affects the results of meta-analyses., Data Sources: Primary studies from five systematic reviews with meta-analysis on VPT birth and childhood IQ., Study Selection and Data Extraction: Information on study design, sample characteristics and results was extracted from studies. Study features covered study type, sample size, follow-up rates, adjustment for social context, management of severe impairments and test type., Synthesis: We used random-effects subgroup meta-analyses and meta-regressions to investigate the contribution of study features to between-study variance in standardised mean differences (SMD) in IQ between groups., Results: In 58 cohorts (56%), children with severe impairments were excluded, while 23 (22%) cohorts accounted for social factors. The least reported feature was the follow-up rate (missing in 38 cohorts). The largest difference in SMDs was between studies using full scale IQ tests (61 cohorts, SMD -0.89, 95% CI -0.96, -0.82) versus short-form tests (27 cohorts, SMD -0.68, 95% CI -0.79, -0.57). The proportion of between-study variance explained by the type of test was 14%; the other features explained less than 1% of the variance., Conclusions: Study design and methodology varied across studies, but most of them did not affect the variance in effect size, except the type of cognitive test. Key features, such as the follow-up rate, were not consistently reported limiting the evaluation of their potential contribution. Incomplete reporting limited the evaluation of the full impact of this methodological diversity., (© 2023 The Authors. Paediatric and Perinatal Epidemiology published by John Wiley & Sons Ltd.)

Aim: To test whether poor childhood pulmonary function explains the relationship between extremely preterm (EP) birth and attention-deficit/hyperactivity disorder (ADHD) symptoms in young adulthood., Methods: EPICure birth cohort participants include children born <26 weeks' gestation in the United Kingdom and Ireland in 1995 and their term-born classmates. Predictor was EP birth. Outcomes were inattention/hyperactivity subscale z-scores at 19 years. Forced expiratory volume (FEV1) z-scores in childhood and young adulthood were mediators. We used recursive path analysis to determine the direct effect of EP birth on inattention/hyperactivity and its indirect effect through pulmonary function., Results: Ninety EP and 47 term-born participants had pulmonary function testing at 11 and 19 years. Inattention z-scores were higher in the EP group (mean difference 0.55 [95% CI 0.11, 0.99]) but not hyperactivity. Compared to term-born peers, EP participants had lower FEV1 z-scores at 11 (mean difference-1.35 [95% CI -1.72, -0.98]) and 19 (mean difference-1.29 [95% CI -1.65, -0.92]). Path models revealed that childhood pulmonary function explained the relationship between EP birth and inattention., Conclusions: Extremely preterm young adults have increased risk for inattention compared to term-born peers. Poor pulmonary function appears to underlie this risk. The mechanisms responsible remain unclear and warrant further study., (© 2022 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background and Objective: Assessment of health-related quality of life for individuals born very preterm and/or low birthweight (VP/VLBW) offers valuable complementary information alongside biomedical assessments. However, the impact of VP/VLBW status on health-related quality of life in adulthood is inconclusive. The objective of this study was to examine associations between VP/VLBW status and preference-based health-related quality-of-life outcomes in early adulthood., Methods: Individual participant data were obtained from five prospective cohorts of individuals born VP/VLBW and controls contributing to the 'Research on European Children and Adults Born Preterm' Consortium. The combined dataset included over 2100 adult VP/VLBW survivors with an age range of 18-29 years. The main exposure was defined as birth before 32 weeks' gestation (VP) and/or birth weight below 1500 g (VLBW). Outcome measures included multi-attribute utility scores generated by the Health Utilities Index Mark 3 and the Short Form 6D. Data were analysed using generalised linear mixed models in a one-step approach using fixed-effects and random-effects models., Results: VP/VLBW status was associated with a significant difference in the Health Utilities Index Mark 3 multi-attribute utility score of - 0.06 (95% confidence interval - 0.08, - 0.04) in comparison to birth at term or at normal birthweight; this was not replicated for the Short Form 6D. Impacted functional domains included vision, ambulation, dexterity and cognition. VP/VLBW status was not associated with poorer emotional or social functioning, or increased pain., Conclusions: VP/VLBW status is associated with lower overall health-related quality of life in early adulthood, particularly in terms of physical and cognitive functioning. Further studies that estimate the effects of VP/VLBW status on health-related quality-of-life outcomes in mid and late adulthood are needed., (© 2022. The Author(s).)

Children born extremely preterm (EP) have poorer academic attainment than their term-born peers. There is a need to identify the specific cognitive mechanisms that are associated with poor academic attainment in preterm populations to inform the development of intervention strategies. A parallel mediation analysis was conducted with cross-sectional data from 152 EP children (< 27 weeks of gestation) and 120 term-born controls who were assessed at age 11. Mathematics and reading attainment was assessed using the Wechsler Individual Achievement Test 2nd Edition. Controlling for sex and socio-economic status we evaluated the following mediators: verbal working memory, visuospatial working memory, verbal processing speed, attention, and visuospatial processing. These were assessed using subtests from the standardized NEPSY-II test and Wechsler Intelligence Scale for Children-5th Edition. Verbal working memory, visuospatial working memory, visuospatial processing and verbal processing speed, but not attention, were significant independent mediators between EP birth and attainment in reading. No direct relationship between EP birth and reading attainment remained in the mediated model. All five neuropsychological variables mediated the relationship between EP birth and attainment in mathematics, but a direct effect of EP birth on mathematics remained in the mediated model. Together, all five neuropsychological abilities indirectly explained 44% of the variance in reading and 52% of the variance in mathematics. Visuospatial processing was the strongest mediator of both mathematics and reading. Components of executive function, especially visuospatial processing, are important predictors of academic attainment. Interventions to improve visuospatial skills could be trialed in EP populations.

Objective: To compare health-related quality of life (HRQL) in childhood for extremely preterm (EP) births before 26 weeks of gestation in England in two eras: 1995 and 2006., Design: Prospective cohort studies., Setting: School or home-based assessments at 11 years of age., Participants: Available data for 88 EP children born before 26 weeks of gestation in 2006 (EPICure2) were compared with those of 140 born in England during 1995 (EPICure). To account for social secular trends, the comparison between eras was also made for term-born controls as reference., Main Outcome Measures: HRQL was measured using the parent-completed Health Utilities Index (HUI) questionnaire with utility scores calculated using the HUI3 classification system. Eight attributes were assessed: vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain., Results: At 11 years, mean utility scores were significantly lower in EPICure2 (2006) than in EPICure (1995; Δ -0.12, 95% CI -0.20 to -0.04). The difference increased (Δ -0.27, 95% CI -0.41 to -0.12) after adjusting for significant perinatal and demographic differences between cohorts. Rates of suboptimal function were increased in EPICure2 for all eight attributes, but statistically significant differences were only found in speech (p=0.004) and dexterity (p=0.020). After excluding children with severe neurodevelopmental impairment, the adjusted difference between cohorts remained significant but attenuated (-0.14 (-0.26 to -0.01)). Mean utility scores for controls were similar between cohorts (Δ -0.01 (-0.04 to 0.02))., Conclusions: Using parent report, there was a clinically significant decline in HRQL ratings for EP children over time. Areas contributing the most to the decline were speech and dexterity., Trial Registration Number: ISRCTN86323684., Competing Interests: Competing interests: NM declares consultancy fees from Novartis and Shire outside this study., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Recently several studies have reported adult outcomes for individuals born at extremely low gestations, although they tend to be included as part of slightly more mature populations. The growth in collaborative studies allows greater confidence in the identification of persisting risk and allows us to have confidence in the likely outcomes in more contemporary cohorts. This review shows the persistence of adverse outcomes through to adult life and includes a range of outcomes including all body systems evaluated. Nonetheless adult outcomes demonstrate that most survivors appear to be free of major disabling conditions and demonstrate good participation in society. Several studies have reported outcomes in the third decade, but subsequent ageing trajectories have not yet been defined. The stability of many of the outcomes evaluated over childhood into adult life and the lack of improvement in prevalence of childhood impairments found in contemporary cohorts indicates persisting levels of risk., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Research suggests that children born very preterm (≤32 weeks' gestation) are at greater risk of impairments in information processing (particularly when information is presented simultaneously rather than sequentially) and visuo-spatial short-term and working memory relative to children born at term. This study compared the performance of children born very preterm with their term-born peers to elucidate the nature of group differences in these areas. 113 children (65 very preterm; 48 term-born) aged 8-to-11 years completed four visuo-spatial recall tasks. Tasks varied by presentation type (simultaneous or sequential) and memory type (short-term or working memory). Both groups recalled more locations in simultaneous than sequential tasks, and in short-term than working memory tasks. In short-term memory tasks, children born at term recalled more locations than children born very preterm for the sequential task, but groups did not differ on the simultaneous task. The opposite pattern was observed in the working memory tasks, with no group differences on the sequential task, but better performance on the simultaneous task for children born at term. Our findings indicate that simultaneous processing may not be impaired in children born very preterm per se , with poorer performance observed only under high cognitive demand. This interaction suggests very preterm birth may affect the level of cognitive resources available during feature integration, the consequences of which become apparent when resources are already stretched. The impact of interactions with cognitive demand in this population should be an important consideration for educational support strategies, and for assessment in research and clinic.

Objectives: To determine growth outcomes at 11 years of age in children born <27 weeks of gestation in England in 2006 (EPICure2) and to compare growth from birth to 11 years of age for births<26 weeks with those in England in 1995 (EPICure)., Methods: 200 EPICure2 children assessed at 11 years alongside 143 term-born controls. Growth measures from birth to 11 years were compared for births<26 weeks between EPICure2 (n=112) and EPICure (n=176). Growth parameter z-scores were derived from 1990 UK standards., Results: Among EPICure2 children, mean z-scores for height and weight were close to the population standards (0.08 and 0.18 SD, respectively) but significantly below those of controls: difference in mean (Δ) z-scores for weight -0.42 SD (95% CI -0.68 to -0.17), for height -0.45 SD (-0.70 to -0.20) and for head circumference (HC) -1.05 SD (-1.35 to -0.75); mean body mass index (BMI) z-score in EPICure2 children was 0.18 SD, not significantly different from controls (0.43 SD, p=0.065). Compared with EPICure, EPICure2 children born <26 weeks at 11 years had higher z-scores for weight (Δ 0.72 (0.47, 0.96)), height (Δ 0.55 (0.29, 0.81)) and BMI (Δ 0.56 (0.24, 0.87)), which were not fully explained by perinatal/demographic differences between eras. Weight catch-up was greater from term-age to 2.5/3 years in EPICure2 than in EPICure (1.25 SD vs 0.53 SD; p<0.001). Poor HC growth was observed in EPICure2, unchanged from EPICure., Conclusions: Since 1995, childhood growth in weight, height and BMI have improved for births <26 weeks of gestation, but there was no improvement in head growth., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Context: There is a lack of research on individual perceptions of social experiences and social relationships among very preterm (VP) adults compared with term-born peers., Objective: To investigate self-perceived social functioning in adults born VP (<32 weeks' gestation) and/or with very low birth weight (VLBW) (<1500g) compared with term-born adults (≥37 weeks' gestation) using an individual participant data (IPD) meta-analysis., Data Sources: Two international consortia: Research on European Children and Adults born Preterm and Adults Born Preterm International Collaboration., Study Selection: Cohorts with outcomes assessed by using the Adult Self-Report Adaptive Functioning scales (friends, spouse/partner, family, job, and education) in both groups., Data Extraction: IPD from 5 eligible cohorts were collected. Raw-sum scores for each scale were standardized as z scores by using mean and SD of controls for each cohort. Pooled effect size was measured by difference (Δ) in means between groups., Results: One-stage analyses (1285 participants) revealed significantly lower scores for relationships with friends in VP/VLBW adults compared with controls (Δ -0.37, 95% confidence interval [CI]: -0.61 to -0.13). Differences were similar after adjusting for sex, age, and socioeconomic status (Δ -0.39, 95% CI: -0.63 to -0.15) and after excluding participants with neurosensory impairment (Δ -0.34, 95% CI: -0.61 to -0.07). No significant differences were found in other domains., Limitations: Generalizability of research findings to VP survivors born in recent decades., Conclusions: VP/VLBW adults scored their relationship with friends lower but perceived their family and partner relationships, as well as work and educational experiences, as comparable to those of controls., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Marlow declares consultancy fees from RSM Consulting, Takeda, and Novartis in the past 3 years outside this study. The other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Importance: Birth before 32 weeks' gestation (very preterm [VPT]) and birth weight below 1500 g (very low birth weight [VLBW]) have been associated with lower cognitive performance in childhood. However, there are few investigations of the association of neonatal morbidities and maternal educational levels with the adult cognitive performance of individuals born VPT or VLBW (VPT/VLBW)., Objective: To assess differences in adult IQ between VPT/VLBW and term-born individuals and to examine the association of adult IQ with cohort factors, neonatal morbidities, and maternal educational level among VPT/VLBW participants., Data Sources: Systematic review of published data from PubMed and meta-analysis of individual participant data (IPD) of cohorts from 2 consortia (Research on European Children and Adults Born Preterm [RECAP] and Adults Born Preterm International Collaboration [APIC])., Study Selection: The meta-analysis included prospective longitudinal cohort studies that assessed the full-scale IQ of adults born VPT or VLBW and respective control groups comprising term-born adults., Data Extraction and Synthesis: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline for analyses of individual participant data and identified 8 studies that provided data from 2135 adults (1068 VPT/VLBW and 1067 term-born participants) born between 1978 and 1995. Meta-analyses of IPD were performed using a 1-stage approach, treating VPT birth or VLBW and cohort as random effects., Main Outcomes and Measures: Full-scale IQ scores were converted to z scores within each cohort using the combined SD of VPT/VLBW participants and a control group of term-born participants, with scores centered on the mean of the control group., Results: A total of 426 records were identified and screened. After exclusions, 13 studies were included in the aggregate meta-analysis. The IPD meta-analysis included 8 of the 9 RECAP and APIC cohorts with adult IQ data. The mean (SD) age among the 8 IPD cohorts was 24.6 (4.3) years, and 1163 participants (54.5%) were women. In unadjusted analyses, VPT/VLBW participants had mean adult IQ scores that were 0.78 SD (95% CI, -0.90 to -0.66 SD) lower than term-born participants, equivalent to a difference of 12 IQ points. Among VPT/VLBW participants, lower gestational age (score difference per week of gestation, 0.11; 95% CI, 0.07-0.14), lower birth weight z scores (score difference per 1.0 SD, 0.21; 95% CI, 0.14-0.28), the presence of neonatal bronchopulmonary dysplasia (score difference, -0.16; 95% CI, -0.30 to -0.02) or any grade of intraventricular hemorrhage (score difference, -0.19; 95% CI, -0.33 to -0.05), and lower maternal educational level (score difference, 0.26; 95% CI, 0.17-0.35) were all significantly associated with lower IQ scores in adulthood., Conclusions and Relevance: In this IPD meta-analysis, lower gestational age, lower weight for gestational age, neonatal morbidities, and lower maternal educational levels were all important risk factors associated with lower IQ among young adults born VPT or VLBW.

Objective: To determine whether improvements in school age outcomes had occurred between two cohorts of births at 22-25 weeks of gestation to women residents in England in 1995 and 2006., Design: Longitudinal national cohort studies., Setting: School-based or home-based assessments at 11 years of age., Participants: EPICure2 cohort of births at 22-26 weeks of gestation in England during 2006: a sample of 200 of 1031 survivors were evaluated; outcomes for 112 children born at 22-25 weeks of gestation were compared with those of 176 born in England during 1995 from the EPICure cohort. Classroom controls for each group acted as a reference population., Main Outcome Measures: Standardised measures of cognition and academic attainment were combined with parent report of other impairments to estimate overall neurodevelopmental status., Results: At 11 years in EPICure2, 18% had severe and 20% moderate impairments. Comparing births at 22-25 weeks in EPICure2 (n=112), 26% had severe and 21% moderate impairment compared with 18% and 32%, respectively, in EPICure. After adjustment, the OR of moderate or severe neurodevelopmental impairment in 2006 compared with 1995 was 0.76 (95% CI 0.45 to 1.31, p=0.32). IQ scores were similar in 1995 (mean 82.7, SD 18.4) and 2006 (81.4, SD 19.2), adjusted difference in mean z-scores 0.2 SD (95% CI -0.2 to 0.6), as were attainment test scores. The use of multiple imputation did not alter these findings., Conclusion: Improvements in care and survival between 1995 and 2006 are not paralleled by improved cognitive or educational outcomes or a reduced rate of neurodevelopmental impairment., Competing Interests: Competing interests: All authors declare no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work. NM declares consultancy fees from Novartis in the past 3 years outside this study; the other authors have no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess whether adolescents born very preterm (VP; <32 weeks' gestation) have an excess of mathematics anxiety compared with their classmates born at term., Methods: This cohort study included 127 adolescents born VP (51% male, mean age 13.9 years, SD 0.7) and 95 term-born classmates (56% male, mean age 13.7 years, SD 0.7) who completed the Wechsler Individual Achievement Test Second UK Edition and the Mathematics Anxiety Scale-UK at the age of 11 to 15 years. Self-reported trait anxiety was assessed using a composite of 3 items from the Strengths and Difficulties Questionnaire., Results: Adolescents born VP had significantly poorer mathematics attainment than adolescents born at term (difference in means: -0.64 SD; 95% confidence interval -0.95 to -0.34). However, there were no between-group differences in self-reported mathematics anxiety or trait anxiety. There were significant moderate associations between mathematics anxiety and mathematics attainment for adolescents born VP (rho: -0.45) and at term (rho: -0.54), after controlling for trait anxiety., Conclusion: Adolescents born VP do not have heightened mathematics anxiety compared with their term-born classmates, despite poorer attainment in mathematics. Improving domain-general cognitive skills and scaffolding learning in the classroom may be more promising avenues for intervention than attempting to reduce mathematics anxiety., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate the cost-effectiveness of two rates of enteral feed advancement (18 vs 30 mL/kg/day) in very preterm and very low birth weight infants., Design: Within-trial economic evaluation alongside a multicentre, two-arm parallel group, randomised controlled trial (Speed of Increasing milk Feeds Trial)., Setting: 55 UK neonatal units from May 2013 to June 2015., Patients: Infants born <32 weeks' gestation or <1500 g, receiving less than 30 mL/kg/day of milk at trial enrolment. Infants with a known severe congenital anomaly, no realistic chance of survival, or unlikely to be traceable for follow-up, were ineligible., Interventions: When clinicians were ready to start advancing feed volumes, infants were randomised to receive daily increments in feed volume of 30 mL/kg (intervention) or 18 mL/kg (control)., Main Outcome Measure: Cost per additional survivor without moderate to severe neurodevelopmental disability at 24 months of age corrected for prematurity., Results: Average costs per infant were slightly higher for faster feeds compared with slower feeds (mean difference £267, 95% CI -6928 to 8117). Fewer infants achieved the principal outcome of survival without moderate to severe neurodevelopmental disability at 24 months in the faster feeds arm (802/1224 vs 848/1246). The stochastic cost-effectiveness analysis showed a likelihood of worse outcomes for faster feeds compared with slower feeds., Conclusions: The stochastic cost-effectiveness analysis shows faster feeds are broadly equivalent on cost grounds. However, in terms of outcomes at 24 months age (corrected for prematurity), faster feeds are harmful. Faster feeds should not be recommended on either cost or effectiveness grounds to achieve the primary outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To develop research priorities on the consequences of very preterm (VPT) birth for the RECAP Preterm platform which brings together data from 23 European VPT birth cohorts., Design and Setting: This study used a two-round modified Delphi consensus process. Round 1 was based on 28 research themes related to childhood outcomes (<12 years) derived from consultations with cohort researchers. An external panel of multidisciplinary stakeholders then ranked their top 10 themes and provided comments. In round 2, panel members provided feedback on rankings and on new themes suggested in round 1., Results: Of 71 individuals contacted, 64 (90%) participated as panel members comprising obstetricians, neonatologists, nurses, general and specialist paediatricians, psychologists, physiotherapists, parents, adults born preterm, policy makers and epidemiologists from 17 countries. All 28 initial themes were ranked in the top 10 by at least six panel members. Highest ranking themes were: education (73% of panel members' top 10 choices); care and outcomes of extremely preterm births, including ethical decisions (63%); growth and nutrition (60%); emotional well-being and social inclusion (55%); parental stress (55%) and impact of social circumstances on outcomes (52%). Highest ranking themes were robust across panel members classified by background. 15 new themes had at least 6 top 10 endorsements in round 2., Conclusions: This study elicited a broad range of research priorities on the consequences of VPT birth, with good consensus on highest ranks between stakeholder groups. Several highly ranked themes focused on the socioemotional needs of children and parents, which have been less studied., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: The Movement Assessment Battery for Children-Second Edition (Movement ABC-2) is widely used to assess children's motor function, yet there is a lack of normative data for many countries., Aims: To assess the extent to which the application of different population reference norms for the Movement ABC-2 affects the classification and prevalence of motor impairment., Design: Data were obtained from two Portuguese regions participating in the Screening to Improve Health in Very Preterm Infants in Europe (SHIPS) Study, which was a five year follow-up of a cohort of children born at <32 weeks' gestation in 2011-2012 in 19 regions in 11 European countries. Perinatal data were extracted from medical records and the Movement ABC-2 was administered at five years of age., Subjects: Of 542 Portuguese children eligible for the five-year follow-up, 413 (76.2%) were evaluated., Outcome Measures: Movement ABC-2 raw scores were converted to standardized scores using norms from four countries with national standardisations (UK, Netherlands/Belgium, France and Italy)., Results: The prevalence of significant movement difficulties (total score ≤ 5th percentile) was 28.5% using Dutch/Flemish norms, 23.3% using French norms, 16.5% using UK norms and 11.4% using Italian norms; 10.8% and 68.3% of the children were consistently classified as having significant movement difficulties and as not having significant movement difficulties, respectively, according to any norms. However, for 20.9% of children there was a disagreement in motor function status using different norms., Conclusion: The use of different test norms has a large impact on the proportion of children classified with significant movement difficulties, with implications for clinical referrals, healthcare costs and research. Our results underscore the importance of using appropriately validated tests with sound psychometric properties, and raise questions about the large differences in norms for the Movement ABC-2 in European countries., Competing Interests: Declaration of competing interest The authors have no potential conflicts of interest relevant to this article to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To report outcomes at 2 years corrected age for children of women recruited to a trial comparing alternative policies for timing of cord clamping and immediate neonatal care at very preterm birth., Design: Parallel group randomised (1:1) trial., Setting: Eight UK tertiary maternity units., Participants: Two hundred and seventy-six babies born to 261 women expected to have a live birth before 32 +0 weeks' gestation., Interventions: Deferred cord clamping (≥2 min) and immediate neonatal care with cord intact or immediate (≤20 s) clamping and immediate neonatal care after clamping., Main Outcome Measure: Composite of death or adverse neurodevelopmental outcome at 2 years corrected age., Results: Six babies born after 35 +6 weeks were excluded. At 2 years corrected age, outcome data were not available for a further 52 children, leaving 218 for analysis (115 deferred clamping, 103 immediate clamping). Overall, 24/115 (21%) children allocated deferred clamping died or had an adverse neurodevelopmental outcome compared with 35/103 (34%) allocated immediate clamping; risk ratio (RR) 0.61 (95% CI 0.39 to 0.96); risk difference (RD) -13% (95% CI -25% to -1%). Multiple imputation for missing data gave an RR 0.69 (95% CI 0.44 to 1.09) and RD -9% (95% CI -21% to 2%)., Conclusions: Deferred clamping and immediate neonatal care with cord intact may reduce the risk of death or adverse neurodevelopmental outcome at 2 years of age for children born very premature. Confirmation in larger studies is needed to determine the real benefits and harms., Trial Registration Number: ISRCTN21456601., Competing Interests: Competing interests: JD reports grants from NIHR during the conduct of the trial; LD reports memberships to CTUs funded by NIHR. All other authors have nothing to disclose., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Observational data suggest that slowly advancing enteral feeds in preterm infants may reduce necrotising enterocolitis but increase late-onset sepsis. The Speed of Increasing milk Feeds Trial (SIFT) compared two rates of feed advancement., Objective: To determine if faster (30 ml/kg/day) or slower (18 ml/kg/day) daily feed increments improve survival without moderate or severe disability and other morbidities in very preterm or very low-birthweight infants., Design: This was a multicentre, two-arm, parallel-group, randomised controlled trial. Randomisation was via a web-hosted minimisation algorithm. It was not possible to safely and completely blind caregivers and parents., Setting: The setting was 55 UK neonatal units, from May 2013 to June 2015., Participants: The participants were infants born at < 32 weeks' gestation or a weight of < 1500 g, who were receiving < 30 ml/kg/day of milk at trial enrolment., Interventions: When clinicians were ready to start advancing feed volumes, the infant was randomised to receive daily feed increments of either 30 ml/kg/day or 18 ml/kg/day. In total, 1400 infants were allocated to fast feeds and 1404 infants were allocated to slow feeds., Main Outcome Measures: The primary outcome was survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for gestational age. The secondary outcomes were mortality; moderate or severe neurodevelopmental disability at 24 months corrected for gestational age; death before discharge home; microbiologically confirmed or clinically suspected late-onset sepsis; necrotising enterocolitis (Bell's stage 2 or 3); time taken to reach full milk feeds (tolerating 150 ml/kg/day for 3 consecutive days); growth from birth to discharge; duration of parenteral feeding; time in intensive care; duration of hospital stay; diagnosis of cerebral palsy by a doctor or other health professional; and individual components of the definition of moderate or severe neurodevelopmental disability., Results: The results showed that survival without moderate or severe neurodevelopmental disability at 24 months occurred in 802 out of 1224 (65.5%) infants allocated to faster increments and 848 out of 1246 (68.1%) infants allocated to slower increments (adjusted risk ratio 0.96, 95% confidence interval 0.92 to 1.01). There was no significant difference between groups in the risk of the individual components of the primary outcome or in the important hospital outcomes: late-onset sepsis (adjusted risk ratio 0.96, 95% confidence interval 0.86 to 1.07) or necrotising enterocolitis (adjusted risk ratio 0.88, 95% confidence interval 0.68 to 1.16). Cost-consequence analysis showed that the faster feed increment rate was less costly but also less effective than the slower rate in terms of achieving the primary outcome, so was therefore found to not be cost-effective. Four unexpected serious adverse events were reported, two in each group. None was assessed as being causally related to the intervention., Limitations: The study could not be blinded, so care may have been affected by knowledge of allocation. Although well powered for comparisons of all infants, subgroup comparisons were underpowered., Conclusions: No clear advantage was identified for the important outcomes in very preterm or very low-birthweight infants when milk feeds were advanced in daily volume increments of 30 ml/kg/day or 18 ml/kg/day. In terms of future work, the interaction of different milk types with increments merits further examination, as may different increments in infants at the extremes of gestation or birthweight., Trial Registration: Current Controlled Trials ISRCTN76463425., Funding: This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 18. See the NIHR Journals Library website for further project information., Competing Interests: Jane Abbott, Janet Berrington, Elaine Boyle, Ursula Bowler, Jon Dorling, Nicholas Embleton, Kenny McCormick, William McGuire, Edmund Jaszczuk, Samantha Johnson, Madeleine Hurd, Oliver Hewer, Andrew King, Alison Leaf, Louise Linsell, Christopher Partlett, David Murray, Ben Stenson, Judith Rankin and Tracy Roberts report funding from the National Institute for Health Research (NIHR) for the trial. Jon Dorling, Janet Berrington, Elaine Boyle, Nicholas Embleton, Edmund Jaszczuk, Samantha Johnson, Andrew King, Louise Linsell, William McGuire, Christopher Partlett and Tracy Roberts report receipt of funding from NIHR, outside the submitted work. Jon Dorling reports grants from Nutrinia (Nazareth, Israel) outside the submitted work; specifically, he was funded for part of his salary to work as an expert advisor on a trial of enteral insulin. Furthermore, he was a member of the NIHR Health Technology Assessment (HTA) General Board (2017–18) and the NIHR HTA Maternity, Newborn and Child Health Panel (2013–18). Elaine Boyle reports grants from the Medical Research Council and East Midlands Specialised Commissioning Group outside the submitted work. Janet Berrington reports grants and personal fees from Danone Early Life Nutrition (Paris, France) and grants from Prolacta Biosciences US (Duarte, CA, USA) outside the submitted work. Nicholas Embleton reports grants from Prolacta Biosciences US and Danone Early Life Nutrition and personal fees from Nestlé Nutrition Institute (Vevey, Switzerland), Baxter (Deerfield, IL, USA) and Fresenius Kabi (Bad Homburg vor der Höhe, Germany) outside the submitted work. Samantha Johnson reports grants from Action Medical Research (Horsham, UK), EU Horizon 2020 (Brussels, Belguim), the Medical Research Council (London, UK), Sparks (London, UK) and the Nuffield Foundation (London, UK) outside the submitted work. William McGuire is a member of the NIHR HTA Commissioning Board (2013 to present) and the HTA and Efficacy and Mechanism Evaluation Editorial Board (2012 to present). Edmund Juszczak was a member of the NIHR HTA General Board from 2016 to 2017 and the HTA funding committee (commissioning) from 2013 to 2016.

Background: Socioeconomic factors influence language development in the general population, but the association remains poorly documented in children born very preterm (VPT). We assessed the impact of maternal education on language development in children born VPT and effect modification by perinatal risk., Methods: Data were from the Effective Perinatal Intensive Care in Europe (EPICE) population-based cohort of children born <32 weeks' gestational age (GA) in 2011/2012. Regions from six countries (Estonia, France, Germany, Italy, Sweden and UK) used a validated short form MacArthur Developmental Communicative Inventories Checklist to assess language at 2 years corrected age. Perinatal variables were collected from clinical records. We assessed expressive language delay (ELD), defined as (a) not combining words; and (b) expressive vocabulary <10th percentile of norms for age and sex. Perinatal risk (low, moderate and high) was determined using GA, small for GA and neonatal morbidities. We estimated adjusted risk ratios (aRR) of ELD by maternal education with inverse weighting to account for non-response bias., Results: Of 2741 children, 24.6% were not combining words and 39.7% had a low expressive vocabulary. Low maternal education (lower secondary or less compared with a bachelor's degree or more) increased risks of ELD: not combining words: aRR=1.52 (95% CI 1.36 to 1.69); low expressive vocabulary: aRR=1.25 (1.04 to 1.51). For children with low perinatal risk, the aRR were 1.88 (1.26 to 2.80) and 1.44 (1.06 to 1.95), respectively, compared with those with high perinatal risks: 1.36 (1.10 to 1.67) and 1.11 (0.97 to 1.27), respectively., Conclusion: Low maternal education affects ELD for children born VPT, although the association appears attenuated among those with highest perinatal risk., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Children born extremely preterm (EP) (<26 weeks' gestation) have lower cognitive scores and an increased rate of cognitive impairment compared with their term-born peers. However, the neuropsychological presentation of these EP individuals in adulthood has not been described. The aim of this study was to examine neuropsychological outcomes in early adulthood after EP birth in the 1995 EPICure cohort and to investigate if the rate of intellectual impairment changed longitudinally., Methods: A total of 127 young adults born EP and 64 term-born controls had a neuropsychological assessment at 19 years of age examining general cognitive abilities (IQ), visuomotor abilities, prospective memory, and aspects of executive functions and language., Results: Adults born EP scored significantly lower than term-born controls across all neuropsychological tests with effect sizes (Cohen's d ) of 0.7 to 1.2. Sixty percent of adults born EP had impairment in at least 1 neuropsychological domain; deficits in general cognitive functioning and visuomotor abilities were most frequent. The proportion of EP participants with an intellectual impairment (IQ <70) increased by 6.7% between 11 and 19 years of age ( P = .02). Visuospatial functioning in childhood predicted visuomotor functioning at 19 years., Conclusions: Adults born EP continue to perform lower than their term-born peers in general cognitive abilities as well as across a range of neuropsychological functions, indicating that these young adults do not show improvement overtime. The prevalence of intellectual impairment increased from 11 years into adulthood., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Aim: We attempted to determine how handedness changes with age and its relation to brain injury and cognition following birth before 26 weeks of gestation., Methods: We used data from the EPICure study of health and development following birth in the British Isles in 1995. Handedness was determined by direct observation during standardized testing at age 2.5, six, and 11 years and by self-report using the Edinburgh Handedness Inventory at 19 years. Control data from term births were included at six, 11, and 19 years., Results: In extremely preterm children left handedness increased from 9% to 27% between 2.5 and 19 years, with a progressive reduction in mixed handedness from 59% to 13%. Although individual handedness scores varied over childhood, the between-group effects were consistent through 19 years, with greatest differences in females. In extremely preterm participants, neonatal brain injury was associated with lower right handedness scores at each age and left-handed participants had lower cognitive scores at 19 years after controlling for confounders, but not at other ages., Conclusion: Increasing hand lateralization is seen over childhood in extremely preterm survivors, but consistently more individuals have non-right preferences at each age than control individuals., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Inattention is one of the most common neurobehavioral problems following very preterm birth. Attention problems can persist into adulthood and are associated with negative socio-emotional and educational outcomes. This study aimed to determine whether the cognitive processes associated with inattention differ between term-born and very preterm children. Sixty-five children born very preterm (<33+0 weeks' gestation) aged 8-11 years were recruited alongside 48 term-born controls (?37 20 +0 weeks' gestation). Both groups included children with a wide spectrum of parent-rated inattention (above average attention to severe inattention) measured as a continuous dimension using the Strengths and Weaknesses of ADHD and Normal-Behavior (SWAN) scale. The children completed tests to assess basic cognitive processes and executive function. A hierarchical multiple regression analysis was implemented to assess which neurocognitive processes explained variance in parent-rated inattention and whether these differed between preterm and term-born children. In both groups, poorer verbal and visuospatial short-term memory and poorer visuospatial working memory independently explained variance in parent-rated inattention. Slower motor processing speed explained variance in inattention among very preterm children only. The cognitive mechanisms associated with parent-rated inattention were predominantly overlapping between groups, but relationships between motor processing speed and inattention were unique to very preterm children. These associations may reflect risk factors for inattention in term and very preterm children. Future research should assess the efficacy of these cognitive processes as potential targets for intervention.

To investigate trajectories of behavior, attention, social and emotional problems to early adulthood in extremely preterm survivors compared to a term-born comparison group. Longitudinal analysis of a prospective, population-based cohort of 315 surviving infants born < 26 completed weeks of gestation recruited at birth in 1995, from the UK/Republic of Ireland, and a term-born comparison group recruited at age 6. The parent-report Strengths and Difficulties Questionnaire was completed at age 6, 11, 16 and 19 years. The Total Behavioral Difficulties Score was 4.81 points higher in extremely preterm individuals compared to their term-born peers over the period (95% CI 3.76-5.87, p < 0.001) and trajectories were stable in both groups. The impact of difficulties on home life, friendships, school or work and/or leisure activities was greater in the EPT group (RR 4.28, 95% CI 2.89-6.35, p < 0.001), and hyperactivity/inattention and peer problems accounted for the largest differences. A clinically significant behavioral screen at age 2.5 was associated with a higher Total Behavioral Difficulties Score from 6 years onwards in extremely preterm participants (Mean difference 6.90, 95% CI 5.01-8.70, p < 0.0.01), as was moderate/severe cognitive impairment at last assessment (Mean difference: 4.27, 95% CI 2.76-5.77, p < 0.001). Attention, social and emotional problems in extremely preterm individuals persist into early adulthood with significant impact on daily life. A positive behavioral screen in infancy and moderate/severe cognitive impairment are associated with early adult outcomes.

Objective: To determine the trajectory of cognitive test scores from infancy to adulthood in individuals born extremely preterm compared with term-born individuals., Design: A prospective, population-based cohort study., Setting: 276 maternity units in the UK and Ireland., Patients: 315 surviving infants born less than 26 completed weeks of gestation recruited at birth in 1995 and 160 term-born classroom controls recruited at age 6., Main Outcome Measures: Bayley Scales of Infant Development-Second Edition (age 2.5); Kaufman Assessment Battery for Children (ages 6/11); Wechsler Abbreviated Scale of Intelligence-Second Edition (age 19)., Results: The mean cognitive scores of extremely preterm individuals over the period were on average 25.2 points below their term-born peers (95% CI -27.8 to -22.6) and remained significantly lower at every assessment. Cognitive trajectories in term-born boys and girls did not differ significantly, but the scores of extremely preterm boys were on average 8.8 points below those of extremely preterm girls (95% CI -13.6 to -4.0). Higher maternal education elevated scores in both groups by 3.2 points (95% CI 0.8 to 5.7). Within the extremely preterm group, moderate/severe neonatal brain injury (mean difference: -10.9, 95% CI -15.5 to -6.3) and gestational age less than 25 weeks (mean difference: -4.4, 95% CI -8.4 to -0.4) also had an adverse impact on cognitive function., Conclusions: There is no evidence that impaired cognitive function in extremely preterm individuals materially recovers or deteriorates from infancy through to 19 years. Cognitive test scores in infancy and early childhood reflect early adult outcomes., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

There is no question that birth at extremely low gestational ages presents a significant threat to an infant's survival, health and development. Growing evidence suggests that gestational age may be conceptualised as a continuum in which births before 28 weeks of gestation (extremely preterm: EP) represent the severe end of a spectrum of health and developmental adversity. Although comprising just 1%-2% of all births, EP deliveries pose the greatest challenge to neonatal medicine and to health, education and social services for the provision of ongoing support for survivors with additional needs. Studying the outcomes of these infants remains critical for evaluating and enhancing clinical care, planning long-term support and for advancing our understanding of the life-course consequences of immaturity at birth. Here we review literature relating to early and long-term neurodevelopmental, cognitive, behavioural and educational outcomes following EP birth focusing on key themes and considering implications for intervention., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Children born extremely preterm are at high risk for intellectual disability, learning disabilities, executive dysfunction and special educational needs, but little is understood about the comorbidity of intellectual and learning disabilities in this population., Aims: This study explored comorbidity in intellectual disability (ID) and learning disabilities (LD) in children born extremely preterm (EP; <26 +0 weeks' gestation)., Subjects and Study Design: A UK national cohort of 161 EP children and 153 term-born controls without neurosensory impairments was assessed at 11years of age (the EPICure Study)., Outcome Measures: IQ, mathematics and reading attainment, executive function, visuospatial processing and sensorimotor skills were assessed using standardised tests, and curriculum-based attainment and special educational needs (SEN) using teacher reports., Results: Overall, 75 (47%) EP children and 7 (4.6%) controls had ID or LD (RR 10.12; 95% CI 4.81, 21.27). Comorbidity in ID/LD was more common among EP children than controls (24% vs. 0%). EP children with comorbid ID/LD had significantly poorer neuropsychological abilities and curriculum-based attainment than EP children with an isolated disability or no disabilities. LD were associated with a 3 times increased risk for SEN. However, EP children with ID alone had poorer neuropsychological abilities and curriculum-based attainment than children with no disabilities, yet there was no increase in SEN provision among this group., Conclusions: EP children are at high risk for comorbid intellectual and learning disabilities. Education professionals should be aware of the complex nature of EP children's difficulties and the need for multi-domain assessments to guide intervention., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: To investigate antecedents of attention-deficit/hyperactivity disorder (ADHD) symptoms in children born extremely preterm (EP; <26-wk gestation)., Method: The EPICure study recruited all babies born EP in the United Kingdom and Ireland in March-December 1995. Neurodevelopmental outcomes were assessed at 2.5 (n = 283; 90%), 6 (n = 160; 78%), and 11 (n = 219; 71%) years of age. Parents and teachers completed the DuPaul Rating Scale IV to assess inattention and hyperactivity/impulsivity symptoms at 11 years. Regression analyses were used to explore the association of neonatal, neurodevelopmental, and behavioral outcomes to 6 years with ADHD symptoms at 11 years., Results: Extremely preterm (EP) children had significantly more inattention (mean difference, 1.2 SD; 95% CI, 0.9-1.5) and hyperactivity/impulsivity (mean difference, 0.5 SD; 95% CI, 0.2-0.7) than controls, with a significantly greater effect size for inattention than hyperactivity/impulsivity. Significant independent predictors of inattention at 11 years included smaller head circumference, lower intelligence quotient (IQ), and pervasive peer relationship problems at 6 years, and motor development at 2.5 years. In contrast, significant independent predictors of hyperactivity/impulsivity included lower IQ, pervasive conduct problems and ADHD symptoms at 6 years, externalizing problems at 2.5 years, and non-white maternal ethnicity., Conclusions: Extremely preterm children are at increased risk for ADHD symptoms, predominantly inattention, for which the antecedents differ by symptom domain. Attention deficits after EP birth were associated with poor brain growth and neurological function. Cognitive and behavioral assessments in early and middle childhood to identify neurodevelopmental and peer relationship problems may be beneficial for identifying EP children at risk for inattention.

Objective: Risk factors associated with adverse behavioral outcomes in very preterm (VPT) or very low birth weight (VLBW) infants are poorly understood. The aim of this article is to identify prognostic factors for behavioral problems and psychiatric disorders in children born ≤32 weeks gestational age or with birth weight ≤1250 g., Method: A systematic review was conducted using MEDLINE, Embase, and Pyscinfo databases to identify studies published between January 1, 1990 and June 1, 2014 reporting multivariable prediction models for behavioral problems or psychiatric disorders in VPT/VLBW children. Fifteen studies were identified and 2 independent reviewers extracted key information on study design, outcome definition, risk factor selection, model development, reporting, and conducted a risk of bias assessment., Results: The 15 studies included reported risk factor analyses for the following domains: general behavioral problems (n = 8), any psychiatric disorder (n = 2), autism spectrum symptoms/disorders (n = 5), and attention deficit/hyperactivity disorder (n = 1). Findings were inconclusive because of the following: small number of studies in each domain, heterogeneity in outcome measures, lack of overlap in the risk factors examined, and differences in strategies for dealing with children with neurological impairments., Conclusion: There is a lack of evidence concerning risk factors for behavior problems and psychiatric disorders among VPT/VLBW survivors. This review has identified the need for further research examining the etiology of disorders of psychological development in the VPT/VLBW population to refine risk prediction and identify targets for intervention. Large well-conducted studies that use standard diagnostic evaluations to assess psychiatric disorders throughout childhood and adolescence are required.

Children born very preterm have poorer attainment in all school subjects, and a markedly greater reliance on special educational support than their term-born peers. In particular, difficulties with mathematics are especially common and account for the vast majority of learning difficulties in this population. In this paper, we review research relating to the causes of mathematics learning difficulties in typically developing children, and the impact of very preterm birth on attainment in mathematics. Research is needed to understand the specific nature and origins of mathematics difficulties in very preterm children to target the development of effective intervention strategies.

Objective: To determine outcomes at age 3 years in babies born before 27 completed weeks' gestation in 2006, and to evaluate changes in outcome since 1995 for babies born between 22 and 25 weeks' gestation., Design: Prospective national cohort studies, EPICure and EPICure 2., Setting: Hospital and home based evaluations, England., Participants: 1031 surviving babies born in 2006 before 27 completed weeks' gestation. Outcomes for 584 babies born at 22-25 weeks' gestation were compared with those of 260 surviving babies of the same gestational age born in 1995., Main Outcome Measures: Survival to age 3 years, impairment (2008 consensus definitions), and developmental scores. Multiple imputation was used to account for the high proportion of missing data in the 2006 cohort., Results: Of the 576 babies evaluated after birth in 2006, 13.4% (n=77) were categorised as having severe impairment and 11.8% (n=68) moderate impairment. The prevalence of neurodevelopmental impairment was significantly associated with length of gestation, with greater impairment as gestational age decreased: 45% at 22-23 weeks, 30% at 24 weeks, 25% at 25 weeks, and 20% at 26 weeks (P<0.001). Cerebral palsy was present in 83 (14%) survivors. Mean developmental quotients were lower than those of the general population (normal values 100 (SD 15)) and showed a direct relation with gestational age: 80 (SD 21) at 22-23 weeks, 87 (19) at 24 weeks, 88 (19) at 25 weeks, and 91 (18) at 26 weeks. These results did not differ significantly after imputation. Comparing imputed outcomes between the 2006 and 1995 cohorts, the proportion of survivors born between 22 and 25 weeks' gestation with severe disability, using 1995 definitions, was 18% (95% confidence interval 14% to 24%) in 1995 and 19% (14% to 23%) in 2006. Fewer survivors had shunted hydrocephalus or seizures. Survival of babies admitted for neonatal care increased from 39% (35% to 43%) in 1995 to 52% (49% to 55%) in 2006, an increase of 13% (8% to 18%), and survival without disability increased from 23% (20% to 26%) in 1995 to 34% (31% to 37%) in 2006, an increase of 11% (6% to 16%)., Conclusion: Survival and impairment in early childhood are both closely related to gestational age for babies born at less than 27 weeks' gestation. Using multiple imputation to account for the high proportion of missing values, a higher proportion of babies admitted for neonatal care now survive without disability, particularly those born at gestational ages 24 and 25 weeks.