Predicting School-Aged Cognitive Impairment in Children Born Very Preterm
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Predicting School-Aged Cognitive
Impairment in Children Born
Very Preterm
Carmina Erdei, MD,a,b Nicola C. Austin, DM,c,d Sara Cherkerzian, ScD,a,b Alyssa R. Morris, MA,e Lianne J. Woodward, PhDf
Children born very preterm (VPT) are at high risk of cognitive
BACKGROUND AND OBJECTIVES: abstract
impairment that impacts their educational and social opportunities. This study examined the
predictive accuracy of assessments at 2, 4, 6, and 9 years in identifying preterm children with
cognitive impairment by 12 years.
METHODS: We prospectively studied a regional cohort of 103 children born VPT (#32 weeks’
gestation) and 109 children born term from birth to corrected age 12 years. Cognitive
functioning was assessed by using age-appropriate, standardized measures: Bayley Scales
of Infant Development, Second Edition (age 2); Wechsler Preschool and Primary Scale of
Intelligence (ages 4 and 6); and Wechsler Intelligence Scale for Children, Fourth Edition
(ages 9 and 12).
RESULTS:By 12 years, children born VPT were more likely to have severe (odds ratio 3.9; 95%
confidence interval 1.1–13.5) or any (odds ratio 3.2; 95% confidence interval 1.8–5.6)
cognitive impairment compared with children born term. Adopting a severe cognitive
impairment criterion at age 2 under-identified 44% of children born VPT with later severe
impairment, whereas a more inclusive earlier criterion identified all severely affected children
at 12 years. Prediction improved with age, with any delay at age 6 having the highest
sensitivity (85%) and positive predictive value (66%) relative to earlier age assessments.
Inclusion of family-social circumstances further improved diagnostic accuracy.
CONCLUSIONS: Cognitive risk prediction improves with age, with assessments at 6 years offering
optimal diagnostic accuracy. Intervention for children with early mild delay may be beneficial,
especially for those raised in socially disadvantaged family contexts.
a
Brigham and Women’s Hospital, Boston, Massachusetts; bDepartment of Pediatrics, Harvard Medical School, WHAT’S KNOWN ON THIS SUBJECT: Approximately half
Harvard University, Boston, Massachusetts; cChristchurch Women’s Hospital, Christchurch, New Zealand; of children born very preterm have mild to moderate
d
Department of Pediatrics, University of Otago, Christchurch, New Zealand; eDepartment of Psychology, University cognitive impairments by school age. Early
of Southern California, Los Angeles, California; and fSchool of Health Sciences, University of Canterbury,
identification is challenging because cognition is
Christchurch, New Zealand
difficult to assess at younger ages. It is unclear when
Study enrollment and patient monitoring and follow-up occurred at Christchurch Women’s Hospital school-aged cognitive risk is best predicted.
in New Zealand.
WHAT THIS STUDY ADDS: Cognitive risk prediction
Dr Erdei conceptualized the research questions of this study, performed the analysis and
improves with age during early childhood, with
interpretation of the data in conjunction with the coauthors, drafted the initial manuscript, and
edited the manuscript; Dr Cherkerzian contributed to the statistical methods and analysis and
assessments at age 6 years offering the best
critically reviewed and helped revise the present manuscript; Ms Morris conducted the initial diagnostic accuracy. Both mild and severe early delay
analysis and critically reviewed the present manuscript; Prof Woodward and Associate Prof Austin place children at risk later, with risk being further
conceptualized the design of this study in addition to the larger study on which this analysis is exacerbated by family-social disadvantage.
based, coordinated and supervised data collection, contributed to the data analysis plan, and
critically reviewed and helped revise the present manuscript; and all authors approved the final To cite: Erdei C, Austin NC, Cherkerzian S, et al. Predicting
manuscript as submitted and agree to be accountable for all aspects of the work. School-Aged Cognitive Impairment in Children Born Very
Preterm. Pediatrics. 2020;145(4):e20191982
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PEDIATRICS Volume 145, number 4, April 2020:e20191982 ARTICLEChildren born very preterm followed children born VPT or classified as showing severe
(VPT) remain at high risk for extremely preterm prospectively to impairment if their IQ score was
neurodevelopmental impairments examine the relations between early .2 SDs below the term group
despite advances in neonatal care.1–3 ability and middle childhood mean and any impairment (mild or
These impairments span multiple cognitive functioning, with variable severe) if their IQ was .1 SD
domains, with cognitive difficulties results.21–31 Some studies report below the term mean at each
affecting approximately half of good concordance between Bayley assessment point.1,6
surviving children.1,4–7 Between 40% assessments and later cognitive 2. Examine the predictive accuracy of
and 50% of children born VPT meet function in children,21,23,25,30 whereas standardized cognitive measures
criteria for either mild or severe others suggest poor correlation at ages 2, 4, 6, and 9 in identifying
cognitive or intellectual impairment, with preschool-26,31 and school- cognitive impairment at age 12 in
which is defined as an IQ .1 SD aged22,24,27 cognitive outcomes. One children born VPT.
below the normative mean. These study of extremely preterm survivors
3. Assess whether cognitive risk
cognitive difficulties are in turn examined the accuracy of the Bayley
prediction for children born VPT
associated with high rates of special scales in predicting cognitive function
could be further improved by
education service use,8,9 longer-term at school age using multiple age
considering the family-social
educational underachievement,10 assessments.23 Results suggested that
context.
social1,5,6 and mental health11 early assessments were relatively
difficulties, as well as reduced earning good predictors of later cognitive
and employment potential in function, with accuracy of risk
METHODS
adulthood.12,13 This suggests that prediction improving with age. The
even milder cognitive impairments generalizability of these observations Sample
may have significant impacts on to VPT survivors remains uncertain.
Two groups of children were
functioning over the life course.
An additional and important included. The VPT group comprised
Early neurodevelopmental consideration is the social context in 103 children born at #32 weeks’
intervention is therefore critical to which children are raised given that gestational age (GA) consecutively
mitigate these adverse long-term family socioeconomic factors also admitted into a level III NICU at
effects. Not only is the brain impact cognitive development.4,5,32–34 Christchurch Women’s Hospital in
undergoing rapid development Mangin et al35 found that family- New Zealand from 1998 to 2000
during early childhood but it is also social adversity contributed (92% recruitment) and followed
characterized by a high degree of additively to preterm children’s through age 12 years. Exclusion
neural plasticity and sensitivity to cognitive risk in middle childhood. criteria included congenital
positive and negative environmental Other data suggest that over time, abnormalities and non–English-
influences.14,15 Yet, a major challenge environmental factors may play an speaking parents. Recruited infants
for early identification of cognitive increasingly important role in did not differ from nonrecruited
impairment is that some deficits do shaping VPT children’s cognitive infants on clinical or family-social
not manifest until older ages, when development than earlier perinatal factors. Excluding post–NICU-
the demands of the environment exposures.33 This highlights the discharge deaths (n = 3), retention at
exceed the developmental capabilities importance of considering not only ages 4, 6, 9, and 12 was 98%, 97%,
of the child. This raises important the timing of earlier assessments 96%, and 97%, respectively.
questions regarding the optimal but also the extent of family-social The term group comprised 109
duration of developmental disadvantage when assessing children born at 37 to 41 weeks’
monitoring to ensure accurate and need for ongoing monitoring and gestation identified from hospital
timely identification and intervention intervention for children born VPT. birth records, recruited at age 2, and
for children born VPT with clinically
followed through age 12 years.
significant cognitive and learning Therefore, our aims in this study were Children were matched for sex and
needs.16,17 as follows: pregnancy due date, with 62% (n =
The Bayley Scales of Infant 1. Examine the extent of severe and 113) of regionally representative
Development18 represent the most any (mild or severe) cognitive eligible infants being included.
commonly used measure of cognitive impairment in children born VPT Nonparticipation reasons included
ability before age 3. After this time, compared with those born term at primarily family circumstances.6
cognition is typically assessed by corrected ages 2, 4, 6, 9, and Retention rates at ages 4, 6, 9, and
using standardized intelligence 12 years. For consistency with 12 were 96%, 96%, 97%, and
measures.19,20 Multiple studies have other studies, children were 96%, respectively.
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2 ERDEI et alProcedures TABLE 1 Study Sample: Clinical and Demographic Characteristics (N = 212)
Procedures and measures were VPT Term Test Statistica P
(N = 103) (N = 109)
approved by the Canterbury Regional
Ethics Committee with written Child clinical characteristics
GA, mean (SD) 28 (2) 39 (1) 245.1 ,.001b
informed consent obtained from
Birth wt, mean (SD) 1061 (314) 3585 (411) 250.4 ,.001b
all parents and/or guardians. All Male sex, n (%) 52 (50) 60 (55) 0.4 .51
children underwent comprehensive Twin birth, n (%) 34 (33) 4 (4) 31.0 ,.001b
neurodevelopmental assessments Small for GA, n (%) 11 (11) 1 (1) 9.5 .002b
close to their second, fourth, sixth, Culture-proven sepsis, n (%) 30 (29) 0 (0) na —
Oxygen use at 36 wk, n (%) 36 (35) 0 (0) na —
ninth, and 12th birthdays (corrected
ROP stage 3 or 4, n (%) 4 (4) 0 (0) na —
for GA). Cognitive assessments were IVH grade 3 or 4, n (%) 6 (6) 0 (0) na —
completed by a blinded registered Moderate to severe white matter abnormality, 19 (18) 0 (0) na —
psychologist. Although GA correction n (%)
through age 12 is not routinely Postnatal dexamethasone, n (%) 6 (6) 0 (0) na —
Early intervention and learning support
performed clinically, this approach
Early intervention services by 4 y, n (%) 63 (61) 1 (1) — ,.001b
was adopted to reduce the likelihood Remedial support at 6 y, n (%) 44 (43) 22 (20) — ,.001b
of overestimation of cognitive Family and social characteristics
impartment among children born Maternal age, mean (SD) 31 (5) 31 (4) 20.4 .69
VPT.36 At ages 2, 4, and 6, families Ethnic minority, n (%) 14 (14) 13 (12) 0.1 .74
Single-parent family, n (%) 20 (19) 13 (12) 2.2 .14
were surveyed about their children’s
Mother did not complete high school, n (%) 42 (41) 20 (18) 12.6 ,.001b
participation in early intervention Low family SES, n (%) 31 (30) 11 (10) 13.1 ,.001b
and/or special education services. Family-social risk index
Teachers were also questioned None, n (%) 38 (37) 66 (61) 11.9 ,.001b
regarding remedial support at age 6, Low, 1 family-social risk factor, n (%) 31 (30) 28 (26) 0.5 .47
High, 2 or more family-social risk factors, n (%) 34 (33) 14 (13) 12.3 ,.001b
and clinical agencies were contacted
to confirm the nature and duration of IVH, intraventricular hemorrhage; na, not applicable; ROP, retinopathy of prematurity; —, not available.
a Continuous distributions (normally distributed) compared by group status by using a t test and binary variables
services children received. compared by using a x2 test.
b Comparison statistically significant at a , .05 based on a 2-sided test.
Measures
At corrected age 2 years, cognitive
encompass the indices of the full years), maternal education (did not
function was estimated by using the
form: Verbal Comprehension, graduate high school), single-parent
Bayley Scales of Infant Development,
Perceptual Reasoning, Working family, and family socioeconomic
Second Edition.18 At 4 and 6 years’
Memory, and Processing Speed. Three status (SES) (semiskilled, unskilled,
corrected age, the short form of the
preterm children were assigned or unemployed). Each variable was
Wechsler Preschool and Primary
a score of 40, and 1 preterm child had coded as either present or absent and
Scale of Intelligence, Revised19 was
an IQ estimated from 2 subtests then summed to form a composite
administered, consisting of 2 verbal
(Vocabulary and Matrix Reasoning) at family-social risk index. Because few
(Comprehension and Arithmetic) and
9 years because of inability to children were exposed to .2 risk
2 performance (Picture Completion
complete the assessment. At 12 years, factors, the index was operationalized
and Block Design) subtests that
2 preterm children were assigned an to reflect 0, 1, or $2 family-social risk
correlate highly with full-scale IQ (r =
IQ of 40 (severe disability). factors.
0.89–0.92).37 One preterm child at
age 4 and 2 children at age 6 were Across all assessments, the average Statistical Analysis
assigned the minimum IQ score of 1-SD cutoff point ranged from 91.5
We calculated means, SDs, and
40 because of severe disability. (age 2) to 95.3 (age 6), with the
percentages of relevant demographic
One term child was excluded at age 4 average 2-SD cutoff score ranging
and clinical characteristics and
(incomplete assessment), and one from 70.6 (age 2) to 83.7 (age 6).
compared them by term status using
preterm child was excluded at age 6
the t test and x2 test, respectively.
(administration error). Family-Social Risk The magnitude of between-group
At corrected ages 9 and 12 years, We collected 5 measures of family- differences in cognitive performance
a short form of the Wechsler social risk during the first 2 years of by age was assessed by using Cohen’s
Intelligence Scale for Children, Fourth life: maternal minority ethnicity d or x2 and/or Fisher’s exact tests.
Edition was administered,20 (non–New Zealand European), For any (IQ .1 SD) cognitive
consisting of 5 subtests that maternal age at child birth (,21 impairment measures, the odds ratios
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PEDIATRICS Volume 145, number 4, April 2020 3FIGURE 1
Comparison of the distributions of cognitive performance by group status across ages of assessment: 2, 4, 6, 9, and 12 years. The smoothed distribution
of scores among children born VPT and term are represented on kernel density estimate curves. The histograms represent the distribution of IQ scores
by group status. The kernel density estimate curves represent nonparametric estimates of the probability functions for IQ by VPT status. For the kernel
density estimate curves, the parameter that determines the degree of smoothness in the estimated density function (ie, the bandwidth) is based on an
approximation of the mean integrated square error calculated as the sum of the integrated squared bias and the variance. IQ_4, IQ at age 4; IQ_6, IQ at
age 6; IQ_9, IQ at age 9; IQ_12, IQ at age 12.
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4 ERDEI et alTABLE 2 Rates of Severe (IQ .2 SDs) and Any (Mild or Severe: IQ .1 SD) Cognitive Impairment at Each Time Point by Group Status
Age of Cognitive Impairment VPT Term Effect Size, Comparisons by Group
Assessment Threshold (N = 103), (N = 109), d Test Pb Unadjusted 95% Adjusted 95% CI
% % Statistica ORc CI ORc
2 20.5
Severe 13 5 — .04b 2.7 (1.0–7.2) 2.3 (0.8–6.5)
Any 40 15 15.3 ,.001b 2.7 (1.6–4.5) 2.5 (1.4––4.2)
4 20.7
Severe 10 2 — .02b 5.1 (1.1–22.7) 3.4 (0.7–15.7)
Any 35 12 14.7 ,.001b 2.8 (1.6–5.0) 2.4 (1.3–4.4)
6 20.8
Severe 16 4 — .004b 4.2 (1.4–12.0) 3.4 (1.1–10.2)
Any 49 16 25.7 ,.001b 3.1 (1.9–4.9) 2.8 (1.7–4.7)
9 20.6
Severe 13 3 — .008b 4.5 (1.3–15.5) 3.2 (0.9–11.4)
Any 34 12 14.5 ,.001b 2.8 (1.6–5.0) 2.4 (1.3–4.3)
12 20.6
Severe 11 3 — .03b 3.9 (1.1–13.5) 2.8 (0.8–10.2)
Any 38 12 19.2 ,.001b 3.2 (1.8–5.6) 2.8 (1.5–5.1)
—, not available.
a Proportions by group status were compared by using the x2 test and Fisher’s exact test (when cell sizes were small [,5]).
b a , .05 based on a 2-sided test.
c Odds of any (.1 SD) cognitive impairment among children (VPT versus term); adjusted analyses for family-social risk status (0, 1, or 2).
(ORs) and 95% confidence intervals to less educated women of lower SES. By age 12, 14 children (VPT, n = 11
(CIs) were assessed by using logistic Reflecting these increased levels of [11%]; term, n = 3 [3%]; P = .03) met
regression models, both unadjusted social disadvantage, children born criteria for severe impairment, and 52
and adjusted for family-social risk. The VPT were 2.6 times more likely to be (VPT, n = 39 [38%]; term, n = 13 [12%];
classification accuracy of identifying raised in families with $2 family- P , .001) met criteria for any cognitive
cognitive impairment at age 12 by social risk factors (33% VPT; 13% impairment.
using severe (IQ .2 SDs) and any (IQ term). With regard to support
.1 SD) criteria at ages 2, 4, 6, and services, 63 children (61%) born VPT Given the higher rates of family
9 years was evaluated on the basis of received intervention by 4 years: disadvantage among the VPT group
sensitivity, specificity, positive 48 received 1 service, 12 received 2 (ORs; Table 2), we examined to what
predictive value (PPV), negative services, and 3 received 3 services. extent between-group differences may
predictive value (NPV), and receiver In addition, more children born VPT partly reflect the effects of social risk.
operating curve (ROC). Effect received remedial support at 6 years Accounting for family-social risk in
modification by family-social risk was (43% VPT; 20% term). regression models (adjusted ORs;
examined by comparing the Table 2) attenuated effect estimates by
classification accuracy of the best roughly 10%. Nonetheless, the odds of
Extent of Cognitive Impairment
cognitive impairment predictor by cognitive impairment remained higher
Examination of scores at each age for children born VPT even after
family-social risk strata. All tests of
indicated that children born VPT adjustment for family-social risk.
statistical significance were 2 tailed
performed significantly worse than
with a , .05. Analyses were
those born term across all cognitive
conducted by using SAS 9.4 (SAS Predictive Utility of Earlier
measures (Fig 1). Correspondingly, Assessments in Identifying 12-Year
Institute, Inc, Cary, NC).
significantly more children born VPT Cognitive Risk
were subject to severe (10%–16%) or
Figure 2 examines the predictive
any (34%–49%) cognitive
RESULTS accuracy of cognitive impairment
impairment compared with children
classification at 2, 4, 6, and 9 years in
Sample Characteristics born term.
identifying VPT children at risk for
The clinical and family characteristics Table 2 shows the extent of severe and cognitive impairment at 12 years.
of the 2 study groups are shown in any cognitive impairment among all Results show that adopting a severe
Table 1. Notably, infants in the VPT children, with children in the VPT group impairment predictor criterion had
group were more likely to be of obtaining significantly lower cognitive poorer sensitivity in identifying cases of
multiple gestation and small for GA; and/or IQ scores than children born severe cognitive impairment at age 12
they were also more likely to be born term across all assessments (P , .05). than any impairment criterion.
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PEDIATRICS Volume 145, number 4, April 2020 5family-social circumstances (21
family-social risk factors) improved
the diagnostic accuracy of any
cognitive impairment at age 6
predicting any later cognitive
impairment during middle childhood.
Diagnostic accuracy was better
among children in the high versus
low family-social risk group with
superior PPV (79% vs 58%),
sensitivity (88% vs 82%), and
specificity (75% vs 72%).
DISCUSSION
This study is the first to evaluate
the predictive accuracy of early
standardized assessments in
identifying VPT children at risk for
cognitive delay through middle
school. Study strengths included the
recruitment of representative cohorts
of children, high sample retention,
and availability of cognitive
FIGURE 2 assessments throughout early and
Classification accuracy of cognitive impairment at age 12 (severe: IQ .2 SD; any: IQ .1 SD) among middle childhood using well-
VPT children using measures of cognitive impairment at 2, 4, 6, and 9 years. Prediction of severe validated measures. Study findings
cognitive impairment at 12 years using earlier (A) severe and (B) any impairment. Prediction of any and implications are discussed below.
cognitive impairment at 12 years using earlier (C) severe and (D) any impairment criteria.
Similar to others,4,25–27 we found that
children born VPT had higher rates of
Specifically, the severe cognitive predictors was moderate (56% [age cognitive impairment relative to their
impairment predictor criterion at ages 2, 2] to 66% [age 6]), whereas the term-born peers, with odds of any
4, and 6 missed between 18% and 44% specificity (73% [ages 2 and 6] to impairment ranging from 3.7 (95% CI
of severe cases (Fig 2A), whereas the 81% [age 9]) and NPV (76% [age 4] 1.9–7.4) at age 2 to 5.0 (95% CI
more inclusive any impairment criterion to 89% [age 6]) were high. Results 2.6–9.6) at age 6. Notably, most
successfully predicted all severe suggest that any delay at age 6 was children born VPT experience mild
impairment cases at 12 years (Fig 2B). particularly sensitive in detecting risk (27.2%) rather than severe (10.7%)
of any cognitive impairment at age cognitive impairment at 12 years.
Further examination of diagnostic 12 years among children born VPT. This finding has potential clinical
accuracy showed that the diagnostic
Risk prediction was further assessed implications because children with
precision of early severe impairment
by plotting the age-specific ROCs for mild impairment often do not qualify
in identifying any cognitive
the prediction of any cognitive for school assistance programs.
impairments at age 12 was modest
(Fig 2C). In contrast, employing impairment at age 12 using any In keeping with other longitudinal
a criterion of early Mental impairment criterion at earlier ages studies,21,23,25 we found that early
Developmental Index (MDI) and/or (Fig 3). Results from this analysis severe cognitive impairment was
IQ .1 SD to identify any cognitive confirmed the above observation that a relatively good indicator of
impairment cases at age 12 years had any cognitive impairment at age 6 continued problems into middle
generally good diagnostic properties offers the best prediction of any school. However, a high proportion
(Fig 2D). That is, 100% of the severe cognitive impairment at 12 years. (38%) of children born VPT were
cases and 43% (age 4) to 79% (age 6) subject to either mild or severe
of the any impairment cases at Effect Modification by Family-Social cognitive impairment at 12 years.
12 years were identified by using the Risk Importantly, 44% of these children
earlier any impairment predictors. Figure 4 shows the extent to which would have been missed at their 2-
PPV for the any impairment additional consideration of a child’s year assessment if only those with
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6 ERDEI et algeneral developmental level rather
than accurately predict higher-order
cognitive functions.
We recognize that rates of any
cognitive impairment were particularly
elevated at age 6 in both groups. This
finding may represent a measurement
artifact. Alternatively, it could reflect
the increased cognitive expectations
experienced by children at age 6
relative to their earlier preschool years.
All study children started elementary
school around their fifth birthday, with
this transition and its accompanying
increased cognitive demands and
expectations potentially resulting in
milder deficits becoming more
apparent. Furthermore, the high rates
of cognitive difficulties in the VPT
cohort at 6 years might also reflect the
additive effect of family-social risk.
Findings suggest that monitoring
cognitive functioning of children born
VPT until age 6 might be beneficial to
create a safety net for this high-risk
population during the challenging
transition to school.
Risk-stratification findings suggest that
children born VPT who experienced
FIGURE 3
ROCs: diagnostic accuracy in predicting any cognitive impairment (IQ .1 SD) at age 12 by using any $2 family-social risk factors were at
impairment at ages 2, 4, 6, and 9 years. Any cognitive impairment cutoffs are marked with black additional risk of persistent cognitive
circles. Among earlier assessments, the model with any IQ delay at age 6 has optimal discriminatory impairment above and beyond the risk
ability. AUC, area under the curve. conferred by earlier delay, with
prediction of impairment at 12 years
severe impairment were deemed of cognitive measures improved with being superior in the high– versus
eligible for ongoing monitoring. age. This was further confirmed by low–social-risk subgroup. This
Examination of the diagnostic ROC analyses, which indicated that IQ reaffirms the additive effects of
accuracy of early childhood delay at 12 years was optimally prematurity and social disadvantage on
assessments further suggested that predicted by any IQ delay at age 6. cognitive function and emphasizes the
adopting a more inclusive (MDI Notably, IQ performance at age 9 was importance of not only considering
and/or IQ .1 SD) criterion offered also a good predictor of any cognitive children’s early developmental
improved prediction for both severe delay at age 12 given its more functioning but also the extent of social
and any cognitive impairment at proximal assessment (Fig 3). adversity when determining a child’s
12 years in children born VPT. Given However, such a late assessment is eligibility for developmental
the long-term ramifications that even likely of limited use if the goal is early monitoring and/or intervention.
milder cognitive impairments may detection and proactive intervention
for the child and family. Our finding Limitations
have on functional outcomes,
adopting a more inclusive approach that 2- and 4-year assessments were Our data indicate that having any
when identifying at-risk children may not as good predictors of school-aged cognitive impairment at age 6
be warranted. functioning as the 6- and 9-year appears to be the best predictor of
assessments is consistent with other cognitive impairment at age 12 from
Consistent with an earlier study of reports22,26,27 and may reflect the the models evaluated. Given the
children born extremely preterm,23 limitations of early evaluations that relatively high false-positive rate
we found that the predictive accuracy are designed to gauge a child’s (34%), this model has its limitations;
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PEDIATRICS Volume 145, number 4, April 2020 7neurodevelopmental outcomes is
warranted.
Implications
Our findings highlight the potential
benefit of monitoring children at high
risk with early delay until elementary
school. We acknowledge that this
would result in a higher number of
referrals and potentially increased
short-term costs. Developmental
follow-up is costly,38 yet early
developmental services are valuable
and positively impact preterm
children’s cognitive39 and
preacademic skills.40 Future work
should examine which specific
strategies and interventions have the
greatest potential to positively impact
cognitive outcomes in children
born VPT.
CONCLUSIONS
Cognitive impairment in middle
school is poorly predicted by early
severe delay. Monitoring children
born VPT until age 6, intervening for
FIGURE 4 children with early mild cognitive
ROCs: effect modification by family-social risk of the diagnostic accuracy of any cognitive impairment delay, and assisting families with
at age 6 predicting any cognitive impairment at 12 years. Any cognitive impairment cutoffs are social disadvantages are factors that
marked with black circles. Any IQ delay at 6 years in high–social-risk strata has better discrimi-
natory ability. AUC, area under the curve. warrant consideration in supporting
preterm children in achieving their
however, this can be improved by early family-social risk was best potential long-term.
using risk stratification. a relatively simple composite of
Furthermore, it is likely that in factors extracted from clinical data. ACKNOWLEDGMENTS
addition to family-social risk, other However, we acknowledge that other We give special thanks to the study
factors associated with the child- factors, including medical risk, families for their time and support of
rearing environment may contribute parental mental health, family this project.
to children’s cognitive functioning stability, and parenting, are likely to
and risk of delay. Intervention play a role in shaping cognitive
support services may have also outcomes. Future research is ABBREVIATIONS
impacted later cognitive functioning; important to better understand the
CI: confidence interval
yet, taking this into account is developmental pathways that modify
GA: gestational age
challenging given that the children cognitive risk for children born VPT MDI: Mental Developmental Index
who received support are those and assess whether the inclusion of NPV: negative predictive value
identified with early impairment. additional factors in risk-prediction OR: odds ratio
The current study focuses on models improves the diagnostic PPV: positive predictive value
cognitive risk prediction from early accuracy of early assessments. In ROC: receiver operating curve
childhood measures often employed addition, examination of the SES: socioeconomic status
by developmental monitoring predictive accuracy of these VPT: very preterm
programs. Our additional measure of approaches for other
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8 ERDEI et alDOI: https://doi.org/10.1542/peds.2019-1982
Accepted for publication Jan 15, 2020
Address correspondence to Carmina Erdei, MD, Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail:
cerdei@bwh.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Neurological Foundation, Lottery Grants Board, Canterbury Medical Research Foundation, and Health Research Council of New Zealand.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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10 ERDEI et alPredicting School-Aged Cognitive Impairment in Children Born Very Preterm
Carmina Erdei, Nicola C. Austin, Sara Cherkerzian, Alyssa R. Morris and Lianne J.
Woodward
Pediatrics originally published online March 6, 2020;
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019-1982
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019-1982#BIBL
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Downloaded from www.aappublications.org/news by guest on September 23, 2021Predicting School-Aged Cognitive Impairment in Children Born Very Preterm
Carmina Erdei, Nicola C. Austin, Sara Cherkerzian, Alyssa R. Morris and Lianne J.
Woodward
Pediatrics originally published online March 6, 2020;
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located on the World Wide Web at:
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