Predicting School-Aged Cognitive Impairment in Children Born Very Preterm

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Predicting School-Aged Cognitive Impairment in Children Born Very Preterm
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                                                                                                                 ARTICLE
Children 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 al
Procedures                                      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                                                                                                                      3
FIGURE 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 al
TABLE 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                                                                                                                                       5
family-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 al
general 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                                                                                                    7
neurodevelopmental 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 al
DOI: 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.

REFERENCES
  1. Woodward LJ, Moor S, Hood KM,                       8. Litt JS, Gerry Taylor H, Margevicius S,          15. Bick J, Nelson CA. Early adverse
     et al. Very preterm children show                      Schluchter M, Andreias L, Hack M.                    experiences and the developing brain.
     impairments across multiple                            Academic achievement of adolescents                  Neuropsychopharmacology. 2016;41(1):
     neurodevelopmental domains by age                      born with extremely low birth weight.                177–196
     4 years. Arch Dis Child Fetal Neonatal                 Acta Paediatr. 2012;101(12):1240–1245
                                                                                                             16. Hintz SR, Newman JE, Vohr BR.
     Ed. 2009;94(5):F339–F344
                                                         9. Pritchard VE, Bora S, Austin NC, Levin               Changing definitions of long-term
  2. Joseph RM, O’Shea TM, Allred EN,                       KJ, Woodward LJ. Identifying very                    follow-up: should “long term” be even
     et al; ELGAN Study Investigators.                      preterm children at educational risk                 longer? Semin Perinatol. 2016;40(6):
     Neurocognitive and academic outcomes                   using a school readiness framework.                  398–409
     at age 10 years of extremely preterm                   Pediatrics. 2014;134(3). Available at:           17. Doyle LW, Anderson PJ, Battin M, et al.
     newborns. Pediatrics. 2016;137(4):                     www.pediatrics.org/cgi/content/full/                 Long term follow up of high risk
     e20154343                                              134/3/e825                                           children: who, why and how? BMC
  3. Linsell L, Johnson S, Wolke D, et al.              10. Strenze T. Intelligence and                          Pediatr. 2014;14:279
     Cognitive trajectories from infancy to                 socioeconomic success: a meta-analytic           18. Bayley N. Bayley Scales of Infant
     early adulthood following birth before                 review of longitudinal research.                     Development, 2nd ed. San Antonio, TX:
     26 weeks of gestation: a prospective,                  Intelligence. 2007;35(5):401–426                     Psychological Corporation; 1993
     population-based cohort study. Arch Dis
     Child. 2018;103(4):363–370                         11. Koenen KC, Moffitt TE, Roberts AL, et al.         19. Wechsler D; WPPSI-R WD. Wechsler
                                                            Childhood IQ and adult mental                        Preschool and Primary Scale of
  4. Eryigit Madzwamuse S, Baumann N,
                                                            disorders: a test of the cognitive                   Intelligence-Revised. San Antonio, TX:
     Jaekel J, Bartmann P, Wolke D. Neuro-
                                                            reserve hypothesis. Am J Psychiatry.                 Psychological Corporation Harcourt
     cognitive performance of very preterm
                                                            2009;166(1):50–57                                    Brace Jovanovich; 1989
     or very low birth weight adults at
     26 years. J Child Psychol Psychiatry.              12. Darlow BA, Horwood LJ, Pere-Bracken              20. Wechsler D. Wechsler Intelligence Scale
     2015;56(8):857–864                                     HM, Woodward LJ. Psychosocial                        for Children- Fourth Edition (WISC-IV).
                                                            outcomes of young adults born very                   San Antonio, TX: Psychological
  5. Anderson PJ, Doyle LW. Cognitive and
                                                            low birth weight. Pediatrics. 2013;                  Corporation; 2003
     educational deficits in children born
     extremely preterm. Semin Perinatol.                    132(6). Available at: www.pediatrics.            21. Bode MM, D’Eugenio DB, Mettelman BB,
     2008;32(1):51–58                                       org/cgi/content/full/132/6/e1521                     Gross SJ. Predictive Validity of the
                                                        13. Dobson KG, Ferro MA, Boyle MH,                       Bayley, Third Edition at 2 Years for
  6. Woodward LJ, Clark CA, Bora S,
                                                            Schmidt LA, Saigal S, Van Lieshout RJ.               Intelligence Quotient at 4 Years in
     Inder TE. Neonatal white matter
                                                            How do childhood intelligence and early              Preterm Infants. In: J Dev Behav Pediatr,
     abnormalities an important predictor
                                                            psychosocial adversity influence                      vol. 35. 2014:570–575
     of neurocognitive outcome for very
     preterm children. PLoS One. 2012;7(12):                income attainment among adult                    22. O’Shea TM, Joseph RM, Allred EN, et al;
     e51879                                                 extremely low birth weight survivors? A              ELGAN Study Investigators. Accuracy of
                                                            test of the cognitive reserve hypothesis.            the Bayley-II mental development index
  7. Cheong JLY, Anderson PJ, Burnett AC,
                                                            Dev Psychopathol. 2018;30(4):1421–1434               at 2 years as a predictor of cognitive
     et al; Victorian Infant Collaborative
                                                        14. Fox SE, Levitt P, Nelson CA III. How the             impairment at school age among
     Study Group. Changing
     neurodevelopment at 8 years in                         timing and quality of early experiences              children born extremely preterm.
                                                            influence the development of brain                    J Perinatol. 2018;38(7):908–916
     children born extremely preterm since
     the 1990s. Pediatrics. 2017;139(6):                    architecture. Child Dev. 2010;81(1):             23. Doyle LW, Casalaz D; Victorian Infant
     e20164086                                              28–40                                                Collaborative Study Group. Outcome at

                                  Downloaded from www.aappublications.org/news by guest on September 23, 2021
PEDIATRICS Volume 145, number 4, April 2020                                                                                                                9
14 years of extremely low birthweight         29. Victorian Infant Collaborative Study        35. Mangin KS, Horwood LJ, Woodward LJ.
     infants: a regional study. Arch Dis Child         Group. Eight-year outcome in infants            Cognitive development trajectories of
     Fetal Neonatal Ed. 2001;85(3):F159–F164           with birth weight of 500 to 999 grams:          very preterm and typically developing
 24. Hack M, Taylor HG, Drotar D, et al. Poor          continuing regional study of 1979 and           children. Child Dev. 2017;88(1):282–298
     predictive validity of the Bayley Scales          1980 births. J Pediatr. 1991;118(5):
                                                                                                   36. Wilson-Ching M, Pascoe L, Doyle LW,
     of Infant Development for cognitive               761–767
                                                                                                       Anderson PJ. Effects of correcting for
     function of extremely low birth weight        30. Breeman LD, Jaekel J, Baumann N,                prematurity on cognitive test scores in
     children at school age. Pediatrics. 2005;         Bartmann P, Wolke D. Preterm cognitive          childhood. J Paediatr Child Health.
     116(2):333–341                                    function into adulthood. Pediatrics.            2014;50(3):182–188
 25. Munck P, Niemi P, Lapinleimu H,                   2015;136(3):415–423
                                                                                                   37. LoBello SG. A short form of the
     Lehtonen L, Haataja L; PIPARI Study           31. Claas MJ, de Vries LS, Bruinse HW, et al.       Wechsler Preschool and Primary Scale
     Group. Stability of cognitive outcome             Neurodevelopmental outcome over                 of Intelligence-Revised. J Sch Psychol.
     from 2 to 5 years of age in very low              time of preterm born children #750 g            1991;29(3):229–236
     birth weight children. Pediatrics. 2012;          at birth. Early Hum Dev. 2011;87(3):
     129(3):503–508                                                                                38. Behrman R, Stith Butler A; Institute of
                                                       183–191
                                                                                                       Medicine Committee on Understanding
 26. Potharst ES, Houtzager BA, van
                                                   32. Wong HS, Edwards P. Nature or nurture:          Premature Birth and Assuring Healthy
     Sonderen L, et al. Prediction of
                                                       a systematic review of the effect of            Outcomes Board on Health Sciences
     cognitive abilities at the age of 5 years
                                                       socio-economic status on the                    Outcomes. Preterm Birth: Causes,
     using developmental follow-up
                                                       developmental and cognitive outcomes            Consequences, and Prevention.
     assessments at the age of 2 and
     3 years in very preterm children. Dev             of children born preterm. Matern Child          Washington, DC: National Academies
     Med Child Neurol. 2012;54(3):240–246              Health J. 2013;17(9):1689–1700                  Press; 2007

 27. Roberts G, Anderson PJ, Doyle LW;             33. Linsell L, Malouf R, Morris J, Kurinczuk    39. Spittle A, Orton J, Anderson PJ, Boyd R,
     Victorian Infant Collaborative Study              JJ, Marlow N. Prognostic factors for            Doyle LW. Early developmental
     Group. The stability of the diagnosis of          poor cognitive development in                   intervention programmes provided
     developmental disability between ages             children born very preterm or with              post hospital discharge to prevent
     2 and 8 in a geographic cohort of very            very low birth weight: a systematic             motor and cognitive impairment in
     preterm children born in 1997. Arch Dis           review. JAMA Pediatr. 2015;169(12):             preterm infants. Cochrane Database
     Child. 2010;95(10):786–790                        1162–1172                                       Syst Rev. 2015;(11):CD005495
 28. Spencer-Smith MM, Spittle AJ, Lee KJ,         34. Manley BJ, Roberts RS, Doyle LW, et al.     40. Litt JS, Glymour MM, Hauser-Cram P,
     Doyle LW, Anderson PJ. Bayley-III                 Social variables predict gains in               Hehir T, McCormick MC. Early
     cognitive and language scales in                  cognitive scores across the preschool           intervention services improve school-
     preterm children. Pediatrics. 2015;               years in children with birth weights 500        age functional outcome among
     135(5). Available at: www.pediatrics.             to 1250 grams. J Pediatr. 2015;166(4):          neonatal intensive care unit graduates.
     org/cgi/content/full/135/5/e1258                  870–876–2                                       Acad Pediatr. 2018;18(4):468–474

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10                                                                                                                                   ERDEI et al
Predicting 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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Predicting 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;

 The online version of this article, along with updated information and services, is
                        located on the World Wide Web at:
  http://pediatrics.aappublications.org/content/early/2020/03/04/peds.2019-1982

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