Extreme Prematurity Increases Risk of Repeating A Grade, Needing Special Education

CHICAGO -- Children who have survived extreme prematurity due to the advent of advanced medical treatments, primarily the development of lung surfactant, are twice as likely to repeat a grade and need special education compared with children born at full term, a new study at the University at Buffalo has shown.

However, the special needs of these children are no greater than those of babies born prematurely before the use of surfactant and other advanced treatments that now enable neonatologists to save babies born as much as 16 weeks early.

"When neonatologists became able to save these very tiny babies, the prevailing wisdom was that we were shifting these children from the risk of death to the risk of sickness and a low quality of life," said Germaine Buck, Ph.D., UB associate professor of social and preventive medicine, and a lead author on the study.

"What we found through this research was that rescuing these babies has not exaggerated the burden from pre-surfactant days. Many children do have trouble in school, but the level of special education needs has remained fairly stable from the pre-surfactant to post-surfactant era. If these children escape disabling brain injury at birth, they are not necessarily at risk for extensive special needs."

Buck presented results of the study here today (June 23, 1998) at the annual meeting of the Society for Pediatric and Perinatal Epidemiologic Research.

The case-control study involved 108 singleton babies born at, or less than, 28 weeks gestation at Children's Hospital of Buffalo, a regional neonatal intensive-care center, between 1983 and 1986. The 219 full-term infants used as controls were selected randomly from live births at the hospital during the same period.

Children's Hospital has one of the oldest groups of survivors of extreme prematurity. A neonatologist at Children's developed lung surfactant and physicians in Buffalo have used it since the early 1980s. Children in the current study were between 8 and 11 years old when the most recent follow-up was completed in 1995.

To assess the educational development of these children, researchers conducted telephone interviews with parents and gathered information on grades repeated, their need for special education and use of the school resource room. Parents also brought their children to the hospital's pediatric development center for evaluation.

After excluding children with major neurological impairments, such as cerebral palsy, mental retardation, blindness and/or deafness, the children born extremely premature were found to be at more than two times the risk of repeating a grade than the full-term children. Buck noted, however, that in some cases, the parents, not the school, decided a child should repeat a grade because of social immaturity or other reasons not linked to academic failure per se.

The premature children were twice as likely to need special education and three times as likely to need the school's resource room than the control group, findings showed.

"If we are going to save these extremely premature babies, we need to know what is in store for these kids and their families," Buck said. "For the first time at our center, neonatologists have the data to tell parents the risk of having their kids do OK in school, not merely their risk of survival. That is powerful information."

Buck noted that while prematurity is likely to result in educational problems, other factors, such as non-white race and gender, pose a similar risk. Boys and non-white children were 2 1/2 times more likely to repeat a grade than others in the study group, their data showed.

"This finding underscores the importance of addressing both social and medical factors in dealing with school underachievement," Buck said.

Additional researchers on the study were Michael E. Msall, M.D., now at Brown University; Enrique Schisterman, doctoral candidate in the UB Department of Social and Preventive Medicine; Brian Rodgers, M.D., of the UB Department of Pediatrics and Children's Hospital; and Nancy Lyon and Ellen Mahoney, nurse researchers at Children's Hospital.