Call to delay school for premature babies
“Premature babies more likely to underperform at school, study finds,” reports The Independent. Results from a new study have prompted calls that some children should be held back a year before starting school.
Previous research has found that premature babies have worse school performance than babies born at term. A new study has investigated whether this poor performance could be due to premature babies being compared with children born at term who, even if they were born at the same time, are effectively older than they are.
In addition, children who are born prematurely may be enrolled at school a year earlier than predicted by their expected due date. For example, a premature baby born in July could start school a year earlier than if they had been born at full term in September. So they would be enrolled in school effectively a year early, leaving the child constantly struggling to keep up.
The researchers looked at performance on “key stage one” tests – a UK test of reading, writing and maths skills. They also looked at whether children were judged as having special educational needs.
The researchers found that children born premature are at greater risk of having a low key stage one score, and of having special educational needs compared with children born at full term.
However, the risk was greatly reduced for preterm children who, if they had been born on their expected date of delivery, would still have been in the same school year as their actual birth date put them in.
While school performance for children born preterm may improve by delaying entry to school, the social implications of being perceived to be “held back” (to be in a school year with younger children) could have an adverse effect on the child. As the researchers conclude “whether a policy of holding infants born prematurely back to their corrected school year would have a beneficial impact is as yet unknown”.
Where did the story come from?
The study was carried out by researchers from the Neonatal Unit at North Bristol NHS Trust and the University of Bristol. No source of funding was reported.
The study was published in the peer-reviewed journal PLOS One. PLOS One is an open-access journal, which means that the article is available free of charge to read online or download.
The results of the study were well covered by the UK media. All three newspapers who reported on the study – The Independent, The Daily Telegraph and the Daily Mail – provide relevant commentary from independent childcare experts.
What kind of research was this?
This was a cohort study. Previous research has found that preterm babies have worse school performance than term babies. This study aimed to determine if some of this effect was due to preterm children being enrolled in school a year earlier than they would have been if they had been born at their expected due date. In the UK all children are offered a school placement based on their actual date of birth, rather than their expected due date.
To do this, they compared school performance in children born preterm who would have attended school in the same year if their expected date of delivery had been used rather than their actual date of delivery, to the school performance in children born at term.
A cohort study is the ideal study design to address this question.
What did the research involve?
The researchers analysed data from 11,990 children born in the Bristol area between April 1991 and December 1992 who were participating in the Avon Longitudinal Study of Parents and Children (ALSPAC) – an ongoing cohort study.
Data on the gestational age at birth was extracted from clinical notes. The study included infants that were born between 23 and 42 weeks of gestation.
School performance was assessed using the results of key stage one (KS1) tests, which all children in mainstream education sit at the end of year two. In addition, teachers were sent a questionnaire that asked whether children had ever been recognised as having special educational needs.
The two primary outcomes were a low KS1 score (below 2, the expected standard in the “three Rs” of reading, writing and arithmetic), or having teacher-reported special educational needs.
The researchers looked to see if children who had been born preterm were at greater risk of low KS1 scores or having special educational needs, and whether this was due to them being placed in school a year earlier than if they had been born at term. To do this the researchers performed three analyses:
- one where each preterm infant was matched with up to 10 term infants based on their date of birth, and the outcomes for term and preterm infants compared
- one where each preterm infant was matched with 10 term infants based on their expected date of delivery, and the outcomes for term and preterm infants compared
- one where each preterm infant was matched to term infants based on their expected date of delivery and year of school attendance, and the outcomes for term and preterm infants compared
In this final analysis, the researchers compared the risk of low KS1 scores and special education needs only in infants who would still have been in the same school year if they had been born at their expected date of delivery rather than their actual date of delivery.
The researchers adjusted their results for a range of factors (confounders) that could influence academic performance. These included:
- social factors (maternal age, socioeconomic group, education, car ownership, housing, crowding index [the number of household members per room] and ethnicity)
- antenatal factors (the number of times the mother had previously given birth, and gender, weight, length and head circumference at birth of the infant)
- factors during labour (mode of delivery, maternal high blood pressure and fever)
What were the basic results?
The study included 722 children who were born prematurely or “preterm” (at less than 37 weeks) and 11,268 children who were born at term (between 37 and 42 weeks).
Preterm infants were statistically more likely to have a low KS1 score and to receive special educational needs support.
Infants who were placed in the correct school year for their expected delivery date had higher KS1 scores than those children whose actual date of birth had put them in a different school year than their expected delivery date would have.
In children who had been born at full term, average KS1 scores were highest in the children oldest at the time of the test – i.e. children born in September. Average scores gradually decreased as the children entering the year were younger, with children born in August obtaining the lowest mean KS1 scores.
A similar pattern was seen for preterm infants, although the lowest mean KS1 scores were from children born in June.
Children born preterm were at higher risk of low KS1 score and having special educational needs when children were matched on the basis of date of birth; to adjust for the fact that, on average, the oldest children did the best on the test (odds ratio (OR) for low KS1 score 1.57, 95% confidence interval (CI) 1.25 to 1.97; OR for special educational needs 1.57, 95% CI 1.19 to 2.07).
Children born preterm were at higher risk of low KS1 score and having special educational needs when children were matched on the basis of expected date of delivery rather than gestational age (to adjust for the fact that children born preterm are actually younger than their date of birth would suggest). The OR for low KS1 score was 1.53, 95% CI 1.21 to 1.94; the OR for special educational needs was 1.59, 95% CI 1.20 to 2.11.
However, children born preterm were not at significantly higher risk of low KS1 score or of having special educational needs when outcomes were compared only for children attending school in the correct year for their expected date of delivery, and children were matched based on their expected date of delivery (OR for low KS1 score 1.25, 95% CI 0.98 to 1.60; OR for special educational needs 1.13, 95% CI 0.81 to 1.56).
How did the researchers interpret the results?
The researchers concluded that “this study provides evidence that the school year placement and assessment of ex-preterm infants based on their actual birthday (rather than their expected date of delivery) may increase their risk of learning difficulties with corresponding school failure”.
Conclusion
In the UK, all children are offered a school placement based on their actual date of birth, rather than their expected date of birth. This study has found evidence from a large UK cohort that children born preterm may benefit from school entry based on their expected date of delivery rather than their actual birth date.
The study found that children born preterm are at greater risk of having a low key stage one score, and of having special educational needs compared with children born at full term.
However, there was no significant increase in risk among preterm children who would still have attended the same school year even if they had been born on their expected date of delivery.
This arguably suggests that admission policies to schools should be based on a child’s expected date of delivery rather than actual birth date. However, as the researchers rightly point out, the issue of whether an older child would interact well with children who could be, or we perceived to be, younger than them also has to be considered.
As the researchers conclude: “whether a policy of holding infants born prematurely back to their corrected school year would have a beneficial impact is as yet unknown”.
