Gestational age at birth, chronic conditions and school outcomes: a population-based data linkage study of children born in England

Birth weight and school absences and attainment: a longitudinal linked cohort study of compulsory schooling in England

OBJECTIVE

To explore how birth weight and size-for-gestation may contribute to school absences and educational attainment and whether there are different associations across sex and income groups.

DESIGN

Longitudinal linked cohort study.

METHODS

Data were drawn from the Millennium Cohort Study, a nationally representative cohort of children born in 2000-2001; percentage of authorised and unauthorised absences from Year 1 to Year 11, and Key Stage test scores at ages 7, 11 and 16 in English and Maths were linked from the National Pupil Database. Birth outcomes and covariates were derived from the 9-month survey, and linear regressions with complex survey weights were fitted.

RESULTS

Being born small-for-gestational-age (vs average-for-gestational-age) was associated with an increase of 0.47%, 0.55% and 0.40% in authorised absences in Years 1, 3 and 4 (n=6659) and with a reduction of 0.16-0.26 SD in all English and Maths test scores (n=6204). Similar associations were found for birth weight. After adjusting for prior test scores, English (b=0.07) and Maths (b=0.05) performance at age 11 remained associated with birth weight. Socioeconomic status modified the associations: there were larger disparities in test scores among higher-income families, suggesting that higher income did not compensate for being born small-for-gestational-age.

CONCLUSION

Children born smaller missed slightly more classes (~1 day per year) during primary school and had lower English and Maths performance across compulsory education. Exploring specific health conditions and understanding how education and health systems can work together to support children may help to reduce the burden.

Cognitive and academic outcomes of large-for-gestational-age babies born at early term: A systematic review and meta-analysis

INTRODUCTION

Early induction of labor (37+0-38+6 gestational weeks) in large-for-gestational-age infants may reduce perinatal risks such as shoulder dystocia, but it may also increase the long-term risks of reduced cognitive abilities. This systematic review aimed to evaluate the cognitive and academic outcomes of large-for-gestational-age children born early term vs full term (combined or independent exposures).

MATERIAL AND METHODS

The protocol was registered in the PROSPERO database under the registration no. CRD42024528626. Five databases were searched from their inception until March 27, 2024, without language restrictions. Studies reporting childhood cognitive or academic outcomes after early term or large-for-gestational-age births were included. Two reviewers independently screened the selected studies. One reviewer extracted the data, and the other double-checked the data. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. In addition to narrative synthesis, meta-analyses were conducted where possible.

RESULTS

Of the 2505 identified articles, no study investigated early-term delivery in large-for-gestational-age babies. Seventy-six studies involving 11 460 016 children investigated the effects of either early-term delivery or large-for-gestational-age. Children born at 37 weeks of gestation (standard mean difference, -0.13; 95% confidence interval, -0.21 to -0.05), but not at 38 weeks (standard mean difference, -0.04; 95% confidence interval, -0.08 to 0.002), had lower cognitive scores than those born at 40 weeks. Large-for-gestational-age children had slightly higher cognitive scores than appropriate-for-gestational-age children (standard mean difference, 0.06; 95% confidence interval, 0.01-0.11). Similar results were obtained using the outcomes of either cognitive impairment or academic performance.

CONCLUSIONS

No study has investigated the combined effect of early-term delivery on cognitive scores in large-for-gestational-age babies. Early-term delivery may have a very small detrimental effect on cognitive scores, whereas being large for gestational age may have a very small benefit. However, evidence from randomized controlled trials or observational studies is required.

Neurodevelopment at Age 9 Years Among Children Born at 32 to 36 Weeks' Gestation

Importance

Although children born moderate to late preterm (MLP; 32-36 weeks' gestation) have more neurodevelopmental problems compared with children born early term or later (≥37 weeks' gestation), detailed understanding of affected domains at school age is lacking. Little is known of risk factors for poorer development.

Objective

To examine whether being born MLP compared with being born early term or later is associated with neurodevelopmental outcomes at age 9 years and to describe factors associated with poorer neurodevelopment in children born MLP.

Design, Setting, and Participants

This prospective, longitudinal cohort study recruited children born MLP and children born early term or later with healthy birth weight (≥2500 g) at a single tertiary hospital in Melbourne, Victoria, Australia, between December 7, 2009, and March 26, 2014. Nine-year follow-up occurred between June 20, 2019, and February 27, 2024.

Exposure

Moderate to late preterm birth.

Main Outcomes and Measures

Cognitive ability, academic performance, motor function, behavior, and social communication skills, assessed at 9-year follow-up. Group differences were estimated using linear, logistic, or quantile regression adjusted for multiple birth and socioeconomic risk. Multiple imputation was used to account for missing data. Associations of antenatal and neonatal factors and developmental delay at 2 years with poorer 9-year neurodevelopment were explored using univariable regression.

Results

Of 201 recruited children born MLP and 201 born early term or later, 159 born MLP (79.1%; 72 [45.3%] male) and 137 born early term or later (68.2%; 75 [54.7%] male) were assessed. Compared with children born early term or later, children born MLP had lower mean (SD) full-scale IQ scores (105.2 [13.6] vs 110.1 [13.0]; adjusted mean difference, -4.4 [95% CI, -7.7 to -1.0]) and poorer performance for cognitive domains, including verbal comprehension, visuospatial, and working memory. They also had poorer academic performance: pseudoword decoding (mean [SD] score, 103.0 [11.3] vs 107.3 [10.5]; adjusted mean difference, -4.0 [95% CI, -7.0 to -1.1]) and mathematics (mean [SD] score, 96.6 [14.7] vs 101.5 [14.5]; adjusted mean difference, -5.0 [95% CI, -8.8 to -1.2]). Children born MLP had similar manual dexterity to those born early term or later (mean [SD] score, 8.4 [3.5] vs 9.1 [3.4]; adjusted mean difference, -0.9 [95% CI, -1.8 to 0.04]) but more behavioral difficulties (50 of 158 [31.7%] vs 29 of 135 [21.5%]; adjusted risk ratio, 1.57 [95% CI, 1.06-2.33]). Developmental delay at 2 years was associated with poorer 9-year neurodevelopment across multiple domains.

Conclusions and Relevance

In this longitudinal cohort study of children born MLP, neurodevelopmental challenges persisted into school age. An assessment at age 2 years may assist in identifying children born MLP who are at risk of school-age impairments.

Childhood Health and Educational outcomes afteR perinatal Brain injury (CHERuB): protocol for a population-matched cohort study

INTRODUCTION

Over 3000 infants suffer a brain injury around the time of birth every year in England. Although these injuries can have important implications for children and their families, our understanding of how these injuries affect children's lives is limited.

METHODS AND ANALYSIS

The aim of the CHERuB study (Childhood Health and Educational outcomes afteR perinatal Brain injury) is to investigate longitudinal childhood health and educational outcomes after perinatal brain injury through the creation of a population-matched cohort study. This study will use the Department of Health and Social Care definition of perinatal brain injury which includes infants with intracranial haemorrhage, preterm white matter injury, hypoxic ischaemic encephalopathy, perinatal stroke, central nervous system infections, seizures and kernicterus. All children born with a perinatal brain injury in England between 2008 and 2019 will be included (n=54 176) and two matched comparator groups of infants without brain injury will be created: a preterm control group identified from the National Neonatal Research Data Set and a term/late preterm control group identified using birth records. The national health, education and social care records of these infants will be linked to ascertain their longitudinal childhood outcomes between 2008 and 2023. This cohort will include approximately 170 000 children. The associations between perinatal brain injuries and survival without neurosensory impairment, neurodevelopmental impairments, chronic health conditions and mental health conditions throughout childhood will be examined using regression methods and time-to-event analyses.

ETHICS AND DISSEMINATION

This study has West London Research Ethics Committee and Confidential Advisory Group approval (20/LO/1023 and 22/CAG/0068 issued 20/10/2022). Findings will be published in open-access journals and publicised via the CHERuB study website, social media accounts and our charity partners.

Evaluating the real-world implementation of the Family Nurse Partnership in England: a data linkage study

Background/objectives

The Family Nurse Partnership is an intensive home visiting programme for adolescent mothers. We aimed to evaluate the effectiveness of the Family Nurse Partnership on outcomes up to age 7 using national administrative data.

Design

We created a linked cohort of all mothers aged 13-19 using data from health, educational and children's social care and defined mothers enrolled in the Family Nurse Partnership or not using Family Nurse Partnership system data. Propensity scores were used to create matched groups for analysis.

Setting

One hundred and thirty-six local authorities in England with active Family Nurse Partnership sites between 2010 and 2017.

Participants

Mothers aged 13-19 at last menstrual period with live births between April 2010 and March 2019, living in a Family Nurse Partnership catchment area and their firstborn child(ren).

Interventions

The Family Nurse Partnership includes up to 64 home visits by a family nurse from early pregnancy until the child's second birthday and is combined with usual health and social care. Controls received usual health and social care.

Main outcome measures

Indicators of child maltreatment (hospital admissions for injury/maltreatment, referral to social care services); child health and development (hospital utilisation and education) outcomes and maternal hospital utilisation and educational outcomes up to 7 years following birth.

Data sources

Family Nurse Partnership Information System, Hospital Episode Statistics, National Pupil Database.

Results

Of 110,520 eligible mothers, 25,680 (23.2%) were enrolled in the Family Nurse Partnership. Enrolment rates varied across 122 sites (range: 11-68%). Areas with more eligible mothers had lower enrolment rates. Enrolment was higher among mothers aged 13-15 (52%), than 18-19 year-olds (21%). Indicators of child maltreatment: we found no evidence of an association between the Family Nurse Partnership and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 for children born to Family Nurse Partnership mothers (6.6% vs. 5.7%, relative risk 1.15; 95% confidence interval 1.07 to 1.24). Child health and developmental outcomes: there was weak evidence that children born to Family Nurse Partnership mothers were more likely to achieve a Good Level of Development at age 5 (57.5% vs. 55.4%, relative risk 1.05; 95% confidence interval 1.00 to 1.09). Maternal outcomes: There was some evidence that Family Nurse Partnership mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs. 9.3%, relative risk 0.92; 95% confidence interval 0.88 to 0.97). Younger and more vulnerable mothers received higher numbers of visits and were more likely to achieve fidelity targets. Meeting the fidelity targets was associated with some outcomes.

Limitations

Bias by indication and variation in the intervention and usual care over time and between areas may have limited our ability to detect effects. Multiple testing may have led to spurious, significant results.

Conclusions

This study supports findings from evaluations of the Family Nurse Partnership showing no evidence of benefit for maltreatment outcomes measured in administrative data. Amongst all the outcomes measured, we found weak evidence that the Family Nurse Partnership was associated with improvements in child development at school entry, a reduction in rapid repeat pregnancies and evidence of increased healthcare-seeking in the mother and child.

Future work

Future evaluations should capture better measures of Family Nurse Partnership interventions and usual care, more information on maternal risk factors and additional outcomes relating to maternal well-being.

Study registration

The study is registered as NIHR CRN Portfolio (42900).

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/19) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

Risk of Developmental Disorders in Children Born at 32 to 38 Weeks' Gestation: A Meta-Analysis

CONTEXT

Very preterm birth (<32 weeks) is associated with increased risk of developmental disorders. Emerging evidence suggests children born 32 to 38 weeks might also be at risk.

OBJECTIVES

To determine the relative risk and prevalence of being diagnosed with, or screening positive for, developmental disorders in children born moderately preterm, late preterm, and early term compared with term (≥37 weeks) or full term (39-40/41 weeks).

DATA SOURCES

Medline, Embase, Psychinfo, Cumulative Index of Nursing, and Allied Health Literature.

STUDY SELECTION

Reported ≥1 developmental disorder, provided estimates for children born 32 to 38 weeks.

DATA EXTRACTION

A single reviewer extracted data; a 20% sample was second checked. Data were pooled using random-effects meta-analyses.

RESULTS

Seventy six studies were included. Compared with term born children, there was increased risk of most developmental disorders, particularly in the moderately preterm group, but also in late preterm and early term groups: the relative risk of cerebral palsy was, for 32 to 33 weeks: 14.1 (95% confidence intervals [CI]: 12.3-16.0), 34 to 36 weeks: 3.52 (95% CI: 3.16-3.92) and 37 to 38 weeks: 1.44 (95% CI: 1.32-1.58).

LIMITATIONS

Studies assessed children at different ages using varied criteria. The majority were from economically developed countries. All were published in English. Data were variably sparse; subgroup comparisons were sometimes based on single studies.

CONCLUSIONS

Children born moderately preterm are at increased risk of being diagnosed with or screening positive for developmental disorders compared with term born children. This association is also demonstrated in late preterm and early term groups but effect sizes are smaller.

Impact of special educational needs provision on hospital utilisation, school attainment and absences for children in English primary schools stratified by gestational age at birth: A target trial emulation study protocol

Introduction

One third of children in English primary schools have additional learning support called special educational needs (SEN) provision, but children born preterm are more likely to have SEN than those born at term. We aim to assess the impact of SEN provision on health and education outcomes in children grouped by gestational age at birth.

Methods

We will analyse linked administrative data for England using the Education and Child Health Insights from Linked Data (ECHILD) database. A target trial emulation approach will be used to specify data extraction from ECHILD, comparisons of interest and our analysis plan. Our target population is all children enrolled in year one of state-funded primary school in England who were born in an NHS hospital in England between 2003 and 2008, grouped by gestational age at birth (extremely preterm (24-<28 weeks), very preterm (28-<32 weeks), moderately preterm (32-<34 weeks), late preterm (34-<37 weeks) and full term (37-<42 weeks). The intervention of interest will comprise categories of SEN provision (including none) during year one (age five/six). The outcomes of interest are rates of unplanned hospital utilisation, educational attainment, and absences by the end of primary school education (year six, age 11). We will triangulate results from complementary estimation methods including the naïve estimator, multivariable regression, g-formula, inverse probability weighting, inverse probability weighting with regression adjustment and instrumental variables, along with a variety for a variety of causal contrasts (average treatment effect, overall, and on the treated/not treated).

Ethics and dissemination

We have existing research ethics approval for analyses of the ECHILD database described in this protocol. We will disseminate our findings to diverse audiences (academics, relevant government departments, service users and providers) through seminars, peer-reviewed publications, short briefing reports and infographics for non-academics (published on the study website).

Evaluation of variation in special educational needs provision and its impact on health and education using administrative records for England: umbrella protocol for a mixed-methods research programme

INTRODUCTION

One-third of children in England have special educational needs (SEN) provision recorded during their school career. The proportion of children with SEN provision varies between schools and demographic groups, which may reflect variation in need, inequitable provision and/or systemic factors. There is scant evidence on whether SEN provision improves health and education outcomes.

METHODS

The Health Outcomes of young People in Education (HOPE) research programme uses administrative data from the Education and Child Health Insights from Linked Data-ECHILD-which contains data from all state schools, and contacts with National Health Service hospitals in England, to explore variation in SEN provision and its impact on health and education outcomes. This umbrella protocol sets out analyses across four work packages (WP). WP1 defined a range of 'health phenotypes', that is health conditions expected to need SEN provision in primary school. Next, we describe health and education outcomes (WP1) and individual, school-level and area-level factors affecting variation in SEN provision across different phenotypes (WP2). WP3 assesses the impact of SEN provision on health and education outcomes for specific health phenotypes using a range of causal inference methods to account for confounding factors and possible selection bias. In WP4 we review local policies and synthesise findings from surveys, interviews and focus groups of service users and providers to understand factors associated with variation in and experiences of identification, assessment and provision for SEN. Triangulation of findings on outcomes, variation and impact of SEN provision for different health phenotypes in ECHILD, with experiences of SEN provision will inform interpretation of findings for policy, practice and families and methods for future evaluation.

ETHICS AND DISSEMINATION

Research ethics committees have approved the use of the ECHILD database and, separately, the survey, interviews and focus groups of young people, parents and service providers. These stakeholders will contribute to the design, interpretation and communication of findings.

Trends in survival of children with severe congenital heart defects by gestational age at birth: A population-based study using administrative hospital data for England

BACKGROUND

Children with congenital heart defects (CHD) are twice as likely as their peers to be born preterm (<37 weeks' gestation), yet descriptions of recent trends in long-term survival by gestational age at birth (GA) are lacking.

OBJECTIVES

To quantify changes in survival to age 5 years of children in England with severe CHD by GA.

METHODS

We estimated changes in survival to age five of children with severe CHD and all other children born in England between April 2004 and March 2016, overall and by GA-group using linked hospital and mortality records.

RESULTS

Of 5,953,598 livebirths, 5.7% (339,080 of 5,953,598) were born preterm, 0.35% (20,648 of 5,953,598) died before age five and 3.6 per 1000 (21,291 of 5,953,598) had severe CHD. Adjusting for GA, under-five mortality rates fell at a similar rate between 2004-2008 and 2012-2016 for children with severe CHD (adjusted hazard ratio [HR] 0.79, 95% CI 0.71, 0.88) and all other children (HR 0.78, 95% CI 0.76, 0.81). For children with severe CHD, overall survival to age five increased from 87.5% (95% CI 86.6, 88.4) in 2004-2008 to 89.6% (95% CI 88.9, 90.3) in 2012-2016. There was strong evidence for better survival in the ≥39-week group (90.2%, 95% CI 89.1, 91.2 to 93%, 95% CI 92.4, 93.9), weaker evidence at 24-31 and 37-38 weeks and no evidence at 32-36 weeks. We estimate that 51 deaths (95% CI 24, 77) per year in children with severe CHD were averted in 2012-2016 compared to what would have been the case had 2004-2008 mortality rates persisted.

CONCLUSIONS

Nine out of 10 children with severe CHD in 2012-2016 survived to age five. The small improvement in survival over the study period was driven by increased survival in term children. Most children with severe CHD are reaching school age and may require additional support by schools and healthcare services.