There is no denying that one of the achievements of modern medical science is the ability to save babies born extremely prematurely. More and more of us will have had direct experience of this ourselves, in our families or among our friends, and we have all read the happy stories of ‘miracle babies’ surviving against all the odds.
The practice in neonatal intensive care units has also moved forward, from a focus merely on the medical needs of the child to one that includes the emotional needs of parents and babies. ‘Kangaroo care’, where the baby spends time carried next to the parents with skin-to-skin contact, is now commonly used because it helps to regulate the baby’s body temperature, as well as providing important attachment and bonding experiences.
Often, by the time the child reaches school their prematurity is no longer considered an issue, unless there is a physical disability or ongoing medical condition. So the findings of a recent research report may come as a shock to parents and practitioners.
A cohort study based on the Avon Longitudinal Study of Parents and Children and carried out by a team of researchers at the Neonatal Unit, North Bristol NHS Trust, suggests that ‘almost one in three children born prematurely (before 37 weeks) have lower Key Stage 1 (KS1) test results than children who are born at full term (37-42 weeks) and more than a third have special educational needs (SEN).’ (Odd, Evans, Emond, 2013)
The news will not, however, come as a surprise to those early years practitioners who include sensitive gathering of prenatal and birth information in their admission process and special needs assessment and who have noticed an increasing link between pre-term or traumatic birth experience and later difficulties.
The Bristol research starts from the premise that ‘infants born pre-term, both at extreme gestations (for example, less than 32 weeks) but also at more modest gestations (for example, 32-36 weeks), have worse outcomes at school age’ and considers whether the age of entry to school is a factor in this.
The findings suggest ‘that a proportion of the social and educational difficulties seen in these infants may be avoidable by recognising the impact that prematurity has upon school year of entry, in addition to the known impact upon cognitive and motor functions. It is possible that infants at moderate pre-term gestations may similarly be affected.’
This means that if a child’s due date and their actual birth date are in different school years (from September-July), then the premature child could find that any difficulties they may have are compounded by starting school a whole year earlier than they would have done if they had been born on their due date.
GROWING NUMBERS
It seems that premature or ‘pre-term’ births are on the increase, particularly ‘late pre-term’, both globally and in the UK. With chances of survival also increasing, more children who have had pre-term births are entering schools and childcare settings as a matter of course.
Pre-term birth refers to births at less than 37 weeks. This includes:
- ‘very’ or ‘extreme pre-term’ delivery at less than 32 weeks
- ‘moderately pre-term’ at 32-34 weeks, and
- ‘late pre-term’ births at 34 -37 weeks.
Most babies born pre-term will have low or very low birth weight, but not always. This has caused problems in some early research that only considered birth weight; it is possible to be premature and a ‘healthy’ weight or to be small but born to term. This makes a big difference to neurodevelopment, as we will see when we look more closely at the impact of prematurity on a baby’s developing brain.
There are a number of reasons believed to have caused the rise in pre-term births. Numbers have largely changed in minority world countries such as USA, where increased maternal age and extensive use of fertility programmes and the linked rise in multiple births are considered a factor (Loftin et al, 2010). In majority world countries, poor maternal health and lack of drugs may play a part. It is also thought that in the USA, for example, where doctors are becoming increasingly comfortable with the medical aspects of pre-term births, more early elective deliveries are taking place (Beck et al, 2010).
WHY IT MATTERS
Firstly, we now know that the last months in the womb are when hugely important foetal developments are taking place in major organs such as the lungs and in the baby’s brain. Although we think the dangers are reduced the nearer to term a baby is born, missing out on the last months still means missing out on crucial development.
Pre-term birth is also likely to increase stress for the baby, as well as the mother, and this can impact on the amount of stress hormone, cortisol, experienced by both of them, before, during and after the birth.
In one of the longest ongoing studies of pre-term births over 23 years in the USA, Professor of Nursing at Rhode Island University Mary C Sullivan has found a range of possible impacts on health and learning and is now examining whether the stresses experienced by pre-term babies in their earliest weeks lead to illnesses when they are adults (Sullivan, 2013).
We are also increasingly aware of the possible impact of the interventions that take place in order to keep the pre-term baby alive. The NYU Child Study Center suggests:
- breathing tubes in the mouth might increase oral sensitivity and affect mouth muscle development, impacting on later speech and language development
- lying on the back, rather than in the foetal curve of the womb, can result in a shortening of the muscles between the shoulder blades, which might lead to restricted movement later
- wearing nappies that are too large for tiny babies can force an incorrect turnout of the hips, which again can lead to later movement problems
- painful medical procedures, bright lights and noise are all overstimulating to babies at any age and particularly at this extra sensitive stage of development.
In its advice to parents, the NYU centre suggests that pre-term babies may use a whole range of instinctive protective systems to safeguard themselves from overwhelming experiences. These might include:
- hypervigilance – always being alert for painful experiences
- dissociation – shutting down so as not to feel pain or overwhelming stimulation
- distractibility – constantly switching from one stimulated area to another to try to manage the assault on the senses.
Although no longer needed as the child grows, these instinctive behaviours can soon become habitual and by the time they are in school, have the potential to interfere with social, emotional and academic progress.
Yet we don’t always make the connection with a child’s birth experiences when we are assessing behavioural and learning difficulties at a later stage in their lives. Fortunately, practice in neonatal intensive care units has now been adapted to take these and other aspects of care into consideration, but practice in schools and childcare settings doesn’t always reflect awareness of the needs of children who were born pre-term as they get older.
The recent research in Bristol builds on earlier studies (for example, Huddy et al, 2001) suggesting that children born late pre-term are more likely to have developmental delays and difficulties with hyperactivity, fine motor skills, mathematics, speaking, reading and writing than children born full-term. However, these are very generalised statements, and we must remember that premature birth is not like a disease, with a set of pre-determined outcomes.
These children have already shown us their great powers of resilience and determination to survive, and statistics do not tell us anything about the individual. The experience and life chances of each child born pre-term will be formed by a whole range of factors other than just their prematurity.
But if, as it seems, more and more children are born and will survive a pre-term birth, it is imperative that we raise our awareness and understanding of their needs as they reach us in our schools and childcare settings.
Professor Sullivan reminds us that, ‘By identifying the issues pre-term babies face in childhood, adolescence and through adulthood, we can all be better prepared to take steps to mitigate their effects.’
Part 2, to be published in Nursery World on 16 December, will look at ways to support pre-term children and their families
MORE INFORMATION
- ‘Educational and Behavioural Problems in Babies of 32-35 Weeks Gestation’, by CLJ Huddy, A Johnson and PL Hope, in Archives of Disease
- in Childhood Effects of premature birth can reach into adulthood, University of Rhode Island (2011), www.uri.edu/news/releases/?id=5874
- ‘Late Pre-term Birth’, by R Loftin et al (2010), in Reviews in Obstetrics and Gynecology, www.ncbi.nlm.nih.gov/pmc/articles/PMC2876317/
- Premature Infants: a later look, NYU Child Study Center), www.aboutourkids.org/articles/premature_infants_later_look
- ‘Pre-term Birth, Age at School Entry and Educational Performance’, by D Odd, D Evans, A Emond (2013), www.ncbi.nlm.nih.gov/pubmed/24146899?
- The Avon Longitudinal Study of Parents and Children, www.adls.ac.uk/find-administrative-data/linked-administrative-data/avon-longitudinal-study/
- The Worldwide Incidence of Pre-term Birth: a systematic review of maternal mortality and morbidity, S Beck et al (2010), www.who.int/bulletin/volumes/88/
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