Marlow, N., Wolke, D.M., et al. Neurologic and Developmental
Disability at Six Years of Age
Birth. New England J of Medicine, vol. 352, No.1. pp 9
Background. Birth before 26
gestation is associated
with a high prevalence of neurologic and developmental disabilities in
infant during the first two years of life.
Methods. We studied at the time of early
age children who had been born at 25 or fewer completed weeks of gestation in the
Kingdom and Ireland in 1995. Each child had been evaluated at 30 months of
The children underwent standardized cognitive and neurologic assessments at six
of age. Disability was defined as severe (indicating dependence on caregivers), moderate,
mild according to predetermined criteria.
Results. Of 308 surviving children, 241
were assessed at a median age of six years and four months; 160 classmates
at full term served as a comparison group. Although the use of test reference
showed that cognitive impairment (defined as results more than 2 SD below the
was present in 21 percent of the children born extremely preterm (as compared
1 percent in the standardized data), this value rose to 41 percent when the results
compared with those for their classmates. The rates of severe, moderate, and
disability were 22 percent, 24 percent, and 34 percent, respectively; disabling
palsy was present in 30 children (12 percent). Among children with severe
at 30 months of age, 86 percent still had moderate-to-severe disability at 6 years of
In contrast, other disabilities at the age of 30 months were poorly predictive of
problems at 6 years of age.
Conclusions. Among extremely preterm children,
and neurologic impairment is common at
school age. A comparison with
classroom peers indicates a level of impairment that is greater than is recognized
the use of standardized norms.
1. Saigal S, den Ouden L, Wolke D,
School-age outcomes in children who were
extremely low birth weight from four international
population-based cohorts. Pediatrics
2. Whitfield MF, Grunau RV, Holsti
Extremely premature (< or = 800 g) schoolchildren:
multiple areas of hidden disability.
Arch Dis Child Fetal Neonatal Ed 1997;77:
3. Taylor HG, Klein N, Hack M.
consequences of birth weight less than
750 g: a review and update. Dev Neuropsychol
4. Hack M, Flannery DJ, Schluchter
Cartar L, Borawski E, Klein N. Outcomes in
young adulthood for very-low-birth-weight
infants. N Engl J Med 2002;346:149-57.
5. Fanaroff AA, Poole K, Duara S,
Micronates: 401-500 grams: the NICHD Neonatal
Research Network Experience 1996-
2001. Pediatr Res 2003;54:398A. abstract.
6. Lorenz JM, Wooliever DE, Jetton
Paneth N. A quantitative review of mortality
and developmental disability in extremely
premature newborns. Arch Pediatr Adolesc
7. Wood NS, Marlow N, Costeloe K,
AT, Wilkinson AR. Neurologic and developmental
disability after extremely preterm
birth. N Engl J Med 2000;343:378-84.
8. Costeloe K, Hennessy E, Gibson
N, Wilkinson AR. The EPICure study:
outcomes to discharge from hospital for
infants born at the threshold of viability.
9. Jacobs SE, O’Brien K, Inwood S,
Whyte HE. Outcome of infants 23-26 weeks’
gestation pre and post surfactant. Acta Paediatr
10. Disability and perinatal care:
of two working groups convened by the
National Perinatal Epidemiology Unit and
the former Oxford Regional Health Authority.
March 1994. Oxford, England: NPEU and
11. Evans P, Alberman E, Johnson
L. Standardisation of recording and reporting
cerebral palsy. Dev Med Child Neurol
12. Kaufman A, Kaufman N. Kaufman
Assessment Battery for Children (K-ABC).
Circle Pines, Minn.: American Guidance Service,
13. Griffiths R. The abilities of
Somerset, U.K.: Young and Son, 1970.
14. Korkman M, Kirk U, Kemp S.
the NEPSY: a developmental neuropsychological
assessment. San Antonio, Tex.: Psychological
Testing Corporation, 1998.
15. Wolke D, Ratschinski G, Ohrt
K. The cognitive outcome of very preterm
infants may be poorer than often reported:
an empirical investigation of how methodological
issues make a big difference. Eur
J Pediatr 1994;153:906-15.
16. Flynn J. Searching for
justice: the discovery
of IQ gains over time. American Psychologist
17. Wolke D, Meyer R. Cognitive
attainment, and prereading skills of
6-year-old very preterm children and their
peers: the Bavarian Longitudinal Study. Dev
Med Child Neurol 1999;41:94-109.
18. Bhutta AT, Cleves MA, Casey
MM, Anand KJ. Cognitive and behavioral
outcomes of school-aged children who
were born preterm: a meta-analysis. JAMA
19. Aylward GP, Pfeiffer SI,
Wright A, Verhulst
SJ. Outcome studies of low birth weight
infants published in the last decade: a metaanalysis.
J Pediatr 1989;115:515-20.
20. Laucht M, Esser G, Baving L,
et al. Behavioral
sequelae of perinatal insults and early
family adversity at 8 years of age. J Am Acad
Child Adolesc Psychiatry 2000;39:1229-
21. Taylor HG, Burant CJ, Holding
N, Hack M. Sources of variability in sequelae
of very low birth weight. Neuropsychol Dev
Cogn Sect C Child Neuropsychol 2002;8:
22. Nelson KB, Ellenberg JH.
“outgrew” cerebral palsy. Pediatrics 1982;69:
23. Drillien CM. Abnormal
24. Kraemer S. The fragile
male. BMJ 2000;
in the first year of life in low-birthweight
infants: possible prognostic significance.
Dev Med Child Neurol 1972;14:575-84.
25. Brothwood M, Wolke D, Gamsu H, Benson
J, Cooper D. Prognosis of the
birthweight baby in relation to
Dis Child 1986;61:559-64.
26. Hack M, Fanaroff AA. Outcomes
of extremely low birthweight and gestational
age in the 1990’s. Early Hum Dev
27. Emsley HC, Wardle SP, Sims DG,
ML, D’Souza SW. Increased survival
and deteriorating developmental outcome in
23 to 25 week old gestation infants, 1990-4
compared with 1984-9. Arch Dis Child Fetal
Neonatal Ed 1998;78:F99-F104.
28. Piecuch RE, Leonard CH, Cooper
Kilpatrick SJ, Schlueter MA, Sola A. Outcome
of infants born at 24-26 weeks’ gestation:
II. Neurodevelopmental outcome.
Obstet Gynecol 1997;90:809-14.
29. Doyle LW. Outcome at 5 years
of age of
children 23 to 27 weeks’ gestation: refining
the prognosis. Pediatrics 2001;108:134-41.
30. Johnson A, Townshend P, Yudkin
D, Wilkinson AR. Functional abilities at age 4 years of children born
before 29 weeks of
gestation. BMJ 1993;306:1715-8.
31. Finnstrom O, Gaddlin PO,
Leijon I, Samuelsson
S, Wadsby M. Very-low-birth-weight
children at school age: academic achievement,
behavior and self-esteem and relation
to risk factors. J Matern Fetal Neonatal Med
32. Lorenz JM, Paneth N, Jetton
Ouden L, Tyson JE. Comparison of management
strategies for extreme prematurity in
New Jersey and the Netherlands: outcomes
and resource expenditure. Pediatrics 2001;
33. D’Angio CT, Sinkin RA, Stevens
TP, et al.
Longitudinal, 15-year follow-up of children
born at less than 29 weeks’ gestation after
introduction of surfactant therapy into a
region: neurologic, cognitive, and educational
outcomes. Pediatrics 2002;110:1094-
34. Hille ET, den Ouden AL, Saigal
S, et al.
Behavioural problems in children who weigh
1000 g or less at birth in four countries. Lancet
35. Botting N, Powls A, Cooke RW,
N. Attention deficit hyperactivity disorders
and other psychiatric outcomes in very low
birthweight children at 12 years. J Child Psychol