Dissertation committee:
Μπακούλα-Τζουμάκα Χρυσάνθη, Ομότιμη Καθηγήτρια, Ιατρική ΕΚΠΑ
Χρούσος Γεώργιος, Καθηγητής, Ιατρική ΕΚΠΑ, 1η Πανεπιστημιακή Παιδιατρική Κλινική Ν. Π. " Η Αγία Σοφία"
Κανακά - Geintenbein Χριστίνα, Καθηγήτρια, Ιατρική ΕΚΠΑ, 1η Πανεπιστημιακή Παιδιατρική Κλινική Ν. Π. " Η Αγία Σοφία"
Σιαχανίδου Σουλτάνα, Αναπληρώτρια Καθηγήτρια, Ιατρική ΕΚΠΑ, 1η Πανεπιστημιακή Παιδιατρική Κλινική Ν. Π. " Η Αγία Σοφία"
Λαγκώνα Ευαγγελία, Αναπληρώτρια Καθηγήτρια, Ιατρική ΕΚΠΑ
Πονς Ροζέ, Επίκουρη Καθηγήτρια, Ιατρική ΕΚΠΑ, 1η Πανεπιστημιακή Παιδιατρική Κλινική Ν. Π. " Η Αγία Σοφία"
Ιακωβίδου Νικολέττα, Καθηγήτρια, Ιατρική ΕΚΠΑ, Νεογνολογική Κλινική Αρεταίειου Νοσοκομείου
Summary:
Late preterm babies, are those born between 34-36+6 weeks of gestation. This definition came into effect in 2005, amidst worries regarding the rapid rise in their numbers, short term morbidity and possible long-term neurodevelopmental sequelae. However, there is in fact little evidence from epidemiological studies, as late preterms have mostly been dealt with at postnatal wards and were not considered candidates for follow-up programs. This is also true of the Greek late preterm population, whose development has not been previously considered to be in danger.
The purpose of this study is therefore, to examine the neurodevelopmental outcome of the late preterm population in Greece. To this effect we will analyze, from an epidemiologic point of view, the outcomes of late preterm (LP) infants, at age seven and 18 years and we will compare them with the more preterm <34 weeks of gestation (PT) and with term infants ≥ 37 weeks of gestation (TM).
The data used for the analysis is derived from three national, prospective epidemiologic studies: A) the 1st Panhellenic Perinatal Study (consecutive births during the month of April 1983) with a population of 10.433 neonates (after excluding babies who died during the 1st month, multiples and those with congenital disorders), B) the follow-up study of the Health and Development of Greek Children at seven years of age (1990), with a final population 6.284 children and C) the second follow-up study of Factors Affecting the Health and Development of Teenagers at 18 years of age (2001), which include 2.004 of the original children, after cross-matching.
At first we assessed whether the populations at age 7 and 18 years, were representative of the original. We found no statistical differences regarding the weight, height, head circumference at birth (p=0.12, 0.51, 0.36 respectively), regarding were the family lived, rural or city dwelling (p 0.05), the type of main carer - mostly the mother- (p 0.46), maternal (p 0.44) and paternal ages (p 0.14). Most importantly the three populations were representative of the birth cohort regarding the distribution in the three gestational age groups PT, LP, TM (p=0.86).
Age 7 years: We found little statistical difference between LP and TM babies regarding their motor and sensory development. Term-born children have 40% higher odds as compared to late preterms of writing numbers 1-9 at this age (p 0.04), and a 22% decreased risk of learning difficulties (p 0.001). LPs and TM children have no statistically significant differences in school attainment, both by subject and overall achievement. On the other hand, children born <34 weeks of gestation, as expected, bear the burden of disability and have worse school performance, are described more often as “difficult” children by both teachers and parents and have a tendency to destroy objects more often. Besides gestational age, pregnancy-induced hypertension, low maternal educational level, poor or no attendance at preschool and school absenteeism, are other significant risk factors for poor school performance at this age.
Regarding possible behavioral problems at this age, we used Rutter’s Parents Questionnaire, calculated Rutter’s score and further analyzed data, by multilinear regression model, using as cut-off the 98th centile. Gestational age was not found to be statistically significant, while maternal age ≤20 years, mother’s smoking habit, non-regular attendance at school and >1 month time needed to adjust to school, appear to be the only risk factors leading to a high Rutter’s score.
Age 18 years: Gestational age does not appear to affect school performance, by subject and overall grade, plans for higher education, or behavior (using Achenbach’s Youth Self Report tool) neither for LPs, nor for PT-born children, to any statistically significant degree at this age. It appears from our study that other factors become important in this age group and determine teenager’s further development: Children, who describe themselves as happier with their life, from a higher socioeconomic background and girls have better school attainment and more chance of wanting to enter higher education. Parental involvement is also extremely important: Those children, whose parents seldom take an interest in their studies versus those whose parents are often involved have a 3.5 increased risk of not wanting to continue their education, and higher odds of poor performance in Greek Language, mathematics and overall grades by 2.6, 1.82 and 3 respectively.
Regarding teenager’s behavior we analyzed their YSR scores and used again the 98th centile as a cut-off for possible problems. The teenagers poor image of themselves is a consistently significant risk factor for all symptoms in the YSR scale, while smoking and chronic illness also lead to increased risk. Gestational age was not found to be statistically significant.
In conclusion, from our analysis, the LPs neurodevelopmental course through life appears to be almost parallel with that of TM babies. Minor disabilities were found at age 7 and cannot be fully explored by an epidemiologic study non-inclusive of a neurologic examination; however it appears that gestational age is not the only risk factor; other biological factors, the family’s socioeconomic status and parental involvement are also equally important. The latter two are also major determinants of the children’s outcomes at age 18.
These findings are especially significant at this time of economic crisis in Greece, when vulnerable populations suffer most. It becomes then, both the family’s and the duty of society as a whole to ensure that these children receive comprehensive care: Protocols that underscore perinatal awareness, provide pathways for timely intervention and suitable parental guidance at birth must be in place. Neonates should be entered into follow-up programs and benefit from early intervention and age-appropriate assistance as required, so that they can attain their full potential.
