Special health care needs explains the effect of extremely low birth weight on math but not language achievement
Introduction
Adolescents born at extremely low birth weight (ELBW, < 1000 g) have poor academic achievement compared to term born normal birth weight (NBW) children [1], [2], [3], [4], [5], [6]. Data also indicate significantly worse functional outcomes for ELBW survivors related to higher rates of chronic respiratory disease and neurosensory impairment [4], [7]. Our group recently reported the persistence of high rates of special health care needs (SHCN) into adolescence, with 74% having an identified chronic condition at 14 years [8]. In fact, the odds of having a SHCN at age 14 was 2.8 (95% CI = 1.7, 4.6) among ELBW adolescents compared to NBW peers.
The relationship between SHCN and school achievement has focused primarily on asthma, diabetes, and epilepsy and found a negative impact of chronic illness on achievement [9]. A meta-analysis revealed that children with diabetes suffer a disadvantage at school and have cognitive and executive function problems [10]. Another meta-analysis revealed that children with severe asthma diagnoses had poorer academic achievement than healthier peers [11]. One recent study of school-age children in urban St. Louis revealed significant differences on academic achievement testing in those with severe asthma compared to milder forms [12].
Noting that ELBW adolescents are at increased risk for both poor academic achievement and SHCN related to chronic illnesses, one might hypothesize that SHCN play a causal role in poor achievement in this population. A recent study tested this relationship in a cohort of infants born < 2500 g. Those with SHCN at 8 years of age had significantly lower scores on academic achievement at age 18 compared to those without a SHCN [13]. As all study participants had low birth weight, it was not possible to examine interactional effects of birth weight and SHCN on achievement.
We aim to further understand the role of SHCN in explaining higher rates of academic underachievement among adolescents with ELBW. We hypothesize that having a SHCN modifies the relationship between low birth weight and poor achievement. Being agnostic as to the causal relationships under study, we tested the possibility that SHCN acts as a mediator, an effect modifier, or a mediated modifier of achievement among adolescents with ELBW.
Section snippets
Sample
Participants included the 238 survivors of 344 children born < 1 kg admitted to the Neonatal Intensive Care Unit (NICU) at Rainbow Babies and Children's Hospital, Cleveland, Ohio from 1992 through 1995. A NBW comparison group of 176 children born at term gestation (> 36 weeks by parent report) was recruited at 8 years from the same school as the ELBW child and of the same sex, race, and age within 3 months.
Two hundred and nineteen children (92%) were followed to age 8 years, 181 (83%) were followed to
Results
Participants at 14-year follow-up included 181 adolescents in the ELBW group (mean birth weight 815 ± 124 g) and 115 in the NBW group (mean birth weight 3260 ± 524 g). The groups did not differ by age, sex, race, or maternal education, marital status, or income (Table 1). Mothers of ELBW adolescents were on average older than mothers of NBW adolescents at time of follow-up (43.7 vs. 40.6, p < 0.05).
The proportion of children with persistent SHCN at 14 years was significantly different between birth
Discussion
Children born with ELBW are at increased risk for poor academic achievement and specific learning problems in math compared to NBW peers [20]. Adolescents with low birth weight were more likely to have SHCN compared to NBW controls and those with a SHCN have lower average scores on tests of achievement. Our decomposition analysis revealed a highly complex interrelationship among birth weight, SHCN, and achievement.
The effect of SHCN on academic achievement has not been widely studied among
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Funding source
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Potential conflicts of interest
The authors have no conflicts of interest relevant to this article to disclose.
Author's statement
Dr. Hack supervised the study, had access to all of the data in the study, and assumed responsibility for the integrity of the data.
Drs. Hack, Taylor, and Litt developed the study concept and design.
Drs. Hack and Andreias acquired the data.
Drs. Litt and Taylor and Ms. Minich participated in the analysis, including statistical analysis and interpretation of the data.
Dr. Litt drafted the first version of the manuscript and all the co-authors participated in the critical revision of the manuscript
Acknowledgements
We thank Kathy Winter, who coordinated the project and participated in the interview of the parents; Laura Andreias, MD, MS, Ellen Durand, MA, and Heather Marcinick, MA, research assistants, who tested the children and administered the questionnaires; Sheree Hemphill, who developed the REDCap database; Lydia Cartar, MA, who participated in the initial data management and analysis; and Bonnie Tarantino and Alpher Torres, who provided clerical assistance.
References (39)
- et al.
School achievement and absence in children with chronic health conditions
J. Pediatr.
(Apr 1985) - et al.
The impact of special healt care needs on academic achievement in children born prematurely
Acad. Pediatr.
(May-Jun 2016) - et al.
Cognitive and educational outcome of very-low-birthweight children in early adolescence
Dev. Med. Child Neurol.
(Oct 1998) - et al.
Outcome at 14 years of extremely low birthweight infants: a regional study
Arch. Dis. Child. Fetal Neonatal Ed.
(Nov 2001) - et al.
School difficulties at adolescence in a regional cohort of children who were extremely low birth weight
Pediatrics
(Feb 2000) - et al.
Middle-school-age outcomes in children with very low birthweight
Child Dev.
(Nov–Dec 2000) - et al.
Psychosocial and academic characteristics of extremely low birth weight (< or = 800 g) adolescents who are free of major impairment compared with term-born control subjects
Pediatrics
(2004 Dec) - et al.
Brain morphometry and IQ measurements in preterm children
Brain
(Dec 2004) - et al.
Health and school performance of teenagers born before 29 weeks gestation
Arch. Dis. Child. Fetal Neonatal Ed.
(May 2003) - et al.
Self-reported adolescent health status of extremely low birth weight children born 1992–1995
Pediatrics
(Jul 2012)
Chronic health conditions and student performance at school
J. Sch. Health
Childhood asthma and student performance at school
J. Sch. Health
The relationship between school absence, academic performance, and asthma status
J. Sch. Health
Woodcock-Johnson III Tests of Achievement
Validity of the Wechsler abbreviated scale of intelligence and other very short forms of estimating intellectual functioning
Assessment
Manual for the Wechsler Abbreviated Scales of Intelligence
Shortening the questionnaire for identifying children with chronic conditions: what is the consequence?
Pediatrics
The questionnaire for identifying children with chronic conditions: a measure based on a noncategorical approach
Pediatrics
A unification of mediation and interaction: a 4-way decomposition
Epidemiology
Cited by (2)
School and language performance in children born with low birth weight
2023, Jornal de PediatriaCharacterizing early state regulation in preterm infants
2019, Journal of Developmental and Behavioral Pediatrics