A Longitudinal Look

April 1, 2015

UH Rainbow experts continue long-standing research into infants born extremely premature

Innovations in Pediatrics - Spring 2015 - View Full PDF

H. Gerry Taylor, PhD

Pediatric Neuropsychologist, UH Rainbow Babies & Children’s Hospital Professor, Case Western Reserve University School of Medicine

Maureen Hack, MB, CHB

Professor Emeritus, Case Western Reserve University School of Medicine

Innovations in neonatology over the past three decades have changed the equation for families experiencing a preterm birth, with infants born prematurely today surviving at birth weights that would have been inconceivable just a few years ago. However, with this good news has come the realization that preterm birth often has lasting effects on a child’s cognition, behavior and learning, especially for the child with more extreme prematurity. 


“In the vast majority of cases, there are some early effects on the brain,” says H. Gerry Taylor, PhD, a pediatric neuropsychologist at University Hospitals Rainbow Babies & Children’s Hospital. “I’ve been interested in looking at how these effects manifest themselves as a child grows.”

Dr. Taylor has been tracking neuropsychological outcomes in extremely premature/extremely low birth-weight (ELBW) infants since the 1980s. At the same time, neonatologist Maureen Hack, MB, ChB, has been tracking these infants’ physical growth, health conditions and educational achievement, with cohorts dating back to 1977. Dr. Hack reported 20-year outcomes of a 1977 – 1979 cohort in The New England Journal of Medicine in 2002, noting that the educational disadvantages associated with very low birth weight appear to persist into young adulthood.


More recently, Dr. Taylor and Dr. Hack have followed a cohort of ELBW infants born between 2001 and 2003. They’ve found that these children have rates of cognitive deficits three to six times higher than that of their normal birth-weight peers. In addition, they’ve found that these kids tend to have lower academic achievement in kindergarten, higher rates of attention-deficit hyperactivity disorder (ADHD) and much higher rates of teacher-identified problems with attention, behavior self-regulation and social functioning. 

Now, Dr. Taylor and Dr. Hack have completed the first study to include direct observations of how these children actually behave in a kindergarten classroom. Writing in the journal Early Human Development earlier this year, they report that ELBW children receive more attention from teachers and are more often off-task in the classroom, when compared with their normal birth-weight peers.

“This is evidence that the problems we see in the cognitive testing and the problems parents and teachers report in rating scales actually translate to how these children perform in the classroom,” Dr. Taylor says. “It’s not necessarily surprising, but it does point to the predictive value of cognitive testing. It also points to the need for more individual attention for these kids and the need for targeted special education strategies.”

For their study, Dr. Taylor, Dr. Hack and colleagues observed 111 ELBW children and 110 normal birth-weight controls in the kindergarten classroom over a one-hour period. Observers were blind to each child’s birth-weight status, with one observer assigned to one child at a time. Each observation minute was divided into three 20-second segments. During the first segment, the observers noted what the child was doing. During the second, they noted what the teacher was doing. During the last, they noted the activity of the classroom as a whole. 

Results showed clear differences between the ELBW and normal birth-weight children, with effects most pronounced in the lowest birth-weight children. However, some classroom factors seemed to blunt the effect of birth weight. ELBW children functioned more effectively in the kindergarten classroom when the teacher was more experienced, when there was another adult present and when the class was small.

For Dr. Hack, these findings confirm the struggles that ELBW kids continue to have in meeting the demands of the classroom. However, she is quick to add that they don’t necessarily apply to every ELBW child. “There are individual differences,” she says. “Certainly we know some people do amazingly well.”

“One thing you learn following these kids is just how resilient human beings are,” Dr. Taylor adds. “Despite the odds and despite the severe insult experienced so early in life, some kids do absolutely fine.”

Going forward, Dr. Taylor and Dr. Hack hope to learn more about the factors that may lead to these better outcomes. “There is some neuroplasticity or set of experiences that can make a difference,” Dr. Taylor says. “We need to find out more about what those are so that we can promote better outcomes in everyone.”

In the meantime, they hope their work leads to a better understanding of the services that are necessary for ELBW children to succeed, both from parents and from schools. “Our findings give the impetus for policy changes that would allow for more individual interventions for these children,” Dr. Taylor says. “In addition, they show that neuropsychological findings are meaningful in predicting school behaviors.”

For ELBW kids, Dr. Taylor recommends a rich diet of activities that build school readiness. “These kinds need lots of language stimulation, preschool experiences, socialization and help in developing executive function,” he says. In addition, he recommends baseline neuropsychological testing by the time the child enters school. “Earlier recognition can lead to better understanding of their problems and a better understanding of the interventions they need.” 

Contact Dr. Taylor at Peds.Innovations@UHhospitals.org. 

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