Review
Growing up after extremely preterm birth: Lifespan mental health outcomes

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Summary

There is growing interest in the long-term mental health sequelae of extremely preterm birth. In this paper we review literature relating to mental health outcomes across the lifespan. Studies conducted in the preschool years, school age and adolescence, and adulthood show continuity in outcomes and point to an increased risk for inattention, socio-communicative problems and emotional difficulties in individuals born extremely preterm. Both behavioural and neuroimaging studies also provide evidence of a neurodevelopmental origin for mental health disorders in this population. Here we summarise contemporary evidence and highlight key methodological considerations for carrying out and interpreting studies in this field.

Introduction

Extremely preterm (EP) births, before 28 weeks of gestation, continue to pose the greatest challenge for neonatal medicine. Providing life-sustaining treatment, minimising environmental stressors and supporting the family through a traumatic life event are key challenges for neonatologists and other professionals involved in perinatal care. For these babies and their families, however, the care does not end there. The biological vulnerability conferred by EP birth, which may be amplified through socio-economic disadvantage, can have a profound impact on development with consequences that extend across the lifespan. Although EP births comprise just 0.6% of all births, morbidity is highest among these survivors [1], [2]. Cognitive impairments are the most frequent adverse outcomes [3], [4], but there is growing interest in the impact of preterm birth on mental health and wellbeing. Here we review literature relating to mental health outcomes following EP birth. Although we focus on reports from the most contemporary cohorts, much may be gained through understanding outcomes for older cohorts now in adult life.

Section snippets

Studying mental health following extremely preterm birth

Mental health outcomes are generally evaluated as part of longitudinal studies which have, for the most part, sought to identify the prevalence of disorders at various ages. Like all outcome studies, these suffer the inherent problems of selective drop-out. Some of the issues relating to the maintenance of cohorts have recently been discussed [5]. Key aspects of cohort evaluations are:

  • Having a clear denominator in order to evaluate how the findings may be extrapolated to other studies and how

Behaviour and emotional problems in the preschool years

There is a surprising lack of research regarding behavioural outcomes during the preschool years. Studies in infancy have focused on the development of attachment relationships, temperament and parent–infant interaction (see Korja et al. [42] and Vanderbilt [43] for reviews). The assessment of early psychopathology becomes more refined from the age of 2–3 years when well-standardised tools are available to identify clinically significant difficulties, such as the Child Behavior Checklist (CBCL)

Dimensional studies

EP survivors are at high risk for clinically significant problems throughout middle childhood, with prevalence estimates of 18–38% *[24], *[26], [61], [62], [63]. Studies have also shown that the mental health problems of EP children have a greater impact on their daily living than those of term-born controls [62], [64]. Commensurate with the temporal stability in neurodevelopmental outcomes [65], the rate of mental health problems remains high despite advances in neonatal care [61], [64].

Mental health in adulthood

Emerging data from population registry linkage studies in Scandinavia indicate a significant increase in the risk of adult mental health disorders with decreasing gestational age at birth. Because of the relatively low population prevalence of these conditions, such large, and necessarily broad, studies are the only ones to reliably report such findings. Moster et al. [81] reported an increased relative risk (RR) of ASD [9.5; 95% confidence interval (CI): 1.5, 36.2] and other disorders of

A biological basis for psychiatric morbidity

A biological basis for psychiatric disorders in EP survivors is perhaps understandable after consideration of the effect of prematurity on brain development, which has been described as a complex amalgam of destructive and developmental influences [90]. Studies using magnetic resonance imaging and computational techniques have identified differences in the brains of EP children and adults which may act as biomarkers for these evolving conditions [91]. These include not only ongoing adaptation

Conclusions

Studies of mental health outcomes following EP birth have largely sought to document the prevalence of disorders in middle childhood and adolescence, but reports of longer-term outcomes are beginning to surface as contemporary cohorts reach adulthood. Early attention and regulatory problems are evident in the preschool years and, by childhood, the greater specificity in outcomes points to a cluster of inattention, peer relationship problems and emotional symptoms. Approximately 25% have

Funding sources

Neil Marlow receives a proportion of funding from the Department of Health's NIHR Biomedical Research Centres funding scheme at UCLH/UCL.

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