Patrick H. Casey

CONTEXT: The cognitive and behavioral outcomes of school-aged children who were born preterm have been reported extensively. Many of these studies have methodological flaws that preclude an accurate estimate of the long-term outcomes of prematurity. OBJECTIVE: To estimate the effect of preterm birth on cognition and behavior in school-aged children. DATA SOURCES: MEDLINE search (1980 to November 2001) for English-language articles, supplemented by a manual search of personal files maintained by 2 of the authors. STUDY SELECTION: We included case-control studies reporting cognitive and/or behavioral data of children who were born preterm and who were evaluated after their fifth birthday if the attrition rate was less than 30%. From the 227 reviewed studies, cognitive data from 15 studies and behavioral data from 16 studies were selected. DATA EXTRACTION: Data on population demographics, study characteristics, and cognitive and behavioral outcomes were extracted from each study, entered in a customized database, and reviewed twice to minimize error. Differences between the mean cognitive scores of cases and controls were pooled. Homogeneity across studies was formally tested using a general variance-based method and graphically using Galbraith plots. Linear meta-analysis regression models were fitted to explore the impact of birth weight and gestational age on cognitive outcomes. Study-specific relative risks (RRs) were calculated for the incidence of attention-deficit/hyperactivity disorder (ADHD) and pooled. Quality assessment of the studies was performed based on a 10-point scale. Publication bias was examined using Begg modified funnel plots and formally tested using the Egger weighted-linear regression method. DATA SYNTHESIS: Among 1556 cases and 1720 controls, controls had significantly higher cognitive scores compared with children who were born preterm (weighted mean difference, 10.9; 95% confidence interval [CI], 9.2-12.5). The mean cognitive scores of preterm-born cases and term-born controls were directly proportional to their birth weight (R(2) = 0.51; P<.001) and gestational age (R(2) = 0.49; P<.001). Age at evaluation had no significant correlation with mean difference in cognitive scores (R(2) = 0.12; P =.20). Preterm-born children showed increases in externalizing and internalizing behaviors in 81% of studies and had more than twice the RR for developing ADHD (pooled RR, 2.64; 95% CI, 1.85-3.78). No differences were noted in cognition and behaviors based on the quality of the study. CONCLUSIONS: Children who were born preterm are at risk for reduced cognitive test scores and their immaturity at birth is directly proportional to the mean cognitive scores at school age. Preterm-born children also show an increased incidence of ADHD and other behaviors.

OBJECTIVES: To develop a brief screen to identify families at risk for food insecurity (FI) and to evaluate the sensitivity, specificity, and convergent validity of the screen. PATIENTS AND METHODS: Caregivers of children (age: birth through 3 years) from 7 urban medical centers completed the US Department of Agriculture 18-item Household Food Security Survey (HFSS), reports of child health, hospitalizations in their lifetime, and developmental risk. Children were weighed and measured. An FI screen was developed on the basis of affirmative HFSS responses among food-insecure families. Sensitivity and specificity were evaluated. Convergent validity (the correspondence between the FI screen and theoretically related variables) was assessed with logistic regression, adjusted for covariates including study site; the caregivers' race/ethnicity, US-born versus immigrant status, marital status, education, and employment; history of breastfeeding; child's gender; and the child's low birth weight status. RESULTS: The sample included 30,098 families, 23% of which were food insecure. HFSS questions 1 and 2 were most frequently endorsed among food-insecure families (92.5% and 81.9%, respectively). An affirmative response to either question 1 or 2 had a sensitivity of 97% and specificity of 83% and was associated with increased risk of reported poor/fair child health (adjusted odds ratio [aOR]: 1.56; P < .001), hospitalizations in their lifetime (aOR: 1.17; P < .001), and developmental risk (aOR: 1.60; P < .001). CONCLUSIONS: A 2-item FI screen was sensitive, specific, and valid among low-income families with young children. The FI screen rapidly identifies households at risk for FI, enabling providers to target services that ameliorate the health and developmental consequences associated with FI.

OBJECTIVE: To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age. METHODS: This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001-2499 g) and lighter low birth weight (LLBW; < or = 2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status. RESULTS: We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (-0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2). CONCLUSIONS: The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.