Elsevier

The Lancet

Volume 357, Issue 9269, 26 May 2001, Pages 1641-1643
The Lancet

Articles
Behavioural problems in children who weigh 1000 g or less at birth in four countries

https://doi.org/10.1016/S0140-6736(00)04818-2Get rights and content

Summary

Background

The increased survival chances of extremely low-birthweight (ELBW) infants (weighing ≤1000 g at birth) has led to concern about their behavioural outcome in childhood. In reports from several countries with different assessments at various ages, investigators have noted a higher frequency of behavioural problems in such infants, but cross-cultural comparisons are lacking. Our aim was to compare behavioural problems in ELBW children of similar ages from four countries.

Methods

We prospectively studied 408 ELBW children aged 8–10 years, whose parents completed the child behaviour checklist. The children came from the Netherlands, Germany, Canada, and USA. The checklist provides a total problem score consisting of eight narrow-band scales. Of these, two (aggressive and delinquent behaviour) give a broad-band externalising score, three (anxious, somatic, and withdrawn behaviour) give a broad-band internalising score, and three (social, thought, and attention problems) indicate difficulties fitting neither broad-band dimension. For each cohort we analysed scores in ELBW children and those in normal-birthweight controls (two cohorts) or national normative controls (two cohorts). Across countries, we assessed deviations of the ELBW children from normative or control groups.

Findings

ELBW children had higher total problem scores than normative or control children, but this increase was only significant in European countries. Narrow-band scores were raised only for the social, thought, and attention difficulty scales, which were 0·5–1·2 SD higher in ELBW children than in others. Except for the increase in internalising scores recorded for one cohort, ELBW children did not differ from normative or control children on internalising or externalising scales.

Interpretation

Despite cultural differences, types of behavioural problems seen in ELBW children were very similar in the four countries. This finding suggests that biological mechanisms contribute to behavioural problems of ELBW children.

Introduction

Follow-up studies of extremely low-birthweight (ELBW) children (≤1000 g) have identified major disabilities such as cerebral palsy, mental retardation, blindness, and deafness. High rates of behavioural problems have also been noted in ELBW children of school age, with attention problems being the most frequently cited.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 Since behavioural problems adversely affect school performance and development of social relations, these are important long-term effects of preterm birth. Investigators from several countries have noted a higher frequency of behavioural problems in ELBW children than in other infants. However, cross-cultural studies are lacking.

Is the development of behavioural problems related to low-birthweight and its associated medical risk factors or do cultural aspects play a part? Our aim was to answer this question by studying the types and rates of behavioural problems recorded in ELBW children in four population-based cohorts from North America and Europe.

Section snippets

Study population

We obtained behavioural data for all survivors from four large prospective cohorts of preterm infants in four countries. These cohorts were: the neonatal brain-hemorrhage cohort (NBH) from the USA (1105 births ≤2000 g, born 1984–87);12 the McMaster ELBW cohort (McM) from Canada (397 births ≤1000 g, born 1977–82);13 the Bavarian longitudinal study of children at biological risk (BLS) from Germany (682 birth <1500 g, <32 weeks, or both; born 1985–86);14 and the project on preterm and small for

Results

We assessed 78–150 ELBW children in each of the four cohorts (table 1). The overall rate of follow-up was 78%. Mean birth weight was 860 g, and mean gestational age was 28 weeks. Although birth weight differed only slightly among cohorts (f=5·437, p=0·001), gestational age was 2 weeks lower in North American than in European cohorts (f=26·551, p<0·001).

The differences in total problem score between ELBW boys and controls ranged from 3·3 points in USA to 9·8 in Netherlands, and in girls from 3·7

Discussion

We identified very similar types of behavioural problems in all four countries, despite cultural differences in mean scores. Crijnen and colleagues18, 19 have also shown that the child behavioural checklist can identify difficulties for which children might need help, even when they are from diverse cultural backgrounds. The mean total problem score in Canadian ELBW and control children was high relative to that of the other three countries, but the difference between ELBW and controls was in

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