Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Population Study Article
  • Published:

The long-term effect of very preterm birth on school readiness: exploring preschool mediating pathways

Pediatric Research (2025)Cite this article

Abstract

Background

Very preterm children face developmental challenges at school entry, yet the mechanisms underlying these difficulties during preschool remain unclear. We examined the association between very preterm birth and children’s math skills, behavioural, and emotional difficulties in children aged 8–12, and the mediating role of executive functions and receptive vocabulary from ages 3 to 6.

Methods

Using data from the ‘Encuesta Longitudinal de la Primera Infancia’ Chilean cohort, the study involved 10,098 children (147 very preterm). Very preterm status and sociodemographics were assessed at ages 1–3 in 2010. Executive functions and receptive vocabulary were measured in 2012, and math skills, behavioural, and emotional difficulties in 2017.

Results

Structural equation modelling indicated that very preterm children exhibited significantly lower math skills compared to term-born peers. This association was partially mediated by reduced executive functions and receptive vocabulary at preschool. No total or direct effects were found between very preterm birth and behavioural or emotional difficulties, but indirect effects, via general cognitive abilities, were observed.

Conclusion

This study highlights the long-term effects of very preterm birth on children’s school readiness. Early interventions that enhance executive functions and receptive vocabulary at preschool may help mitigate the adverse effects of very preterm birth.

Impact

  • Very preterm children show lower math skills at school age than full-term peers, mediated by early difficulties in executive functions and receptive vocabulary.

  • Very preterm status does not have a direct association with children’s behavioural and emotional difficulties at school age; however, an indirect pathway via early difficulties in general cognitive skills was identified.

  • Findings add to the existing literature by identifying early cognitive mechanisms underlying long-term academic challenges for this high-risk group.

  • Early intervention programs targeting executive functions and receptive vocabulary at preschool can help mitigate the adverse effects of very preterm birth on educational outcomes.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Path diagram of the structural equation model.
Fig. 2: Standardised coefficients for the final structural equation model.

Similar content being viewed by others

Data availability

The datasets generated during and/or analysed during the current study are available in the ELPI repository, https://observatorio.ministeriodesarrollosocial.gob.cl/elpi-primera-ronda.

References

  1. Gregory, T. et al. Associations between school readiness and student wellbeing: a six-year follow up study. Child Indic. Res. 14, 369–390 (2021).

    Article  Google Scholar 

  2. Hutchinson, E. A., De Luca, C. R., Doyle, L. W., Roberts, G. & Anderson, P. J. School-age outcomes of extremely preterm or extremely low birth weight children. Pediatrics 131, e1053–e1061 (2013).

    Article  PubMed  Google Scholar 

  3. McKenzie, K., Lynch, E. & Msall, M. E. Scaffolding parenting and health development for preterm flourishing across the life course. Pediatrics 149, S1 (2022).

    Article  Google Scholar 

  4. Allotey, J. et al. Cognitive, motor, behavioural and academic performances of children born preterm: a meta-analysis and systematic review involving 64061 children. BJOG 125, 16–25 (2018).

    Article  CAS  PubMed  Google Scholar 

  5. Arpi, E. et al. Worse global intellectual and worse neuropsychological functioning in preterm-born children at preschool age: a meta-analysis. Acta Paediatr. 108, 1567–1579 (2019).

    Article  PubMed  Google Scholar 

  6. Brydges, C. R. et al. Cognitive outcomes in children and adolescents born very preterm: a meta-analysis. Dev. Med. Child Neurol. 60, 452–468 (2018).

    Article  PubMed  Google Scholar 

  7. Eves, R. et al. Association of very preterm birth or very low birth weight with intelligence in adulthood: an individual participant data meta-analysis. JAMA Pediatr. 175, e211058–e211058 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Kerr-Wilson, C. O., Mackay, D. F., Smith, G. C. S. & Pell, J. P. Meta-analysis of the association between preterm delivery and intelligence. J. Public Health 34, 209–216 (2012).

    Article  CAS  Google Scholar 

  9. Sentenac, M. et al. Defining very preterm populations for systematic reviews with meta-analyses. JAMA Pediatr. 174, 997–999 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  10. Twilhaar, E. S. et al. Cognitive outcomes of children born extremely or very preterm since the 1990s and associated risk factors: a meta-analysis and meta-regression. JAMA Pediatr. 172, 361–367 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Barre, N. B., Morgan, A. P., Doyle, L. W. M. D. F. & Anderson, P. J. P. Language abilities in children who were very preterm and/or very low birth weight: a meta-analysis. J. Pediatr. 158, 766–774.e761 (2011).

    Article  PubMed  Google Scholar 

  12. Valavani, E. et al. Language function following preterm birth: prediction using machine learning. Pediatr. Res. 92, 480–489 (2022).

    Article  PubMed  Google Scholar 

  13. Burstein, O., Zevin, Z. & Geva, R. Preterm birth and the development of visual attention during the first 2 years of life a systematic review and meta-analysis. JAMA Netw. Open 4, e213687–e213687 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Twilhaar, E. S., De Kieviet, J. F., Van Elburg, R. M. & Oosterlaan, J. Neurocognitive processes underlying academic difficulties in very preterm born adolescents. Child Neuropsychol. 26, 274–287 (2020).

    Article  PubMed  Google Scholar 

  15. van Houdt, C. A., Oosterlaan, J., van Wassenaer-Leemhuis, A. G., van Kaam, A. H. & Aarnoudse-Moens, C. S. H. Executive function deficits in children born preterm or at low birthweight: a meta-analysis. Dev. Med Child Neurol. 61, 1015–1024 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  16. Aarnoudse-Moens, C. S. H., Weisglas-Kuperus, N., van Goudoever, J. B. & Oosterlaan, J. Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatr 124, 717–728 (2009).

    Article  Google Scholar 

  17. McBryde, M., Fitzallen, G. C., Liley, H. G., Taylor, H. G. & Bora, S. Academic outcomes of school-aged children born preterm a systematic review and meta-analysis. JAMA Netw. Open 3, e202027–-e202027 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  18. Simms, V. et al. Nature and origins of mathematics difficulties in very preterm children: a different etiology than developmental dyscalculia. Pediatr. Res. 77, 389–395 (2015).

    Article  PubMed  Google Scholar 

  19. Anderson, P., Doyle, L. W. & and the Victorian Infant Collaborative Study, G. Neurobehavioral outcomes of school-age children born extremely low birth weight or very preterm in the 1990s. JAMA 289, 3264–3272 (2003).

    Article  PubMed  Google Scholar 

  20. Anderson, P. J. et al. Psychiatric disorders in individuals born very preterm/very low-birth weight: an individual participant data (Ipd) meta-analysis. EClinicalMedicine 42, 101216–101216 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Franz, A. P. et al. Attention-deficit/hyperactivity disorder and very preterm/very low birth weight: a meta-analysis. Pediatrics 141, 1 (2018).

    Article  Google Scholar 

  22. Mathewson, K. J. et al. Mental health of extremely low birth weight survivors: a systematic review and meta-analysis. Psychol. Bull. 143, 347–383 (2017).

    Article  PubMed  Google Scholar 

  23. Pyhälä, R. et al. Self-reported mental health problems among adults born oreterm: a meta-analysis. Pediatrics 139, e20162690 (2017).

  24. Bolbocean, C. et al. Health-related quality-of-life outcomes of very preterm or very low birth weight adults: evidence from an individual participant data meta-analysis. Pharmacoeconomics 41, 93–105 (2023).

    Article  PubMed  Google Scholar 

  25. Brogan, E. et al. Inattention in very preterm children: implications for screening and detection. Arch. Dis. Child 99, 834–839 (2014).

    Article  PubMed  Google Scholar 

  26. Clayton, S. et al. Etiology of persistent mathematics difficulties from childhood to adolescence following very preterm birth. Child Neuropsychol. 28, 82–98 (2022).

    Article  PubMed  Google Scholar 

  27. Adrian, J. A., Bakeman, R., Akshoomoff, N. & Haist, F. Cognitive functions mediate the effect of preterm birth on mathematics skills in young children. Child Neuropsychol. 26, 834–856 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Loe, I. M., Feldman, H. M. & Huffman, L. C. Executive function mediates effects of gestational age on functional outcomes and behavior in preschoolers. J. Dev. Behav. Pediatr. 35, 323–33 (2014).

  29. Schnider, B. et al. Executive function deficits mediate the association between very preterm birth and behavioral problems at school-age. Early Hum. Dev. 146, 105076–105076 (2020).

    Article  PubMed  Google Scholar 

  30. Trickett, J. et al. Neuropsychological abilities underpinning academic attainment in children born extremely preterm. Child Neuropsychol. 28, 746–767 (2022).

    Article  PubMed  Google Scholar 

  31. Behrman, J., Bravo, D., & Urzúa, S. Encuesta Longitudinal De La Primera Infancia: Aspectos Metodológicos Y Primeros Resultados. [Early Childhood Longitudinal Survey: Methodological Aspects and First Results], <http://observatorio.ministeriodesarrollosocial.gob.cl/elpi-primera-ronda> (2010).

  32. Wambach, D. et al. in Encyclopedia of Clinical Neuropsychology (eds Kreutzer, J. S., DeLuca, J. & Caplan, B.) 844–849 (Springer New York, 2011).

  33. Dunn, L. M., & Dunn, L. Test De Vocabulario Imágenes Peabody: Adaptación Española. [Peabody Picture Vocabulary Test: Spanish Adaptation] (Mepsa 1986).

  34. Muñoz-Sandoval, A. F., Woodcock, R. W., McGrew, K. S., & Mather, N. Batería Iii Woodcock- Muñoz: Pruebas De Aprovechamiento [Woodcock-Muñoz Battery Iii: Achievement Tests] (Riverside, 2005).

  35. Achenbach, T. M. in Encyclopedia of Clinical Neuropsychology (eds Kreutzer, J. S., DeLuca, J. & Caplan, B.) 546–552 (Springer New York, 2011).

  36. Enders, C. K. & Bandalos, D. L. The relative performance of full information maximum likelihood estimation for missing data in structural equation models. Struct. Equ. Model. 8, 430–457 (2001).

    Article  Google Scholar 

  37. Hu, L. -t & Bentler, P. M. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct. Equ. Model. 6, 1–55 (1999).

    Article  Google Scholar 

  38. Shi, D., Lee, T. & Maydeu-Olivares, A. Understanding the model size effect on sem fit indices. Educ. Psychol. Meas. 79, 310–334 (2019).

    Article  PubMed  Google Scholar 

  39. Rosseel, Y. Lavaan: an R package for structural equation modeling. J. Stat. Softw. 48, 1–36 (2012).

  40. Davis-Kean, P. E., Domina, T., Kuhfeld, M., Ellis, A. & Gershoff, E. T. It matters how you start: early numeracy mastery predicts high school math course-taking and college attendance. Infant Child Dev. 31, e2281 (2022).

  41. Wolke, D., Johnson, S., Jaekel, J., & Gilmore, C. The Impact of Premature Birth on Maths Achievement and Schooling: Briefing Notes and Recommendations, <https://www.nuffieldfoundation.org/wp-content/uploads/2019/11/Nuffield20report20Final20-2012_02_2016.pdf> (2016).

  42. Wolke, D., Johnson, S. & Mendonça, M. The life course consequences of very preterm birth. Annu. Rev. Dev. Psychol. 1, 69–92 (2019).

    Article  Google Scholar 

  43. Eryigit Madzwamuse, S., Baumann, N., Jaekel, J., Bartmann, P. & Wolke, D. Neuro-cognitive performance of very preterm or very low birth weight adults at 26 years. J. Child Psychol. Psychiatry 56, 857–864 (2015).

    Article  PubMed  Google Scholar 

  44. Farkas, C., Girard, L.-C. & MacBeth, A. Predictors of emotional problems in 5-year-old children: an international comparison between two cohorts in chile and scotland. Curr. Psychol. 42, 390–405 (2021).

    Article  Google Scholar 

  45. Quijada, Y., Villagrán, L., Jiménez, P. V., Reyes, C. & Gallardo, L. D. Social inequality and mental health in Chile, Ecuador, and Colombia. Lat. Am. Perspect. 46, 92–108 (2019).

    Article  Google Scholar 

  46. Conti-Ramsden, G., Mok, P. L. H., Pickles, A. & Durkin, K. Adolescents with a history of specific language impairment (Sli): strengths and difficulties in social, emotional and behavioral functioning. Res. Dev. Disabil. 34, 4161–4169 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Girard, L.-C. et al. Physical aggression and language ability from 17 to 72 months: cross-lagged effects in a population sample. PloS ONE 9, e112185–e112185 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  48. Muir, R. A., Howard, S. J. & Kervin, L. Interventions and approaches targeting early self-regulation or executive functioning in preschools: a systematic review. Educ. Psychol. Rev. 35, 27 (2023).

    Article  Google Scholar 

  49. Johnson, S. et al. Improving developmental and educational support for children born preterm: evaluation of an e-learning resource for education professionals. BMJ Open 9, e029720–e029720 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  50. Keenan, K. et al. Concordance between maternal recall of birth complications and data from obstetrical records. Early Hum. Dev. 105, 11–15 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Blencowe, H. M. et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet 379, 2162–2172 (2012).

    Article  PubMed  Google Scholar 

Download references

Funding

This research was supported by ANID – MILENIO – NCS2021_014. María Francisca Morales is supported by InES Género (INGE 230004) Universidad Diego Portales. Victoria Simms is supported by the UKRI Economic and Social Research Council (grant number ES/W002914/1).

Author information

Authors and Affiliations

  1. Faculty of Education, Universidad Diego Portales, Santiago, Chile

    María Francisca Morales

  2. Millennium Nucleus for the Study of the Development of Early Math Skills (MEMAT), Santiago, Chile

    María Francisca Morales, María Inés Susperreguy & Victoria Simms

  3. Faculty of Education, Pontificia Universidad Católica de Chile, Santiago, Chile

    María Inés Susperreguy

  4. School of Psychology, Ulster University, Coleraine, UK

    Victoria Simms

  5. Centre for Early Mathematical Learning (CEML), Swindon, UK

    Victoria Simms

Authors
  1. María Francisca Morales
    View author publications

    Search author on:PubMed Google Scholar

  2. María Inés Susperreguy
    View author publications

    Search author on:PubMed Google Scholar

  3. Victoria Simms
    View author publications

    Search author on:PubMed Google Scholar

Contributions

M.F.M., M.I.S., and V.S. developed the study concept and design; Data cleaning, analyses, and interpretation of data were performed by M.F.M. under the supervision of M.I.S. and V.S.; M.F.M. drafted the paper, and M.I.S. and V.S. provided critical revisions; All authors approved the final version of the paper for submission.

Corresponding author

Correspondence to María Francisca Morales.

Ethics declarations

Competing interests

The authors declare no competing interests.

Consent statement

Before data collection, written consent was obtained from caregivers and from children aged seven or older.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Morales, M.F., Susperreguy, M.I. & Simms, V. The long-term effect of very preterm birth on school readiness: exploring preschool mediating pathways. Pediatr Res (2025). https://doi.org/10.1038/s41390-025-04352-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Version of record:

  • DOI: https://doi.org/10.1038/s41390-025-04352-y

This article is cited by

Search

Advanced search

Quick links