Gestational age at delivery and special educational need: retrospective cohort study of 407,503 schoolchildren.
Gestational age at delivery and special educational need: retrospective cohort study of 407,503 schoolchildren.
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DOI：
10.1371/journal.pmed.1000289
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发表时间：
2010-06-08
期刊：
影响因子：
15.8
通讯作者：
Pell JP
中科院分区：
文献类型：
--
作者：
MacKay DF;Smith GC;Dobbie R;Pell JP
Jill Pell 及其同事对 407,503 名学童进行的一项回顾性队列研究发现，分娩时的胎龄与特殊教育需求的风险存在剂量依赖性关系，这种关系延伸到整个妊娠范围。先前的研究已证明早产与特殊教育需求 (SEN) 风险增加之间存在关联。我们研究的目的是检查整个妊娠期间 SEN 的风险。我们进行了一项以人口为基础的回顾性研究，将居住在 19 个苏格兰地方当局地区的 407,503 名符合条件的学龄儿童的学校人口普查数据（总人口 380 万）与其常规出生数据联系起来。 17,784 名（4.9%）儿童有特殊教育需要； 1,565 名（8.4%）早产者和 16,219 名（4.7%）足月出生者。 SEN 风险在 40 至 24 周的整个妊娠范围内增加：37-39 周调整优势比 (OR) 1.16，95% 置信区间 (CI) 1.12-1.20； 33-36 周调整后 OR 1.53，95% CI 1.43-1.63； 28-32 周调整后 OR 2.66，95% CI 2.38-2.97； 24-27 周调整后 OR 6.92，95% CI 5.58-8.58。选择性分娩与自发分娩之间没有相互作用。总体而言，分娩时妊娠占调整后的 SEN 人群归因比例的 10%。由于发生频率高，早产（37-39 周）占 SEN 病例的 5.5%，而早产（<37 周）仅占 3.6% 的病例。分娩时的妊娠与 SEN 具有很强的剂量依赖性关系，这种关系在整个妊娠范围内都很明显。由于足月早产比早产更为常见，因此前者在 SEN 病例中所占比例较高。我们的研究结果对与择期分娩时间相关的临床实践具有重要意义。 请参阅本文后面的编辑摘要 大多数怀孕持续 40 周左右，但早产婴儿的数量正在增加。例如，在美国，每年有超过 50 万婴儿在妊娠 37 周（妊娠是婴儿在母亲体内发育的时期）之前出生。遗憾的是，这么早出生的婴儿（早产儿）比妊娠 37 至 42 周之间出生的婴儿（足月婴儿）更有可能死亡，而且许多婴儿存在短期和/或长期健康问题。与足月婴儿相比，他们在儿童时期更有可能有“特殊教育需要”（SEN）、学习困难（例如阅读障碍或自闭症）或身体困难（例如耳聋或视力不佳），需要特殊教育帮助。与早产相关的所有问题的严重程度取决于早产的程度。因此，随着胎龄增加至 36 周，与早产相关的 SEN 风险稳步下降。也就是说，妊娠 24 周出生的婴儿比妊娠 36 周出生的婴儿更有可能在以后的生活中出现 SEN。早产（妊娠 37 至 39 周之间）也变得越来越普遍，因为越来越多的母亲出于非医疗原因选择提前分娩（所谓的计划生育）。不幸的是，与 40 周出生的婴儿相比，尚不清楚早产儿患 SEN 的风险是否增加，因为很少有研究关注妊娠 37 至 39 周之间出生的儿童的 SEN 风险。在这项回顾性队列研究中，研究人员调查了整个分娩胎龄范围内的 SEN 风险，并利用其结果计算与不同胎龄分娩相关的 SEN 比例，即“人群归因风险”。在一项回顾性队列研究中，研究人员检查了具有不同特定特征（在本例中为具有特殊教育需要）的人群的医疗记录，以获得特定结果（在本例中为出生胎龄）。研究人员将 19 个苏格兰地方政府地区（覆盖苏格兰人口的四分之三）的 2005 年学校人口普查数据（其中包括所有具有特殊教育需要的儿童的记录）与苏格兰发病率记录中保存的常规出生数据联系起来。近 18,000 名儿童（占儿童的 4.9%）被记录为特殊教育需要。 8.4% 的早产儿和 4.7% 的足月儿被记录为有 SEN。 SEN 的风险在 40 至 24 周的妊娠范围内增加。因此，与 40 周出生的孩子相比，妊娠 37-39 周出生的孩子患有 SEN 的可能性是 1.16 倍，优势比为 1.16。 33-36周、28-32周和24-27周出生的儿童出现SEN的可能性分别是40周出生的儿童的1.53、2.66和6.92倍。尽管早产儿患 SEN 的风险远高于早产儿，但由于 37 至 39 周之间出生的婴儿（约占婴儿的三分之一）比 37 周之前出生的婴儿（每 20 名婴儿中就有一个）要多得多，因此早产儿占 SEN 病例的 5.5%，而早产仅占病例的 3.6%。这些发现表明，分娩时的胎龄在整个胎龄范围内以剂量依赖性方式强烈影响儿童随后发生 SEN 的风险。此外，由于足月早产比早产更为常见，这些研究结果表明，早产导致的 SEN 病例多于早产。由于研究规模及其设计，这些发现可能是准确的，对择期分娩的时间安排具有重要意义。他们建议最好等到怀孕 40 周才分娩，因为即使是 39 周出生的婴儿（目前选择性分娩的正常时间）与一周后出生的婴儿相比，患 SEN 的风险也会增加。请通过此摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.1000289。 March of Dimes 是一个致力于怀孕和婴儿健康的非营利组织，提供有关早产的信息以及一篇关于为何怀孕最后几周的文章（英语和西班牙语） 美国国家儿童健康和人类发展研究所提供有关早产和分娩以及学习障碍的信息 英国政府为家长提供有关特殊教育需求的信息 Medline Plus 提供有关早产和学习障碍的更多信息的链接（英语和西班牙语）
A retrospective cohort study of 407,503 schoolchildren by Jill Pell and colleagues finds that gestational age at delivery has a dose-dependent relationship with the risk of special educational needs that extends across the full gestational range. Previous studies have demonstrated an association between preterm delivery and increased risk of special educational need (SEN). The aim of our study was to examine the risk of SEN across the full range of gestation. We conducted a population-based, retrospective study by linking school census data on the 407,503 eligible school-aged children resident in 19 Scottish Local Authority areas (total population 3.8 million) to their routine birth data. SEN was recorded in 17,784 (4.9%) children; 1,565 (8.4%) of those born preterm and 16,219 (4.7%) of those born at term. The risk of SEN increased across the whole range of gestation from 40 to 24 wk: 37–39 wk adjusted odds ratio (OR) 1.16, 95% confidence interval (CI) 1.12–1.20; 33–36 wk adjusted OR 1.53, 95% CI 1.43–1.63; 28–32 wk adjusted OR 2.66, 95% CI 2.38–2.97; 24–27 wk adjusted OR 6.92, 95% CI 5.58–8.58. There was no interaction between elective versus spontaneous delivery. Overall, gestation at delivery accounted for 10% of the adjusted population attributable fraction of SEN. Because of their high frequency, early term deliveries (37–39 wk) accounted for 5.5% of cases of SEN compared with preterm deliveries (<37 wk), which accounted for only 3.6% of cases. Gestation at delivery had a strong, dose-dependent relationship with SEN that was apparent across the whole range of gestation. Because early term delivery is more common than preterm delivery, the former accounts for a higher percentage of SEN cases. Our findings have important implications for clinical practice in relation to the timing of elective delivery. Please see later in the article for the Editors' Summary Most pregnancies last around 40 weeks, but the number of babies who are born early is increasing. In the US, for example, more than half a million babies a year are now born before 37 weeks of gestation (gestation is the period during which a baby develops in its mother). Sadly, babies born this early (premature babies) are more likely to die than babies delivered between 37 and 42 weeks of gestation (term babies) and many have short- and/or long-term health problems. They are also more likely to have a “special educational need” (SEN) as children, a learning difficulty (for example, dyslexia or autism), or a physical difficulty such as deafness or poor vision that requires special educational help, than term babies. The severity of all the problems associated with being born early depends on the degree of prematurity. Thus, the risk of SEN associated with prematurity declines steadily with advancing gestational age up to 36 weeks. That is, a baby born at 24 weeks of gestation is more likely to have an SEN later in life than one born at 36 weeks of gestation. Early term births (between 37 and 39 weeks of gestation) are also becoming more common, because more mothers are electing to be delivered early for nonmedical reasons (so-called birth scheduling). Unfortunately, it is not known whether early term babies have an increased risk of SEN compared with babies born at 40 weeks, because few studies have looked at SEN in children born between 37 and 39 weeks of gestation. In this retrospective cohort study, the researchers investigate the risk of SEN across the whole spectrum of gestational age at delivery and use their results to calculate the fraction of SEN associated with delivery at different gestational ages—the “population attributable risk.” In a retrospective cohort study, researchers examine the medical records of groups of people who differ in a specific characteristic (in this case, having an SEN) for a particular outcome (in this case, gestational age at birth). The researchers linked 2005 School Census data (which includes a record of all children with an SEN) for more than 400,000 school-aged children in 19 Scottish Local Authority areas (covering three-quarters of the Scottish population) with routine birth data held in the Scottish Morbidity Record. SEN was recorded for nearly 18,000 children (4.9% of the children). 8.4% of the children who were born preterm and 4.7% of those born at term were recorded as having an SEN. The risk of SEN increased across the gestation range from 40 to 24 weeks. Thus, compared to children born at 40 weeks, children born at 37–39 weeks of gestation were 1.16 times as likely to have an SEN—an odds ratio of 1.16. Children born at 33–36, 28–32, and 24–27 weeks were 1.53, 2.66, and 6.92 times as likely to have an SEN, respectively, as children born at 40 weeks. Although the risk of SEN was much higher in preterm than in early term babies, because many more children were born between 37 and 39 weeks (about a third of babies) than before 37 weeks (one in 20 babies), early term births accounted for 5.5% of cases of SEN, whereas preterm deliveries accounted for only 3.6% of cases. These findings show that gestational age at delivery strongly affects a child's subsequent risk of having an SEN in a dose-dependent manner across the whole range of gestational age. Furthermore, because early term delivery is much more common than preterm delivery, these findings show that early term delivery is responsible for more cases of SEN than preterm delivery. These findings, which are likely to be accurate because of the large size of the study and its design, have important implications for the timing of elective delivery. They suggest that deliveries should ideally wait until 40 weeks of gestation because even a baby born at 39 weeks—the normal timing for elective deliveries these days—has an increased risk of SEN compared with a baby born a week later. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000289. The March of Dimes, a nonprofit organization for pregnancy and baby health, provides information on preterm birth and an article on why the last weeks of pregnancy count (in English and Spanish) The US National Institute of Child Health and Human Development has information on preterm labor and birth and on learning disabilities The UK Government provides information for parents on special educational needs Medline Plus has links to further information on both premature birth and learning disabilities (in English and Spanish)
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