Health and Socioeconomic Factors in School Readiness and Achievement Among Children Born Very Preterm

Preterm birth is a leading cause of atypical brain development and cognitive impairment; however, there are sparse data on its association with statutory educational assessments.

To evaluate school readiness at age 5 years and educational attainment at age 6 to 7 years in children born very preterm and to identify the early-life, neonatal, and socioeconomic factors associated with attainment.

This retrospective cohort study included all infants born before gestational age (GA) 32 weeks in England who received care in a neonatal unit and survived to discharge. A linkage between the National Neonatal Research Database and the National Pupil Database was created to integrate neonatal clinical data with educational outcomes. The data analysis was performed between October 1, 2024, and October 31, 2025.

Gestational age and area-level socioeconomic deprivation.

The main outcome was school readiness at age 5 years (as measured by the Early Years Foundation Stage Profile [EYFSP]) and attainment in reading, writing, mathematics, and science at age 6 to 7 years. For each outcome, prevalence of not meeting the expected level of attainment across indices of socioeconomic deprivation and GA stratified by 23 to 26 weeks and 27 to 31 weeks were calculated.

Of a total of 15 857 children included (2595 born at GA 23-26 weeks [16.3%] and 13 262 born at GA 27-31 weeks [83.7%]; 8449 boys [53.3%]), 8602 (56.6%) did not meet the school readiness level at age 5 years, and 7789 (51.8%) did not meet expected attainment at age 6 to 7 years for writing, 7216 (48.1%) for math, 6354 (41.9%) for reading, and 5449 (36.0%) for science. Children born at GA 23 to 24 weeks had a higher odds of not meeting expected school readiness levels compared with those born at 31 weeks (adjusted odds ratio [AOR], 2.86 [95% CI, 2.19-3.73]). Children born in areas with the most deprivation had a higher risk of underattainment compared with those in areas with the least deprivation (EYFSP: AOR, 1.27 [95% CI, 1.11-1.45]). In adjusted models, male sex and season of birth were associated with increased risk (EYFSP: AOR, 1.96 [95% CI, 1.82-2.11] and 2.64 [95% CI, 2.41-2.90], respectively) alongside several potentially modifiable risk factors, including smoking during pregnancy (AOR range from 1.19 [95% CI, 1.08-1.31] for math to 1.31 [95% CI, 1.19-1.44] for reading); exposure to postnatal corticosteroids (EYFSP: AOR, 1.37 [95% CI, 1.13-1.65]); severe acquired neonatal brain injuries, particularly periventricular leukomalacia (EYFSP: AOR, 3.05 [95% CI, 2.04-4.58]) and hydrocephalus (EYFSP: AOR, 2.47 [95% CI, 1.48-4.13]); comorbidities of preterm birth, including necrotizing enterocolitis (EYFSP: AOR, 1.60 [95% CI, 1.20-2.14], retinopathy of prematurity (EYFSP: AOR, 1.46 [95% CI, 1.10-1.93], and bronchopulmonary dysplasia (EYFSP: AOR, 1.30 [95% CI, 1.18-1.44]); and nutrition during neonatal care (EYFSP: AOR, 1.19 [95% CI, 1.07-1.33] and 1.51 [95% CI, 1.37-1.66] for mixed feeding and exclusive formula feeding, respectively, vs breastfeeding).

This cohort study of children born before GA 32 weeks found that preterm birth was associated with a substantial and persistent risk for educational underattainment across early school years, especially when combined with socioeconomic deprivation. Improving outcomes for children born preterm may require reducing social inequalities and minimizing comorbidities of preterm birth. Several modifiable early-life exposures offer practical targets for intervention, including maternal nonsmoking, appropriate corticosteroid use, and breastfeeding. Deferred school entry or targeted academic support may benefit children born very preterm, depending on birth season. These strategies may help parents, clinicians, educators, and policymakers improve long-term educational attainment for children born preterm.