Exploring kindergarten readiness in children born preterm

Exploring kindergarten readiness in children born preterm | Image Credit: © dusanpetkovic1 - © dusanpetkovic1 - stock.adobe.com.

Many preterm infants are considered to be “caught up” to their peers during the toddler years, but evidence is mounting that even late preterm infants may experience ongoing academic and developmental delays.

It’s been argued that delays linked to premature birth can impact kindergarten readiness, with some experts suggesting delayed kindergarten entry may be the best path forward to avoid deficits that can linger throughout the school years.

Ruth Milanaik, DO, a developmental-behavioral pediatric specialist based in New York who co-authored a recent study on the consideration of prematurity when gauging kindergarten readiness. The report, published in the February 2024 edition of Pediatrics, examines the role gestational age might play in determining a child’s appropriateness for kindergarten entry.¹

For most children entering kindergarten, age 5 is the cut-off date for enrollment. This means that cut-off dates will be set to ensure that any child who plans to enter kindergarten that year must be 5 years old on or before the designated cut-off date.

“For typically developing children, 5 years old is certainly an appropriate age to enter kindergarten,” said Milanaik. “However, several factors, such as an early birth or developmental delays can make entering at 5 years old inadvisable for some children.”

Pediatricians are a good source of guidance when it comes to determining kindergarten readiness for any child—but for children with various developmental, physical, or cognitive challenges from a preterm birth, it’s especially important.

Milanaik added that development differences aren’t a concern for all preterm children, and the degree of any disability—if any—can depend on how premature the child was at birth and what effects they face from prematurity.

“Some children experience no lasting physiological or psychological consequences resulting from their preterm birth, while others can suffer significant challenges,” said Milanaik. “Our paper also argues that even if there are no developmental deficits resulting from prematurity, it is not necessarily fair to compare a full-term and preterm child solely in terms of chronological age (age from birth). Instead, we argue that corrected age should be considered.”

Milanaik’s report gives the example that a child is usually considered 0 years and 0 months old at birth. Meanwhile, infants born prematurely—say 4 months early—would be considered 0 years and -4 months old. This is where the term “corrected age” comes from, and it subtracts the period of missed gestation from the child’s age.

Typically, these corrected ages are used until around age 2, when most preterm infants are expected to have caught up to their full-term counterparts, noted Milanaik. Beyond age 2 years, chronological age is the favored tool for measuring milestones, but some researchers suggest this transition may happen too soon.

Deviations from predicted milestones in either corrected or gestational age can be considered a delay in development, but age 5 may be too soon—especially for children who were born preterm and are already considered developmentally younger than their peers.

For these reasons, several studies in the last few years have investigated delaying kindergarten entry by a year to help even the playing field for children who were born early or are otherwise behind their peers in age or development. It’s important, however, that actual or adjusted age aren’t the only factors considered when it comes to kindergarten readiness, added Milanaik.

“On top of the typical academic and intellectual assessments, parents and pediatricians must also consider the social, emotional, and physical capacities of the child in question,” she said. “Kindergarten is not just a time to learn basic academic concepts, but also learn how to interact with peers and adults.”

Additionally, Milanaik noted, children must be able to perform certain physical skills to be considered ready for kindergarten. This can include things like holding a pencil or tying shoes. Not being able to do these tasks can make kindergarten more challenging.

She added, “A child who is particularly young for kindergarten will often be particularly underdeveloped from a muscular perspective, which can create issues in terms of engaging in healthy play and other activities requiring a certain degree of coordination.”

Determining if a child is kindergarten ready requires consideration of several issues, and for some children delaying kindergarten entry by a year can be beneficial. This should be considered on a child-by-child basis, though.

“For typically developing children. Delaying kindergarten entry until age 6 does not necessarily confer any benefits,” said Milanaik. “However, for some children poised to enter kindergarten, particularly those who are less developed, delay can allow a crucial period of further development in an environment like pre-school.”

The additional year before kindergarten entry can give some children extra time to catch up intellectually and physically.

“Being on the same footing from a physical perspective can allow future opportunities in sports and other athletic activities, which can be crucial for child’s happiness,” said Milanaik.

It’s important to view this one-year delay as a year of development that’s gained rather than a year that is lost, she adds. Even for children born at full-term, Milanaik’s study revealed that there were lower rates of disability in children in New York who are born just after kindergarten cut-off date of December 31 compared to children born before the cut-off in October or November. Likewise, schools that use a September 1 cut-off date have found similar patterns with attention-deficit/hyperactivity disorder when comparing children born just before and after kindergarten cut-off dates.

As far as long-term impacts of kindergarten readiness decisions, Milanaik says consequences of entering kindergarten early can carry over unnoticed from year to year but may not be fully evident until around puberty. This is especially true for children who were born preterm and have lasting physiological or psychological consequences from their early birth.

A 2021 study published in the International Journal of Environmental Research and Public Health also assessments of kindergarten readiness by age alone into questions. Even late preterm infants, born between 34 and 37 weeks’ gestation, can encounter subtle delays that are not often obvious until age 2—the age at which “corrected age” is often discarded in assessments.² This calls into question the way kindergarteners are screened both academically and developmentally, according to the report.

Late preterm infants make up about 70% of the preterm population, the report reveals, making gestational age at birth a significant demographic factor when it comes to neurocognitive abilities, academic performance, and even cognitive functioning.² Other studies found similar patterns, with deficits among children born preterm most prominent in areas like mathematics, executive function skills, attention span, and reading performance.^3,4

Milanaik’s paper suggests that these observations are reason enough for pediatricians, parents, and educators to reconsider gestational age and timing of birth as a contributing factor to early childhood kindergarten assessments.

The long-term impacts vary and depend on the degree of early entry. However, given the cumulative nature of education, deficits experienced in kindergarten can often carry into first grade, second grade, etc. In other instances, the consequences of entering kindergarten early may not become evident until later, such as when children start entering puberty. Gestational age can certainly play a role in these long-term impacts, especially if a preterm infant experiences lasting physiological or psychological consequences from their early birth.

References:

1. Barile JG, Han K, Milanaik R. The prematurity paradox: Reevaluating the kindergarten readiness of former preterm infants. Pediatrics. February 2024;153(2):2023063801. doi:10.1542/peds.2023-063801
2. Martinez-Nadal S, Bosch L. Cognitive and learning outcomes in late preterm infants at school age: A systematic review. International Journal of Environmental Research and Public Health. 2021;18(74). doi:10.3390/ijerph18010074
3. Jin JH, Yoon SW, Song J, et al. Long-term cognitive, executive, and behavioral outcomes of moderate and later preterm at school age. CEP. 2020;63(6):219-225. doi:10.3345/kjp.2019.00647
4. McBryde M, Fitzallen GC, Liley HG, et al. Academic outcomes of school-aged children born preterm: A systematic review and meta-analysis. JAMA Network Open. April 2020;3(4):e202027. doi:10.1001/jamanetworkopen.2020.2027