Pre-term children: how do they get an equal chance to thrive?

In Episode 4 of Series 4 we’re talking to Professor Sakari Lemola from the University of Bielefeld and formerly from the University of Warwick. Sakari is one of the Principal Investigators of the DIAL project PremLife, which has been looking at what factors can provide protection and increase resilience for preterm children’s life course outcomes. 


Christine Garrington  0:00 

Welcome to DIAL a podcast where we tune in to evidence on inequality over the life course. In series four, we’re looking at what’s been learned from DIAL projects about how and when inequality manifests in our lives, and what its longer-term consequences might be. For this episode, we’re delighted to be joined by Professor Sakari Lemola. He’s from the University of Bielefeld and formally from the University of Warwick, and one of the Principal Investigators of the DIAL project, PremLife, which has been looking at what factors can provide protection and increase resilience for preterm children’s life course outcomes. So Sakari, thank-you so much for joining us today. It’s great to have you on the DIAL podcast. I wonder if you can start by telling us a bit more specifically what this project has been investigating and why?

Sakari Lemola  0:45 

So the PremLife project has been particularly focused on the role of protective factors for social and educational transitions after preterm birth. Preterm birth is defined as birth before the 37th gestational week. Then there are two further categories one distinguishes between moderately to late preterm children at its birth between the 32nd and 36th gestational week – moderately and late preterm children. But they’re also very preterm children who are born before the 32nd gestational week. So in the PremLife project, we specifically look at both of these groups – the very preterm children and moderately and late preterm children compared to term born children and try to figure out what are their disadvantages they have in their lives? And also, what are protective factors that may improve their outcomes? In some domains they actually do really well when certain protective factors are present.

Christine Garrington  1:50 

Can you tell us something about how common preterm births are?

Sakari Lemola  1:54 

The incidence of preterm birth has been rising in the last few decades. So in the UK, around 7% of all babies are born preterm each year. This means that two children in an average sized primary school class are likely to have been born preterm and in spite of the advances in neonatal care of preterm birth in the last few decades, and also decreasing mortality rates, which is a very good thing. Negative long term, sequels and consequences of preterm birth have still remained, particularly for very preterm children, those born before the 32nd gestational week that means eight weeks too early or even earlier than that. That leads to medical complications, which often require distressing but life saving treatments frequent are, for instance, neonatal asphyxia, hypoxia due to immature lungs. Necessary treatment involves ventilation, continuous positive airway pressure, surfactant treatment, but also treatment with stress hormones, prenatal corticosteroids treatments to accelerate the long development.

Christine Garrington  3:10 

And so Sakari what does life look like for those children compared with their full-term born peers?

Sakari Lemola  3:16 

They often have an increased risk for poor cognitive development, they show poor educational outcomes, less favourable employment outcomes in adulthood and increased risk for developing mental health problems. And in the PremLife project, we try to specifically answer the question, first of all, of course, what are protective factors for those born preterm. But also we try to focus also to figure out out about what are the social and emotional development of the preterm birth, particularly related to social relationships, wellbeing and things like self-esteem and self-confidence.

Christine Garrington  3:58 

Now, there’s considerable policy interest across Europe and indeed elsewhere and ensuring that obviously, that children get the best possible start and in helping those children who for whatever rate, whatever reason may not get off to the best start. How has your work tied into that sort of policy context would you say?

Sakari Lemola  4:17 

In the PremLife project, we particularly aim to answer what can be done by policymakers, by practitioners, stakeholders to improve preterm children’s and adolescent development? So two focal points were, one was on preschool training in math and literacy. The second point was about how schooling should be organised in general. So we compared school systems in Germany, where so called school tracking takes place. That means children are sorted into higher or lower tracks after the first few school years and we compared Germany with the UK and Finland where no school tracking takes place. That means better and the lower performing children remain in their school classes in the UK and in Finland. But children with special needs they receive remedial teaching but they are not sorted into a different school or different school classes. A third focal point was related to physical activity in childhood and adolescence and what role physical activity actually plays for mental health and social emotional development.

Christine Garrington  5:32 

A key piece of work from the project involved the assessment of adults who had been born preterm. What was sort of the main thinking, the main driver for for this work?

Sakari Lemola  5:42 

Previous work has shown that preterm children have an increased risk for poor cognitive development and they also show poor educational outcomes. And particularly, most work has focused on childhood, but less work on later outcomes like adolescence and also in adulthood. In the PremLife project we have now also focused on adolescence and adulthood. And also particularly, we focused on differences in socio-emotional outcomes in adulthood, particularly regarding social relationships, a topic that has previously been neglected So, children who were born preterm in adolescence and in adulthood, they seem to be less satisfied with their social relationships, they are less likely to be partnered in adulthood, and they are also have decreased fertility so they are less likely to have children on their own later in life.

Christine Garrington  6:44 

Okay, and what were the key things then to emerge about how those people who were born preterm faired later on in life?

Sakari Lemola  6:52 

So we found out that children born preterm to still show differences compared to their term born peers, when they are grown up particularly. Yeah, they show more mental health problems, particularly anxiety disorders, they show lower wellbeing then full term born children in friendship relationships, they are less likely to experience intimate relationships in adulthood, they are less likely to become parents on their own. Somehow, it is likely that anxiety and shyness play a role which is increased in preterm children, they are more anxious about making a step for instance, in social relationships, and that may lead to lower rates of being partnered and becoming parents themselves.

Christine Garrington  7:47 

Okay, now, you made some key recommendations from this. Can you talk about those recommendations and just how practitioners, policymakers and those people born preterm might benefit from from those recommendations?

Sakari Lemola  8:00 

With regard to schooling and education outcomes a key recommendation is the importance of early training and early support in math and literacy. So what we found is that preterm children, they appear to disproportionately benefit from preschool training in math and literacy. So, preterm children who perform well in math, reading and writing when entering into school, so very early on age of five, six years, they were more likely to receive GCSE grades that qualify later to go to university than their term bond peers actually. However, it was exactly the other way around for preterm children who perform poorly in math, reading and writing at school entry, they were less likely to get sufficient GCSE grades compared to their term born peers with similar preschool skills. So their skills at school entry, the skills and math, reading and writing appear to be more important for preterm children than for term born children. And that highlights how important early support and rhythm medial teaching plays there. A second point is that school tracking as it happens currently, is it’s the current policy in in Germany, is a negative thing for preterm children probably also for for other children with early difficulties. Where people from a migration background who are not as fluent in German, for instance, as German children so children with more difficulties in school should rather receive remedial teaching but they should not be sorted out into lower performing school tracks as it is currently the case in Germany. We compared it with the outcome of preterm children who go to school in Finland and in the UK, and they seem not to have that. There is no such a negative effect of the school tracking because there is a different policy in the UK and in Finland.

Christine Garrington  10:11 

And what about the social and emotional side of their lives? What did you find there Sakari?

Sakari Lemola  10:15 

Here we had focused on two factors that appear to be relevant for preterm children. So this involves sensitive parenting on one hand and physical activity and playing sports in childhood and adolescence and preterm born children benefit from both from sensitive parenting and physical activities, such as playing sports. So both factors seem to increase self confidence and have to be considered as protective factors against the negative outcomes of preterm birth, particularly negative outcomes regarding social and emotional development.

Christine Garrington  10:53 

So much interesting research to emerge from this project Sakari. I wonder what the key things have been for you, things that have really caught your eye or have been of particular interest to you, things that maybe surprised you?

Sakari Lemola  11:05 

I think the key findings and surprising findings are that this early training in math and literacy, writing and reading are disproportionately important for preterm children compared to term born children. And this may generalise also to other children who may have a more difficult start in school for them. Most probably it is important to have early support. A second important finding was related to the school tracking that means the grouping of the children to higher and lower performance levels in school. So this has a particularly negative effect on preterm children, as we found out in Germany with an effect that, of course, isn’t present in the UK where there’s no such good tracking.

Christine Garrington  11:53 

Okay, that’s really helpful. Now, you’ve been really active in sharing your findings, not not just with academics, but health practitioners and policymakers. I know what has been the response from them, I’m interested to know.

Sakari Lemola  12:03 

So overall, we had very positive feedback from practitioners and policymakers and we are also confident that the messages will be heard, but of course, time will tell what will be applied and what not.

Christine Garrington  12:20 

Thanks to Sakari Lemola for discussing the findings and implications of DIAL’s PremLife project. You can find out more about this and other DIAL research on the website at We hope you enjoyed this episode, which is produced and presented by Chris Garrington of Research Podcasts. And don’t forget to subscribe wherever you find your podcasts to access earlier and forthcoming episodes.