Birthweight

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

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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. 

Transcript

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 dynamicsofinequality.org. 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.

  

Nature, nurture and our later life outcomes: new insights on inequality over the lifecourse

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In Episode 2 of Series 4 of the DIAL Podcast, we are in discussion with Professor Hans van Kippersluis from the Erasmus University in Rotterdam. Hans, Professor of Applied Economics, is the Principal Investigator on the DIAL project, Gene Environment Interplay in the Generation of Health and Education Inequalities, which has used innovative methods and data to explore the interplay between nature and nurture in generating health and education inequalities.

 

Transcript

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 some of the DIAL projects about how and when inequality manifests in our lives, and what its longer term consequences might be. For this second episode of the series, we’re delighted to be joined by Hans van Kippersluis, Professor of Applied Economics at the Erasmus University in Rotterdam. And Principal Investigator of the DIAL project, Gene Environment Interplay in the Generation of Health and Education Inequalities – put more simply nature versus nurture. So Hans, welcome to the podcast. And I wonder if you can start by talking us through what researchers working on this project have actually been looking into.

Hans van Kippersluis  0:42  
What we’ve been doing in this project is essentially incorporating the recent availability of genetic data into social science and most prominently economic analysis. And so most of our work has focused on the interplay between genes and the environment. So in the introduction, you mentioned nature versus nurture, but actually more accurately, what we’re doing is nature and nurture jointly into how they shape essentially education and health outcomes. And I think this is also the main innovation of our project, because biologists have studied nature before; social scientists have  of course, extensively studied nurture, but not many have studied the interplay, the interaction between the two. And I think this was sort of the main innovation for why we got the funding some five years ago. And so what we have done is mostly studying this interplay. But along the way, we have also made some methodological contributions to a field which is very new. Then we’ve also used genetic data to test all their theories, and also, I think, enrich the framework of equality of opportunity.

Christine Garrington  1:35  
Yeah, fantastic project. And as you’ve just said, you’ve made unprecedented use of genomic as well as survey data in the research, tell us a bit more about the information that you’ve been able to access? And how you’ve been able to use it?

Hans van Kippersluis 1:47  
Yeah, sure. So the interesting thing is that more and more social science datasets, so data sets that have been traditionally used by social scientists, and these are mostly extensive surveys,  are now collecting DNA information from their respondents. And this is often from blood or saliva. And what they did is basically, so more than 99% of DNA is the same across human beings. And so what we are using is only this remaining less than 1% of the variation. And these are called snips. And snips are points of your DNA that differ across human beings. And there’s roughly 1 million of them. And so what we do, basically also other people have done is sort of aggregating these tiny effect sizes into an index. And this is called the polygenic index. And this is telling us something about your genetic predisposition towards a certain outcome. And this is quite interesting, because this data, this new variable, essentially can be added to existing datasets. And so we have a wealth of information that has been collected in the past on surveys on existing data. And then we simply add one indicator, one new variable. This is telling us something about people’s genetic predisposition. And just to be clear, this is not like a deterministic variable. It also exhibits quite a bit of measurement error and noise. But at the group level, and that’s what we have been doing is it sort of does tell us something about your genetic predisposition, and it can help us understand how certain life outcomes like education, like health, are shaped by the interplay between your genetic predisposition and your environment.

Christine Garrington  3:07  
Indeed, let’s talk a little bit now then about some of the research findings. And you know, what’s come out of this now, one piece of research we’ve spoken about this actually, in an earlier podcast episode, actually drew links between mothers smoking in pregnancy and their baby’s birth weight. I wonder if you can just sort of summarise that for you what actually came out of that what we learned

Hans van Kippersluis 3:28  
this was work with with my PG students, Rita Dias Pereira and colleague Cornelius Rietveld . And for birthweight we knew that maternal smoking is one of the key environmental risk factors. And we also knew from genetic studies that genes matter in determining your birth weight. And so what we did here was essentially looking at the interaction between the two. So can higher polygenic indices protect against maternal smoking? And the answer, unfortunately, perhaps was no, in the sense that we found very, very little interaction between genes and the environmental exposure of maternal smoking. So it seems that both matter, but there doesn’t seem to be any meaningful interaction between the two. So that was, to some extent surprising, but on the other hand, also perhaps logical in the sense that maternal smoking is apparently such a devastating environmental exposure that even higher genetic predisposition cannot protect you from this.

Christine Garrington  4:16  
Yeah, really interesting. And anybody who’s interested in that can listen to Rita actually discussing that in series three, Episode Seven, of our DIAL podcast called Mums Who Smoke and their Baby’s Birthweight. So do check that out if you’re interested to know a little bit more about what Rita and all of the all of your colleagues did. Now, there have been some interesting findings Hans from the project around the role of genes in a child’s education and specifically around parental investments. I wonder if you can explain a bit more about what you were looking to understand there. 

Hans van Kippersluis 4:50  
Yes, yeah, so this is one of my favourites studies. It’s joint work. Also with another PG student   Muslimova and my colleagues Stephanie von Hinke, Cornelius Rietveld and Fleur Maddens. And the starting point there was actually a theory of human capital formation from economics. And it dates back all the way to the work of Nobel laureate Gary Becker. And one of the crucial assumptions in that model is that parental investments are complementary to your genetic endowments. And this assumption is actually very hard to test because often we do not have a good measure of endowments. And if we do, it may already be contaminated by parental investment. So many people, for example, use birth weights. But of course, well as we just learned, maternal smoking may have a large effect on your birth weight, so it’s not fully free of your parents’ behaviour. And the other thing is that your parental investments often respond to endowments. So if you have a child with specific needs, of course, parents respond to this. So the problem of testing this assumption is that endowments and investments are actually always very closely entangled. And that makes it very hard to test whether they are complementary or not. So what we did here was using one’s genetic endowment, and that is actually has a very nice property and that it’s fixed at conception, so it cannot be affected by your parental investments. And what we did was using the child’s birth order to proxy for parental investments. So what we know from earlier studies is that firstborns tend to get more parental attentions on average than later points. So this is one after all, because they have undivided attention until the arrival of later borns. And this extra parental investment is actually independent of your endowments. It simply derives from the fact that you have more time if you have one child as opposed to multiple children. So what we did in this study is looking within families comparing siblings that were first born to later borns, and then further analysing whether this firstborn advantage was stronger for firstborn siblings who randomly inherited the higher polygenic index for educatio. I think this was a nice, very unique setting to test this theoretical assumption that parental investments are complements to genetic endowment.

Christine Garrington  6:45  
What did you find here? Then what do we learn about the role of genetics in affording in affording certain children advantages later on in life?

Hans van Kippersluis 6:53  
So what we found was that indeed, the firstborn effect seems to be stronger for siblings who randomly inherited higher polygenic indices. And I think this is evidence in favour of this theoretical assumption of complementarity between endowments and investments. And it also means that your genetic predisposition cannot just give you a direct advantage. But it also means that this advantage may be kind of amplified by your parental or your teacher investments. And this complementarity, I think also suggests once again, that for disadvantaged children, so the other side of the coin, we need to start very, very early and follow up these early investments also with data investments to make them as productive as possible.

Christine Garrington  7:29  
So Hans, some fascinating research and findings. I wonder if there’s been a standout or surprising finding for you from the project. 

Hans van Kippersluis 7:36  
I  think methodologically, what we’ve learned is that there’s still a world to explore in terms of using genetic data in social science, because what we have seen is that polygenic indices can be a great tool to improve our understanding of the things we just talked about. But I think the way we use these polygenic indices, are shall I put this sort of a bit naive, in some sense, because what we do is we first construct a score or an index by regressing an outcome on all of these 1 million individual genetic variants. And as you can imagine, if you do these 1 million regressions, then it will be a lot of noise in  these coefficients, and these estimates also come with some uncertainty. And what is surprising to me, what I’ve learned is that many researchers simply sort of seek to use this polygenic index as if it’s some kind of a transferable and deterministic index. And there’s hardly any account in the literature on the uncertainty in this index. And I think what we have done in one paper is actually showing how this uncertainty is sort of leading to different conclusions, because what we did is basically looking at the polygenic index for cardiovascular disease. And in cardiovascular disease, more and more people are using these polygenic indices, this genetic data for personalised decisions regarding, for example, the use of statins. And what we did was sort of constructing six different polygenic indices using different discovery sample using different methods of constructing this polygenic index. And what was fascinating and actually maybe astonishing to see is that only 6% of the individuals are in the top quintile of the polygenic indices, if you look across these six different ways of constructing the same polygenic index. And I think this is fascinating, because it shows that even though polygenic indices are now increasingly being used, apparently it matters a great deal about how you construct these things. And this is one thing we have shown, I think this is quite remarkable, and also an important methodological contribution.

Christine Garrington  9:19  
A really important contribution to how this research might develop in the future. Right, absolutely. And then just finally, Hans, I wonder what this all of this work tells us about the interplay between genes in our environment, or, as we’ve talked about nature and nurture, not nature versus nurture, in better understanding and in tackling inequality.

Hans van Kippersluis 9:41  
So it’s very hard, I think, to give sort of direct policy leads or implications, but there’s a few leads. One thing is that I think we need to start early. We knew already that inequalities arise early in life. And I think this focus on genetics gives us yet another clue that it’s very important to start early. And also because of the work I mentioned about complementarities, it’s very clear that later investments are more effective if the person has had already more investments early in their life. So that’s clearly one more general policy implication, I think. And I think our work is also showing how sort of genes and environment shaping jointly inequalities. And I think this has important implications for the discussions about equality of opportunity. I mean, if you look at politicians across the entire political spectrum, everybody seems to be agreeing that equality of opportunity is a great thing, and that your health and your income should not depend on your parental background. But let me ask two questions about this. One is, what about your genes? There’s hardly any discussion about whether inequalities that are deriving from genetic advantages or disadvantages are fair or not. And what we’ve also shown in this project is that parental background seems to reinforce genetic advantages. So even if you believe that parental background should not be leading to inequalities and your genes may, then how do you treat the interaction between the two? So I think we should have a clear discussion here a societal discussion about what is fair here. And I think that’s why our research is very important, because 30 years studies have already shown that people’s preferences for redistribution, for example, depends strongly on whether they perceive inequalities as fair or unfair. So I don’t think we are political activists here. But I do think that showing how genes and the environment jointly shape outcomes such as health, education, income, but really help people to make up their own mind as to what they regard as fair or unfair inequalities.

Christine Garrington  11:23  
Hans thank you very much some some big advances here. But still some big questions to answer, I guess is the is the summary but fascinating work and thank you for taking time to share it with us. So finally, thanks to Hans van Kippersluis  for discussing the findings and implications of DIAL dial project Gene Environment Interplay in the Generation of Health and Education Inequalities. You can find out more about this and other dial research on the website at www.dynamicsofinequality.org. We hope you enjoyed this episode, which is produced and presented by me Chris Garrington of Research Podcasts. And don’t forget to subscribe wherever you find your podcasts to access earlier and forthcoming episodes.

 

 

Antenatal steroids: are there links with mental and behaviour problems later on?

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In Episode 8 of Series 3 of the DIAL Podcast, Katri Räikkönen from Helsinki University and a member of DIAL’s PremLife project, talks about her research investigating whether the babies of mothers who whilst pregnant are prescribed steroid drugs, because of concerns around premature births, are more likely to develop behavioural and mental disorders later on.

Associations Between Maternal Antenatal Corticosteroid Treatment and Mental and Behavioural Disorders in Children is research published in the Journal of the American Medical Association. 

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Mums who smoke and their baby’s birthweight

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In Episode 7 of Series 3 of the DIAL Podcast, Rita Pereira from the Erasmus University in Rotterdam and a member of DIAL’s Gene Environment Interplay in the Generation of Health and Education Inequalities(GEIGHEI) project, talks about her research looking at the links between mothers’ smoking and their baby’s birthweight.

The Interplay between Maternal Smoking and Genes in Offspring Birth Weight is a DIAL Working Paper by Rita Dias Pereira, Cornelius Rietveld and Hans van Kippersluis.

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Born preterm or low weight? What could that mean for your relationships and wellbeing later on?

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In Episode 4 of Series 3 of the DIAL Podcast, Ayten Bilgin and Marina Mendonça from DIAL’s PremLife project discuss their research looking at the romantic and sexual relationships of adults who were born pre-term or with a low birth weight and the potential knock on effects of that on their physical and mental wellbeing.

Association of Preterm Birth and Low Birth Weight With Romantic Partnership, Sexual Intercourse, and Parenthood in Adulthood: A Systematic Review and Meta-analysis is research by Marina Mendonça, Ayten Bilgin and Dieter Wolke and is published in the Journal of the American Medical Association (JAMA Open)

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