Born Early, Still Catching Up: Preterm Children’s Outcomes at Age Ten

Most children born prematurely are doing well by the time they reach their tenth birthday, but a decade-long look at two of the largest birth cohorts ever assembled in France reveals a more complicated picture hiding beneath that reassuring headline. A new study drawing on the national EPIPAGE-2 and ELFE cohorts, published in eClinicalMedicine, followed thousands of children born preterm in 2011 and compared them with classmates born at term, capturing not only their health and behaviour but also their schooling, friendships, hobbies and their parents’ own perceptions of daily life. The results show that while the majority of preterm children are healthy, in mainstream classrooms and free of serious behavioural problems, a substantial minority continue to need developmental healthcare, educational assistance and social support as they approach adolescence.

The research team, led by Veronique Pierrat of the EPIPAGE-2 consortium together with Marie-Aline Charles and Pierre-Yves Ancel, interviewed the parents of 2,181 children born between 24 and 34 weeks of gestation and 7,236 children born at 37 to 40 weeks. The telephone interviews, conducted between February and September 2022, used identical protocols for both cohorts, allowing direct comparison between children born early and their term-born peers growing up in the same country in the same year. Because EPIPAGE-2 had already assessed these children at two and five years of age, the investigators could also trace how support needs evolved across childhood, a longitudinal perspective that few studies of preterm outcomes have managed to achieve at this scale.

On the surface, the ten-year picture is encouraging. Roughly 80 percent of parents of preterm children described their child as being in good health, and 96 percent of children born preterm were attending mainstream classes in mainstream schools, a figure the authors interpret as evidence that France’s inclusive education policy, enshrined in law in 2005, has largely succeeded in keeping these children integrated. About two-thirds of parents reported no difficulties with their child’s emotions, behaviour or relationships. Yet the headline numbers conceal a gradient of difficulty that tracks closely with how early a child was born, and even children born only moderately preterm, at 32 to 34 weeks, were not spared.

Behavioural difficulties, measured with the well-validated Strengths and Difficulties Questionnaire using a cut-off above the 90th percentile of the reference distribution, affected 16 percent of children born preterm compared with 12 percent of those born at term, a difference that remained statistically significant after adjustment. Emotional symptoms were the most common domain of difficulty, affecting about a quarter of preterm children, followed by hyperactivity and peer problems, both of which were significantly more frequent than in the term-born group. The differences between the three gestational age groups within the preterm cohort were not statistically significant, suggesting that behavioural vulnerability extends across the entire spectrum of prematurity rather than being confined to the most extreme cases.

The use of developmental healthcare told a starker story. Overall, 37 percent of children born preterm were receiving developmental healthcare, educational support, or both at age ten, compared with 20 percent of children born at term. Among the most immature group, born at 24 to 26 weeks, that figure climbed to 55 percent. Even among children born at 32 to 34 weeks, a group often considered low risk, 33 percent were receiving some form of developmental or educational assistance. Speech therapy was the single most common service, used by nearly 19 percent of preterm children, followed by psychological or psychiatric care, psychomotor therapy, occupational therapy and orthoptic treatment. After adjusting for maternal age, education, employment, socioeconomic status, family structure, child sex and other social factors, every gestational age group still showed a significantly elevated risk of behavioural difficulties and service use relative to term-born children, indicating that the excess burden cannot be explained by social disadvantage alone.

Schooling data reinforced the same pattern. Although mainstream placement was nearly universal, the proportion of children whose grade level was delayed for their age rose steeply with decreasing gestational age, from 4 percent among those born at 32 to 34 weeks to 16 percent among those born at 24 to 26 weeks, compared with just 3 percent of term-born children. Educational support, defined broadly to include grade retention, personalised schooling plans, professional support assistants and special education settings, was received by 23 percent of the preterm group overall, ranging from 35 percent in the most preterm children to 20 percent in the moderately preterm group, against 12 percent of term-born children. Parents’ own assessments echoed these findings: for children in mainstream classes at the expected level, around 70 percent of preterm parents reported no difficulties in French or mathematics, compared with 80 percent of term-born parents.

Perhaps the most striking findings concern the quieter dimensions of childhood that rarely appear in medical charts. Children born preterm were significantly less likely to participate in sports, with 69 percent taking part compared with 77 percent of term-born children, a gap that persisted after adjustment for social context. They were also less likely to have had a birthday party organised for their most recent birthday, and markedly less likely to have been invited to sleep over at a friend’s house in the previous twelve months, with only 54 percent of preterm children reporting a sleepover compared with 63 percent of term-born children. These differences were concentrated among children with behavioural difficulties or those receiving educational support, and they matter because peer activities such as parties and sleepovers are building blocks of social competence, self-confidence and well-being during the transition from primary to secondary school.

The longitudinal analysis added a sobering dimension to the service-use data. Among children who were receiving developmental healthcare or educational support at age five, 57 percent were still receiving such support at age ten, indicating that for most children who need help early, the need does not simply resolve. More unexpectedly, 28 percent of children who had no support at age five were receiving support by age ten, meaning that a considerable share of difficulties either emerged or were only recognised after school entry. This pattern challenges the standard practice in many countries, including France, of recommending routine long-term follow-up for preterm children only until two to five years of age, depending on gestational age. Difficulties that surface in pre-adolescence, the authors note, may evolve into chronic conditions precisely because they escape the window during which surveillance is typically maintained.

Parents’ perceptions added yet another layer. Around 20 percent of parents of preterm children reported that their child had significant or serious difficulties with emotions, behaviour or relationships, and 14 percent of parents of children born at 24 to 26 weeks said their child needed assistance with usual activities because of a health condition, compared with 4 percent of parents of children born at 32 to 34 weeks. The authors argue that these perceptions are not merely subjective noise but a legitimate measure of family burden, since nearly 40 percent of the preterm group was receiving some form of developmental or school support, a load that inevitably shapes household routines, finances and parental well-being. Previous research cited in the paper suggests that around 20 percent of mothers experience mental health difficulties in the first two years after a very preterm birth, and little is known about how long those symptoms persist.

The study’s authors are careful to acknowledge its limitations, including attrition, since only about half of surviving preterm children and 53 percent of term-born children completed the ten-year interview, and the children lost to follow-up tended to come from more disadvantaged families and, within the preterm cohort, to have had more severe neurodevelopmental disabilities at age five. Weighted analyses and multiple imputation were used to mitigate this bias, but the authors caution that overall rates of difficulty may still be underestimated. Reporting bias is also possible, since all data came from parental interviews, although the team deliberately framed the study around parental perceptions as an outcome in their own right. Even so, the convergence of these findings with earlier work, including Finnish register data showing elevated rates of mental and neurodevelopmental disorders in preterm children and British EPICure studies documenting persistent difficulties at 11 years, leaves little doubt that the challenges are real. The authors conclude that follow-up recommendations should be individualised according to the child, the family and social circumstances, that follow-up networks should cooperate with adolescent-age services, and that health and education systems must work together to support children born preterm through the vulnerable transition into adolescence.

Subject of Research: Long-term neurodevelopmental, educational, social and behavioural outcomes at age ten in children born preterm, assessed in the French EPIPAGE-2 and ELFE national cohorts.

Article Title: Outcome at ten years of children born preterm: the EPIPAGE-2 and ELFE cohort studies

Article References: Pierrat, V., Marchand-Martin, L., Benhammou, V., Gire, C., Kaminski, M., Marret, S., Muller, J.-B., Pavicic, L., Twilhaar, S., Charles, M.-A., & Ancel, P.-Y. (2026). Outcome at ten years of children born preterm: the EPIPAGE-2 and ELFE cohort studies. eClinicalMedicine, Article 104154. https://doi.org/10.1016/j.eclinm.2026.104154

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104154

Keywords: preterm birth, EPIPAGE-2, ELFE cohort, neurodevelopment, behavioural difficulties, educational support, developmental healthcare, social participation, parental perceptions, age ten outcomes, inclusive education, longitudinal cohort study