Cognitive, Behavioral and Socioemotional Development in a Cohort of Preterm Infants at School Age: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Overview

This study describes the potential effects of preterm birth on children’s cognition and behavior. This manuscript provides a nice description of cognitive and behavioral outcomes for school-age children who were born pre-term. However, this manuscript fails to make a clear and cohesive argument for the hypotheses and results provided or more cohesive conclusions once the reader sees all of the results.  

 

Introduction

1. The connections between the introduction and the hypotheses are very difficult to follow, some of these hypotheses or research questions do not seem to come from the introduction laid out above (e.g., line 72-76). There is value in this paper, but currently, the introduction does not align clearly with the results and the results do not seem cohesive.
2. The manuscript highlights a few environmental factors (line 61-62); however, this study centers around hospital stay length. It would be better for the manuscript to either discuss only hospital stays and child factors (APGAR, weight) or explain how these other factors might be connected because it seems like those other factors are an implied proxy when examining hospital stays. The argument seems more clearly laid out on page 6 starting on line 244.

Methods

3. Please list the ages that the BVN and NEPSY were assessed.

Results

4. Regression tables need to be provided for the regression models run. It is not clear how these regressions were run (e.g., models with a single predictor [hospital stays]). Also, it is not clear if anything was controlled for in these models – otherwise these regressions seem redundant to the correlations.
5. The hypotheses suggest the examination of behaviors as a moderator, but the only behavioral moderator reported is internalizing. If the other behaviors (externalizing, total, social problems) were not significant please report that. If those other indexes were not examined, please provide an explanation for why they were not included.
6. This manuscript examines the relationship between age and behavioral outcomes, but this finding is not novel and it is not clear in the context of this paper why it matters as the introduction does not provide a reason for this. The manuscript posits that parents are more accurate about behaviors or more concerned about deficits (starting line 265). But it is more likely that the difference found could be a result of the different CBCL measures used. These two CBCL measures have different questions and different subscales that make up the externalizing and internalizing subscales and total score which could account for the age differences seen. In addition, there is a developmental component that is not discussed that more adheres to the developmental trajectories or behavior problems more generally. This manuscript should first address what purpose this analysis holds in this paper and then better address the differences found for only the total score.

Conclusions

7. This manuscript suggests that parent education might be a reason for average IQ scores. Although this sample has ~50% of the sample with a college degree it might help the argument to show the relationship between parent education and these cognitive outcomes, particularly as it is suggested in the introduction to be an additional environmental factor
8. Line 268 – it is not internalizing symptoms that are associated with IQ but that internalizing symptoms alter the relationship between hospital stay length and IQ.
9. Line 271 -275: This does not logically follow from the results and was not tested in this manuscript. The association between cognitive deficits and behavioral outcomes are also in term infants. This discussion needs to be further clarified. Is this stating that the relationship is expected to be stronger for preterm infants, which this study is currently unable to do. If the implication is that hospital stay length could be a proxy for preterm infants, there are other reasons for infant stays in the hospital even for term infants. Therefore, this section needs to better clarify this association.
10. Are the children in this study receiving NIDCAP based care (line 252-255)? It is not clear from this section whether that is the case and could be an interesting correlate to better highlight.
11. Line 304-306: This is a strong statement that needs to be altered as the analyses run here are cross-sectional.
12. This article does not highlight the strengths of its research questions or design and I believe that this manuscript should include those (e.g., description of deficits within a preterm birth sample; multitude of assessments for behavior and cognitive domains).

Minor points

13. Point of clarity (line 66-67) “vulnerability to cognitive, behavioral, and socioemotional profiles”-it is not clear what “profiles” means. It might be better to use deficits as it is not clear in this sentence the type of profile being referred to.
14. Line 68-69 – redundancy by saying “might exhibit cognitive impairments at the lower levels of IQ and executive functions”. It would be better to state might exhibit impairments in IQ and executive functions that affect…”.
15. Line 208: change behavioral attitudes to behaviors or problem behaviors.
16. Line 217 – “In contrast,…” Please remove these two words because the simple slopes analysis does not allow for comparisons between high and low internalizing symptoms.

 

Author Response

Dear Editor,

We revised the manuscript entitled “Cross-sectional study of cognitive, behavioral and socioemotional development to school age in a cohort study of preterm infants”, submitted to the Pediatric Reports.

We thank the editor and the reviewers for taking the time for reviewing our article. 

We are grateful for the meaningful suggestion they gave us.

We have followed the reviewers’ suggestions, trying to answer all comments.

You can find our response for each point highlight below.

Reviewer #1

Comment#1: This study describes the potential effects of preterm birth on children’s cognition and behavior. This manuscript provides a nice description of cognitive and behavioral outcomes for school-age children who were born pre-term.

Reply#1: We thank the reviewer for the positive comment

Comment#2: However, this manuscript fails to make a clear and cohesive argument for the hypotheses and results provided or more cohesive conclusions once the reader sees all of the results. The connections between the introduction and the hypotheses are very difficult to follow, some of these hypotheses or research questions do not seem to come from the introduction laid out above (e.g., line 72-76). There is value in this paper, but currently, the introduction does not align clearly with the results and the results do not seem cohesive.

Reply#2: We have rearranged the introduction by giving more emphasis to the areas that reflect our research hypotheses and the analyses we carried out.

 

Comment#3: The manuscript highlights a few environmental factors (line 61-62); however, this study centers around hospital stay length. It would be better for the manuscript to either discuss only hospital stays and child factors (APGAR, weight) or explain how these other factors might be connected because it seems like those other factors are an implied proxy when examining hospital stays. The argument seems more clearly laid out on page 6 starting on line 244.

 

Reply#3: We thank the reviewer for this suggestion. We chose to discuss only hospitalisation and child factors in this article because we have the most information on these data in our sample.

 

Comment#4: Please list the ages that the BVN and NEPSY were assessed.

Reply#4: we added this information in the Measures section.

 

 

 

Comment#5: Regression tables need to be provided for the regression models run. It is not clear how these regressions were run (e.g., models with a single predictor [hospital stays]). Also, it is not clear if anything was controlled for in these models – otherwise these regressions seem redundant to the correlations.

 

Reply#5: We indicated that the regression was done alone and inserted the tables.

 

 

Comment#6: The hypotheses suggest the examination of behaviors as a moderator, but the only behavioral moderator reported is internalizing. If the other behaviors (externalizing, total, social problems) were not significant please report that. If those other indexes were not examined, please provide an explanation for why they were not included.

 

Reply#6: We have provided a better explanation for the moderation models performed.

 

Comment#7: This manuscript examines the relationship between age and behavioral outcomes, but this finding is not novel and it is not clear in the context of this paper why it matters as the introduction does not provide a reason for this. The manuscript posits that parents are more accurate about behaviors or more concerned about deficits (starting line 265). But it is more likely that the difference found could be a result of the different CBCL measures used. These two CBCL measures have different questions and different subscales that make up the externalizing and internalizing subscales and total score which could account for the age differences seen. In addition, there is a developmental component that is not discussed that more adheres to the developmental trajectories or behavior problems more generally. This manuscript should first address what purpose this analysis holds in this paper and then better address the differences found for only the total score.

 

Reply#7: We have improved the introduction by deepening the literature associated with our goal and explaining it with more clarity.

 

Comment#8: This manuscript suggests that parent education might be a reason for average IQ scores. Although this sample has ~50% of the sample with a college degree it might help the argument to show the relationship between parent education and these cognitive outcomes, particularly as it is suggested in the introduction to be an additional environmental factor.

 

Reply#8: We thank the reviewer for the comment, but this is a secondary issue and not our main focus for this paper.

 

Comment#9: Line 268 – it is not internalizing symptoms that are associated with IQ but that internalizing symptoms alter the relationship between hospital stay length and IQ.

 

Reply#9: We correct the statement.

 

Comment#10: Line 271 -275: This does not logically follow from the results and was not tested in this manuscript. The association between cognitive deficits and behavioral outcomes are also in term infants. This discussion needs to be further clarified. Is this stating that the relationship is expected to be stronger for preterm infants, which this study is currently unable to do. If the implication is that hospital stay length could be a proxy for preterm infants, there are other reasons for infant stays in the hospital even for term infants. Therefore, this section needs to better clarify this association.

 

Reply#10: we thank the reviewer for this suggestion. We clarified that sentence.

 

Comment#11: Are the children in this study receiving NIDCAP based care (line 252-255)? It is not clear from this section whether that is the case and could be an interesting correlate to better highlight.

 

Reply#11: The children are not receiving NIDCAP.

 

Comment#12: Line 304-306: This is a strong statement that needs to be altered as the analyses run here are cross-sectional.

 

Reply#12: We thank the reviewer and we decide to delete the statement from the paper. 

 

Comment#13: This article does not highlight the strengths of its research questions or design and I believe that this manuscript should include those (e.g., description of deficits within a preterm birth sample; multitude of assessments for behavior and cognitive domains).

 

Reply#13: We have added a statement that demonstrates the strength of our research.

Comment#14: Point of clarity (line 66-67) “vulnerability to cognitive, behavioral, and socioemotional profiles”-it is not clear what “profiles” means. It might be better to use deficits as it is not clear in this sentence the type of profile being referred to.

Reply#14: We have changed the term “profiles” as suggested.

 

Comment#15: Line 68-69 – redundancy by saying “might exhibit cognitive impairments at the lower levels of IQ and executive functions”. It would be better to state might exhibit impairments in IQ and executive functions that affect…”.

 

Reply#15: We have modified the sentence as suggested.

 

Comment#16: Line 208: change behavioral attitudes to behaviors or problem behaviors.

 

Reply#16: We have modified the sentence as suggested.

 

Comment#17: Line 217 – “In contrast,…” Please remove these two words because the simple slopes analysis does not allow for comparisons between high and low internalizing symptoms.

Reply#17: We have modified the sentence as suggested.

Reviewer 2 Report

I ACCEPT IN THIS FORM

Author Response

Dear Editor,

We revised the manuscript entitled “Cross-sectional study of cognitive, behavioral and socioemotional development to school age in a cohort study of preterm infants”, submitted to the Pediatric Reports.

We thank the editor and the reviewers for taking the time for reviewing our article. 

We are grateful for the meaningful suggestion they gave us.

We have followed the reviewers’ suggestions, trying to answer all comments.

Reviewer #2

Comment#1: This is an interesting study that I appreciated the reading. The topic is interesting and well developed but I have some suggestions and comment before it can be accepted for publication:

Reply#1: We thank the reviewer for the positive comment. 

Comment#2: -page 3 line 95-96 GA and BW please report the full name

Reply#2: We provided the full term.

Comment#3: in the text is reported that the present study is part of a broader investigation showing the results of the second part of this broader longitudinal study so I was wondering if the results of the first part have already been published and if is so I suggest to cite the article.

Reply#3: we thank the reviewer for this suggestion. We included a citation.

Comment#4: I suggest to insert in the text the reference to the ethical approval obtained for conducting the study.

Reply#4: we added the reference in the data collection section.

Comment#5: measures: please insert Cronbach alpha values for the tests used in the present study.

Reply#5: We provided Cronbach alpha values.

Comment#6:  I suggest to add a Statistical Analysis section where report the analysis that the Authors want to perform and their aim also for unburdening the result section

Reply#6: We provided a section for the statistical analysis.

Comment#7:  As regards the regression models I suggest to insert also Adjusted R2 and the confidence intervals

Reply#7: We provided the data in Table 4.

Comment#8:  in the result section the Authors should report only the results and the comments should be reported in the discussion as for "Parents seemed more likely to perceive their children as problematic at age seven rather than at age five" that should be moved in the discussion.

Reply#8: We have followed the advice and move the statement to the Discussion section. 

Comment#9:  I suggest to deepen in the discussion the comment regarding the results showing that more days in hospital are associated to a better cognitive performance because this is quite surprising and in contrast with the broader literature

Reply#9: We thank the reviewer for this suggestion. Although there isn’t much evidence to support our findings, we tried to clarify our results by giving a possible explanation according to literature we found.

Comment#10:  As regards the limits I suggest to add the absence of an evaluation on emotional and cognitive capabilities of parents that may play an important protective or risk role on children capabilities/difficulties.

Reply#10: We added the limit suggested. 

Comment#11:  Please insert a brief conclusion section

Reply#11: We added a conclusion section.

Comment#12:  Tables should report in the note the full names of the scales

Reply#12: We added the information.

You can find our response for each point highlight below.

Reviewer 3 Report

This is an interisting study that I appreciated the reading. The topic is interesting and well developped but I have some suggestions and comment before it can be accepted for publication:

-page 3 line 95-96 GA and BW please report the full name

-in the text is reported that the present study is part of a broader investigation showing the results of the second part of this broader longitudinal study so I was wondering if the results of the first part have already been published and if is so I suggest to cite the article.

-I suggest to insert in the text the reference to the ethical approval obtained for conducting the study.

-measures: please insert Cronbach alpha values for the tests used in the present study.

- I suggest to add a Statistical Analysis section where report the analysis that the Authors want to perform and their aim also for unburdening the result section

- as regards the regression models I suggest to insert also Adjusted R2 and the confidence intervals

-in the result section the Authors should report only the results and the comments should be reported in the discussion as for "Parents seemed  more likely to perceive their children as problematic at age seven rather than at age five" that should be moved in the discussion.

-I suggest to deepen in the discussion the comment regarding the results showing that more days in hospital are associated to a better cognitive performance because this is quite surprising and in contrast with the broader literature

-As regards the limits I suggest to add the absence of an evaluation on emotional and cognitive capabilities of parents that may play an important protective or risk role on children capabilities/difficulties.

- Please insert a brief conclusion section

- Tables should report in the note the full names of the scales.

Author Response

Dear Editor,

We revised the manuscript entitled “Cross-sectional study of cognitive, behavioral and socioemotional development to school age in a cohort study of preterm infants”, submitted to the Pediatric Reports.

We thank the editor and the reviewers for taking the time for reviewing our article.

We are grateful for the meaningful suggestion they gave us.

We have followed the reviewers’ suggestions, trying to answer all comments.

Reviewer #2

Comment#1: This is an interesting study that I appreciated the reading. The topic is interesting and well developed but I have some suggestions and comment before it can be accepted for publication:

Reply#1: We thank the reviewer for the positive comment.

Comment#2: -page 3 line 95-96 GA and BW please report the full name

Reply#2: We provided the full term.

Comment#3: in the text is reported that the present study is part of a broader investigation showing the results of the second part of this broader longitudinal study so I was wondering if the results of the first part have already been published and if is so I suggest to cite the article.

Reply#3: we thank the reviewer for this suggestion. We included a citation.

Comment#4: I suggest to insert in the text the reference to the ethical approval obtained for conducting the study.

Reply#4: we added the reference in the data collection section.

Comment#5: measures: please insert Cronbach alpha values for the tests used in the present study.

Reply#5: We provided Cronbach alpha values.

Comment#6: I suggest to add a Statistical Analysis section where report the analysis that the Authors want to perform and their aim also for unburdening the result section

Reply#6: We provided a section for the statistical analysis.

Comment#7: As regards the regression models I suggest to insert also Adjusted R2 and the confidence intervals

Reply#7: We provided the data in Table 4.

Comment#8: in the result section the Authors should report only the results and the comments should be reported in the discussion as for "Parents seemed more likely to perceive their children as problematic at age seven rather than at age five" that should be moved in the discussion.

Reply#8: We have followed the advice and move the statement to the Discussion section.

Comment#9: I suggest to deepen in the discussion the comment regarding the results showing that more days in hospital are associated to a better cognitive performance because this is quite surprising and in contrast with the broader literature

Reply#9: We thank the reviewer for this suggestion. Although there isn’t much evidence to support our findings, we tried to clarify our results by giving a possible explanation according to literature we found.

Comment#10: As regards the limits I suggest to add the absence of an evaluation on emotional and cognitive capabilities of parents that may play an important protective or risk role on children capabilities/difficulties.

Reply#10: We added the limit suggested.

Comment#11: Please insert a brief conclusion section

Reply#11: We added a conclusion section.

Comment#12: Tables should report in the note the full names of the scales

Reply#12: We added the information.

You can find our response for each point highlight below.

Round 2

Reviewer 1 Report

I appreciate the edits made by the authors and would make additional minor suggestions to the edited portions.

1. It is still not clear from the introduction what the reasoning is behind the moderation of problem behaviors on the relationship between hospital stays and IQ.  You provide a reasonable argument in the discussion line 313-315, so please more clearly state this connection in the introduction.  It is also not clear why this moderation was removed from the hypotheses.
2. In the results, starting on line 249,  it is not internalizing symptoms that are associated with IQ, but that internalizing symptoms alter the relationship between hospital stay length and IQ.
3. In Figure 1, please change "name" in the legend to internalizing problems.
4. Line 247, is this meant to read "hospitalization days and internalizing symptoms on IQ total score" (not CBCL)? Also, if you are not providing a table for these analyses, please report the beta and s.e. along with the p values that are currently provided.

Author Response

Dear Editor,

We revised the manuscript entitled “Cross-sectional study of cognitive, behavioral and socioemotional development to school age in a cohort study of preterm infants”, submitted to the Pediatric Reports.

We thank the editor and the reviewers for taking the time for reviewing our article. 

We are grateful for the meaningful suggestion they gave us.

We have followed the reviewers’ suggestions, trying to answer all comments.

You can find our response for each point highlight below.

Reviewer #1

 

Comment#1: I appreciate the edits made by the authors and would make additional minor suggestions to the edited portions.

Reply#1: We thank the reviewer for the positive comment. 

Comment#2: It is still not clear from the introduction what the reasoning is behind the moderation of problem behaviors on the relationship between hospital stays and IQ.  You provide a reasonable argument in the discussion line 313-315, so please more clearly state this connection in the introduction.  It is also not clear why this moderation was removed from the hypotheses.

Reply#2: We provided further information

Comment#3: In the results, starting on line 249, it is not internalizing symptoms that are associated with IQ, but that internalizing symptoms alter the relationship between hospital stay length and IQ.

Reply#3: We corrected the statement

Comment#4: In Figure 1, please change "name" in the legend to internalizing problems.

Reply#4: We corrected the figure

Comment#5: Line 247, is this meant to read "hospitalization days and internalizing symptoms on IQ total score" (not CBCL)? Also, if you are not providing a table for these analyses, please report the beta and s.e. along with the p values that are currently provided.

Reply#5: We provided the effect size values