and very preterm infants are found to have disadvantages across all domains of development, the moderately preterm infants have more favourable developmental trajectories.33 34 The motor, cognitive, behavioural, and psychiatric disabilities in the moderate and late preterm population, however, have a greater impact being the larger proportion of the preterm population.33 34 An estimated 0.9 million post-neonatal survivors suffer long-term neurodevelopmental impairment with 345000 being moderately or severely affected, presenting a large global burden.35 Impairment is often defined as a composite of neurosensory (CP, blindness, deafness) and developmental outcomes. However, there may be variation in the aspects of these outcomes included and the cut-offs used for defining the developmental delay. 36 Of babies born in the UK before 27 weeks’ GA in 2006, 13.4% (n=77) were categorised as having a severe impairment and 11.8% (n=68) Figure 3 MRI images—preterm infant. Punctate white matter lesions (PWMLs) in a preterm infant born at 32 weeks+3 days and imaged at 40 weeks+5 days in the sagittal (A) and high axial plane (B). PWMLs are small areas of white matter injury and are the most common lesion type seen on MRI in ex-preterm babies imaged at term. PWMLs are typically defined as small foci of high T1 signal in the white matter, less often visualised on T2 sequences. PWMLs detected on a single MRI at termequivalent age without other focal lesions or injuries in the grey matter have been associated with abnormal neuroanatomical development and adverse motor outcome at 20 months. Sciences Library. Protected by copyright. on May 17, 2021 at CU Anschutz Strauss Health http://fn.bmj.com/ Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2020-319450 on 10 May 2021. Downloaded from F4 Soni R, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1–F8. doi:10.1136/archdischild-2020-319450 Review moderate impairment at 3years.32 Outcomes for most neonatal networks and national studies are similar, although differences in cohort and impairment definitions make it challenging to compare the data between countries35 (figure 5). Outcomes at school age or beyond are more valid compared with earlier assessments.33 Male gender and lower maternal education are associated with both lower early learning composite scores and a decline in scores over time.34 Bronchopulmonary dysplasia is found to be a crucial factor for cognitive outcome. Motor Motor impairments are common in the preterm population and include CP, developmental coordination disorder (DCD), and other disorders of movement and its control. CP is the most well defined and the most severe form.33 Prematurity is the most frequent cause of CP, with an incidence of 9.1% in adults born at 23–27 weeks’ gestation inclusive. The spastic subtype accounts for 96% of CP in preterm infants, with 60% being spastic diplegia and 17% spastic quadriplegia.37 Motor difficulties associated with DCD, although often considered ‘minor’, can have a significant impact on the child’s abilities.33 Cognitive Cognitive impairment is well recognised after extreme preterm birth but is complex and influenced by multiple processes and not easily predicted by brain injury. Limitations of the available assessments make it difficult to accurately estimate long-term cognitive challenges.37 Cognitive scores at school age and beyond are 11–12 points lower in children born preterm, with mean IQ being 5–7 points lower than in controls. Those with executive dysfunction have difficulty in tasks such as initiating activities, organisation, flexibility in generating ideas and problem solving, working memory, inhibition and attention problems. Weaknesses in working memory and visual–motor integration are particular challenges in preterm survivors.33 Behaviour Approximately 40% of preterm infants have an overall atypical pattern of behaviour with respect to processing sensory stimuli, and almost 90% have a probable or definite abnormality in one or more sensory processing domains (eg, oral, auditory, tactile, visual).33 Extremely preterm infants are four times at risk of attention deficit hyperactivity disorder as compared with term infants with a fourfold increase in risk of autistic spectrum disorder.38 Psychiatric disorders occur in approximately 25% of those born preterm.33 37 Figure 4 MRI images—term and preterm infant. Representative MRI findings of a term-born and a preterm infant imaged at term-corrected age. Top row: 3T images from a term-born infant born at 41 weeks+4 days and scanned at a postmenstrual age of 42 weeks+1 day. Axial T2 weighted (A), T1 weighted (B) and sagittal T1 (C) weighted images shown. Note the subgaleal collection in the superior parietal convexity. The low T2 and high T1 signal from myelin in the posterior limb of the internal capsule is shown by arrows in A and B. Note also the symmetrical small ventricles and small extracerebral and interhemispheric space in the term-born baby. Lower row (D–F): 3T images from a baby born at 32+3 days and scanned at 40 weeks 5 days. Axial T2 weighted (D), T1 weighted (E) and sagittal (F). Note the scaphocephalic skull shape typical of preterm infants, mildly dilated ventricles, subependymal pseudocysts, probably secondary to a preceding GMH. The myelination