Toward Meaningful Outcomes After IVH

Source: Rees P, Dronavalli M, Carter B, et al. School performance of preterm-born children after intraventricular hemorrhage. JAMA Netw Open. 2025;8;(12):e2547584; doi: 10.1001/jamanetworkopen.2025.47584.Investigators from multiple institutions conducted a retrospective study to evaluate the association between intraventricular hemorrhage (IVH) in very preterm infants and subsequent school performance. For the study, all very preterm infants (gestational age at birth <32 weeks) born in New South Wales, Australia, between 2007 and 2013 were included. As part of their clinical care, cranial ultrasounds were routinely obtained on these participants to assess the presence of IVH, with severity classified as grade 1–4. Three cohorts were developed: very preterm infants without IVH (very preterm controls), those with low-grade IVH (grade 1–2), and those with high-grade IVH (grade 3–4). Scores on standardized school performance tests at school grades 3 (age 8-9), 5 (age 10-11), and 7 (age 12–13) in study participants were collected. Total scores and scores in multiple domains (reading, writing, spelling, grammar, and numeracy) were converted in z-scores for the analysis. Linear regression was used to compare test z-scores between very preterm controls and those in the low-grade IVH cohort and between the control and high-grade IVH cohorts, in separate analyses, at each testing period. The models included multiple demographic and clinical characteristics, as well as parental educational level. An additional analysis included the 3 very preterm infant cohorts and a cohort that included all full-term infants (gestational age ≥37 weeks) born in New South Wales during the study period. The trajectories of test scores from 8–13 years of age in children in each of the 4 cohorts were compared.Data on 2,557 children in the very preterm control cohort, 557 in the low-grade IVH, and 85 in the high-grade IVH cohort, were included in the analyses. After adjusting for confounders, there were no significant differences between children in the very preterm control group and those in the low-grade IVH cohort in overall test z-scores or any of the domain test z-scores at any of the 3 testing periods. However, among those with grade 2 IVH, total test z-scores were significantly lower than in the control group at age 8–9 (adjusted mean difference [AMD], -0.20; 95% CI, -0.36, -0.04). Compared to very preterm controls, children in the high grade IVH group had significantly lower test z-scores at each testing period, including total scores and scores on each domain. To assess trajectory in school performance test scores between 8 and 13 years of age, a full-term cohort of 404,990 children was included. Across the period, scores were highest among those in the full-term control group, followed by those in the very preterm control cohort, low-grade IVH cohort, and high-grade IVH group, in order. Scores improved in each cohort over time, with the relationship between the groups remaining fixed.The authors conclude that very preterm infants with high-grade IVH had worse school performance than those without IVH.Dr King has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The long-term implications of low-grade IVH have remained uncertain despite decades of neonatal research. Traditionally regarded as largely benign, grade 1–2 IVH often has been distinguished from high-grade hemorrhage on the basis of early neurodevelopmental assessments.1 More recent population-based studies and meta-analyses, however, have challenged this dichotomy, reporting associations between low-grade IVH and later neurodevelopmental impairment, particularly when outcomes are assessed beyond infancy. Heterogeneity in study design, outcome definitions, and confounder adjustment has contributed to inconsistent findings, leaving clinicians with limited clarity when counselling families.2,3The present researchers make an important contribution by examining school performance into adolescence and by disaggregating low-grade IVH by severity. By focusing on academic attainment rather than early developmental testing, the authors move beyond short-term prognostication toward outcomes that reflect functional participation in childhood. This shift is timely given growing recognition that commonly used composite neurodevelopmental outcomes are clinician-defined constructs that may not align with what families value.4,5 School performance, while still an imperfect proxy, arguably comes closer to capturing family-relevant concerns and has implications for future opportunity. Notably, the largely parallel academic trajectories observed across IVH severity groups suggest that early brain injury may establish an initial difference rather than drive progressive divergence over time. For families, this distinction matters, as a fixed gap implies predictable needs and the potential for targeted educational support, rather than inevitable deterioration.At the same time, the clinical meaningfulness of the observed differences warrants careful consideration. Statistically significant differences do not necessarily equate to differences that are clinically or practically meaningful.6 Small shifts in standardized test scores may reflect real group-level effects while remaining indistinguishable or inconsequential in the lived experience of individual children and families. Aligning research outcomes with what matters most to children and families should remain a central priority.Very preterm infants with high-grade IVH manifest poor academic performance. Parallel trajectories of academic improvement, however, have been demonstrated, regardless of IVH severity in these children.