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Poverty, Toxic Stress, and Education in Children Born Preterm

Kelly, Michelle M.; Li, Kati

doi: 10.1097/NNR.0000000000000360

Background Preterm birth, defined as birth before the completion of 37 weeks of gestation, is a multifactorial global epidemic with psychosocial, economic, and physical ramifications affecting the child, family, and community at large. Toxic stress—the results of exposure to adverse childhood experiences—results in changes to brain structure and function that negatively affects future health.

Objectives The aim of this study was to apply the eco-bio-developmental (EBD) model of poverty and preterm birth to the cross-sectional data of the 2016 National Survey of Children’s Health to evaluate the associations between poverty, toxic stress, and prematurity on neurodevelopmental and educational outcomes.

Methods A subset of data representing children ages 6–11 years old (n = 15,010) from the 2016 National Survey of Children’s Health was used for multivariate analysis of demographic variables and neurodevelopmental and educational outcome variables. Pearson’s chi-square, logistic regression, and interaction effects explored the relationships between prematurity, toxic stress, and poverty.

Results Children in this sample born preterm had a higher incidence of toxic stress, poverty, developmental delay, learning disability, intellectual disability, speech/language disorders, attention-deficit disorder (ADD)/attention-deficit/hyperactivity disorder (ADHD), autism, and special education/early intervention plans. The combination of poverty, toxic stress, and preterm birth significantly increased the risk of these conditions. After accounting for gender, insurance coverage, race, and parental education, children in the sample born preterm were more likely to experience developmental delay, intellectual disability, speech/language disorder, learning disability, and ADD/ADHD. Toxic stress increased the incidence of ADD/ADHD and autism in both the preterm and full-term samples.

Discussion The negative effect of poverty and toxic stress on children born preterm, as depicted by the eco-bio-developmental model, is supported by this analysis. Healthcare providers are encouraged to address the tripartite vulnerability resulting from prematurity, poverty, and toxic stress.

Michelle M. Kelly, PhD, CRNP, is Assistant Professor, M. Louise Fitzpatrick College of Nursing, Villanova University, Pennsylvania.

Kati Li, PhD, is Research Analyst, Office of Planning & Institutional Research, Villanova University, Pennsylvania.

Accepted for publication October 19, 2018.

The authors would like to thank Suzanne C. Smeltzer, RN, EdD, ANEF, FAAN, the Richard and Marianne Kreider Endowed Professor in Nursing for Vulnerable Populations at M. Louise Fitzpatrick College of Nursing, Villanova University, for her unwavering support and mentorship.

The Villanova University Institutional Review Board evaluated the research plan and deemed the study not subject to federal regulations under HHS 45 CFR 46.

The authors have no conflicts of interest to report.

Corresponding author: Michelle M. Kelly, PhD, CRNP, M. Louise Fitzpatrick College of Nursing, Villanova University, 800 E. Lancaster Avenue, Driscoll Hall 398, Villanova, PA 19085 (e-mail:

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Online date: March 26, 2019

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