Editorial
Thorax: first published as 10.1136/thoraxjnl-2021-218599 on 11 April 2022. Downloaded from http://thorax.bmj.com/ on April 18, 2022 at Universidad El Bosque. Protected by copyright.
Extreme prematurity and adult
respiratory disease
1 2
Warren Lenney  ‍ ‍, Neil Marlow  ‍ ‍
Health professionals have an increasing
tendency to work in silos despite the explo-
sion of knowledge indicating that most
diseases span the life course. Furthermore, it
is increasingly difficult to interest busy adult
physicians about the importance of early
causation of diseases with which they regu-
larly interact. Why should healthcare teams
dealing with COPD and other disorders
presenting in adult life, or paediatricians
specialising in respiratory care, be interested
in the outcomes of babies born premature?
The answer is there is mounting evidence
that virtually all chest diseases have their
origins in childhood, and for many the die is
cast well before birth—through a combination
of external influences such as nicotine use
and air pollution, and the secondary effects
of reduced fetal growth, infection and poor
nutrition. Among individuals precise causative
pathways may differ, but many more patients
are now presenting in childhood or early adult
life with evidence of increased risk of future
respiratory morbidity. Understanding how
this risk has occurred and the implications for
adult morbidity are key areas of interest that
impact on practice across the full lifespan. To
do this we need to join up efforts in obstetrics,
neonatology, paediatrics and adult practice.
In this edition of Thorax, Bardsen et al1
demonstrate that premature birth has long-­ contribute to decreased longevity.
lasting effects on lung growth and development
well into the fourth decade of life. They have
followed Norwegian babies with extreme prema-
turity (EP; born before 28 weeks of gestation or
with <1000 g birth weight) up to 35 years of
age showing tracking of their lung function. Of
more concern they also show that one in three EP
participants meet the postbronchodilator spirom-
etry criteria for COPD diagnosis and this was not
necessarily in those diagnosed with bronchopul-
monary dysplasia (BPD) in the newborn period.
The survival rates of babies born at extremely
low gestational ages continue to increase, thus
ensuring that this population of graduates will
grow in numbers as the years progress.
Many longitudinal studies are now assessing
survivors after entering adult life. In a systematic injury. We have the evidence on which to build
review, Doyle et al2 evaluated the maximal lung
function attained following extremely preterm
birth in late adolescence or early adult life (mean will come to no avail. We owe it to the future
1
Retired Paediatrician, Nantwich, UK
2
Institute for Women’s Health, University College
London, London, UK
Correspondence to Professor Neil Marlow, Institute
for Women’s Health, University College London,
London, UK; ​n.​marlow@​ucl.​ac.​uk
age at lung function testing was 21 years) in 11
studies. They observed reduced lung function
with greater likelihood of COPD in later life.
Bardsen and colleagues1 suggest antenatal
factors other than neonatal BPD may be more
important, a finding noted in other neonatal
studies.3 4 It is crucial to recognise, however,
that neonatal lung disease is a continuum with
BPD at the more severe end of the spectrum.
However, BPD is not a distinct entity due to it
having multiple aetiologies which encompass
many of the pathways described above.5 Recent
evidence has suggested that the risk of clinical
asthma is also a continuum, being highest in
the most preterm but is increased following late
preterm (35–36 weeks of gestation) and early
term (37–39 weeks) birth as well. As the latter
two categories contain greater numbers of babies
than those classed as ‘very preterm’, they will
contribute the majority of attributable risk.6
All these important exposures in early life have
profound implications for adult disease.7
The adult pattern of disease following
neonatal BPD also shows mixed fixed and revers-
ible airflow patterns, but we, among others,
failed to find evidence of ongoing lung inflam-
mation,8 suggesting structural deficits. Further-
more, lung morbidity among extremely preterm
adults is associated with many other important
morbidities, including cognitive impairment9 and
cardiovascular disease,7 8 10 11 all of which may
The challenge for everyone is to recognise as
early as possible those at risk and to ensure their
comprehensive respiratory follow-­ up in child-
hood through adult life. Neonatologists need
to reconnect with paediatric respiratory special-
ists to identify this important group for adult
respiratory services to take on board through
joint transition clinics, as has been happening in
patients with cystic fibrosis for many years. The
process commences by simply taking a perinatal
history.12 Those at risk deserve better attention
and an approved and funded preventative health
programme. This should include research studies
to minimise further lung damage to prevent
progression and complement the extensive peri-
natal/neonatal work on prevention of early lung
a better future, but unless we all work together
with a plan supported by healthcare managers it
respiratory health of the nation to succeed.
Funding  The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Lenney W, Marlow N. Thorax Month 2022 Vol 0 No 0
Ethics approval  This study does not involve human
participants.
Provenance and peer review  Commissioned;
externally peer reviewed.
© Author(s) (or their employer(s)) 2022. No
commercial re-­use. See rights and permissions.
Published by BMJ.
To cite Lenney W, Marlow N. Thorax Epub ahead of
print: [please include Day Month Year]. doi:10.1136/
thoraxjnl-2021-218599
Accepted 31 January 2022
► http://​​dx.​​doi.​​org/​​10.​​1136/​thoraxjnl-​2021-​218400
Thorax 2022;0:1.
doi:10.1136/thoraxjnl-2021-218599
ORCID iDs
Warren Lenney http://orcid.org/0000-0002-5033-5496
Neil Marlow http://orcid.org/0000-0001-5890-2953
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