When Lung Problems Follow You Into Adulthood — and Affect How Well You Can Focus

Understanding the Connection Between Premature Birth, Breathing, and Attention

A Study That Followed Premature Babies to Age 19

When a baby is born more than three months early, breathing is one of the first and most urgent medical challenges. Premature lungs are too immature to work on their own, and many extremely premature babies develop a chronic lung condition called bronchopulmonary dysplasia (BPD) during their NICU stay [1]. BPD affects 40-80% of the most premature infants, is associated with neurodevelopmental impairment [2], and leaves lasting marks on the lungs that can persist for decades [1].

What is less widely recognised is that the same children often grow up to struggle with attention — specifically the inattentive type of ADHD, characterised by difficulty sustaining focus and staying organised, rather than the physically hyperactive behaviour most people associate with the diagnosis [3]. Children born before 26 weeks are two to four times more likely than full-term peers to develop ADHD [3].

A 2023 study in the journal Acta Paediatrica by Dr. Jonathan Litt and colleagues at Harvard Medical School, the University of Leicester, and University College London used data from the EPICure cohort — following babies born in 1995 until they were 19 years old — to ask: does the lung disease premature babies develop in the NICU explain why they struggle with attention as young adults [4]?

The EPICure Study: Four Snapshots Over a Lifetime

The EPICure study is one of the longest-running follow-up studies of extremely premature babies in the world. It enrolled every baby born at less than 26 weeks of pregnancy in the UK and Ireland in 1995 — 315 who survived NICU care. These children were followed by researchers at ages 2.5, 6, 11, and 19 years, and at age 6 a comparison group of healthy classmates born at full term was recruited [5].

By the time of the 2023 analysis, 90 extremely premature participants and 47 of their term-born classmates had both breathing tests at age 11 and 19 years and completed an attention questionnaire at age 19. Seventy percent of the premature group had BPD during their NICU admission [4]. Neuropsychological follow-up of the same cohort at age 19 documented persistent cognitive differences from term-born peers [10].

What the Breathing Tests Showed

Breathing tests — specifically a measure called FEV1 (the volume of air you can breathe out in one second) — showed significantly worse lung function in the extremely premature group compared to term-born peers, both at age 11 [6] and at age 19 [7]. The gap was roughly 1.3 z-scores — a large and clinically meaningful difference. Both groups showed some improvement over time, but the premature group remained consistently below their peers [4].

What the Attention Tests Showed

At age 19, the extremely premature participants had significantly higher scores for inattention — the difficulty concentrating, following through on tasks, and staying organised. They did not show significantly higher scores for hyperactivity or impulsivity [4,5].

This matters: it means the ADHD-type difficulties seen in former premature babies are predominantly the quiet, invisible kind — the student who is daydreaming rather than disrupting the classroom. Behavior trajectories from childhood to young adulthood show inattention persisting while hyperactivity fades [8] — and this is exactly the type most likely to be missed, underdiagnosed, and unsupported [4].

The Discovery: Lung Problems Explain the Attention Gap

Using a statistical method called path analysis — which maps the routes through which one factor causes another — the researchers found that poor lung function at ages 11 and 19 fully explained the relationship between premature birth and inattention at age 19 [4].

Once lung function was accounted for, the direct connection between being born premature and having inattention disappeared entirely. The link between prematurity and attention problems worked through the lungs, not separately from them [4].

This finding was strongest among the premature babies who had been diagnosed with BPD: in that group, every improvement in lung function was linked to meaningfully better attention scores. In those without BPD, the link was much weaker [4]. This is similar to research in full-term children showing that asthma is also associated with attention problems [9] — suggesting there is a genuine biological connection between how well the lungs work and how well the brain's attention systems function.

What This Means for Families

Lung health and brain health are connected. Taking good care of your child's lungs — ensuring proper inhaler use, managing exercise-induced symptoms, addressing sleep disturbances — may benefit their ability to concentrate and learn, not only their breathing [1,3].

Inattention may not look like typical ADHD. Former premature children who struggle with inattention often appear outwardly fine but have difficulty following through on tasks or sustaining focus for long periods. Ask teachers and your paediatrician specifically about inattention, not just disruptive behaviour. Former premature children deserve ADHD screening at school entry and beyond [4,8].

Follow-up matters throughout childhood and into adulthood. This research shows that both respiratory and attentional challenges may emerge or persist well beyond the NICU — into adolescence and young adulthood [4,7]. These are not character flaws but predictable biological consequences of being born too early, and they are best addressed when identified early.

References

  1. Jobe AH. The New BPD: An Arrest of Lung Development. Pediatr Res. 1999;46(6):641-643. doi:10.1203/00006450-199912000-00007
  2. Anderson PJ, Doyle LW. Neurodevelopmental outcome of bronchopulmonary dysplasia. Semin Perinatol. 2006;30(4):227-232. doi:10.1053/j.semperi.2006.05.010
  3. Franz AP, Bolat GU, Bolat H, Matijasevich A, Santos IS, Silveira RC, et al. Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis. Pediatrics. 2018;141(1). doi:10.1542/peds.2017-1645
  4. Litt JS, Johnson S, Marlow N, Tiemeier H. Impaired pulmonary function mediates inattention in young adults born extremely preterm. Acta Paediatr. 2023;112(2):254-260. doi:10.1111/apa.16586
  5. Marlow N, Wolke D, Bracewell MA, Samara M. Neurologic and Developmental Disability at Six Years of Age after Extremely Preterm Birth. N Engl J Med. 2005;352(1):9-19. doi:10.1056/NEJMoa041367
  6. Fawke J, Lum S, Kirkby J, Hennessy E, Marlow N, Rowell V, et al. Lung function and respiratory symptoms at 11 years in children born extremely preterm: the EPICure study. Am J Respir Crit Care Med. 2010;182(2):237-245. doi:10.1164/rccm.200912-1806OC
  7. Hurst JR, Beckmann J, Ni Y, Bolton CE, McEniery CM, Cockcroft JR, et al. Respiratory and Cardiovascular Outcomes in Survivors of Extremely Preterm Birth at 19 Years. Am J Respir Crit Care Med. 2020;202(3):422-432. doi:10.1164/rccm.202001-0016OC
  8. Linsell L, Johnson S, Wolke D, Morris J, Kurinczuk JJ, Marlow N. Trajectories of behavior, attention, social and emotional problems from childhood to early adulthood following extremely preterm birth: a prospective cohort study. Eur Child Adolesc Psychiatry. 2019;28(4):531-542. doi:10.1007/s00787-018-1219-8
  9. Schmitt J, Buske-Kirschbaum A, Roessner V. Is atopic disease a risk factor for attention-deficit/hyperactivity disorder? A systematic review. Allergy. 2010;65(12):1506-1524. doi:10.1111/j.1398-9995.2010.02449.x
  10. O'Reilly H, Johnson S, Ni Y, Wolke D, Marlow N. Neuropsychological Outcomes at 19 Years of Age Following Extremely Preterm Birth. Pediatrics. 2020;145(2). doi:10.1542/peds.2019-2087