Due to significant advances in neonatal care, individuals born preterm (before 37 weeks of gestation) are reaching adulthood in increasing numbers. However, those who were born pre-term face unique long-term health challenges that can increase surgical risks later in life. These risks stem from altered physiology, underdeveloped organ systems, and neurodevelopmental vulnerabilities established in early life. These vulnerabilities manifest across the perioperative and postoperative phases.

One important component of physiological differences common to this population is the altered nociceptive and somatosensory processing associated with extreme premature birth. A study from the UK EPICure cohort demonstrated that young adults born before 26 weeks of gestation exhibited abnormal pain sensitivity and somatosensory function, especially those who underwent neonatal surgery. Notably, sex-specific differences were evident, suggesting that early surgical interventions could disrupt neural development differently in males and females, which could complicate pain management strategies in adult surgeries (1). These neuroplastic alterations have implications for anesthetic planning and postoperative pain management.

Pulmonary vulnerability is another clinical concern with potential implications for surgical risks in patients who were born pre-term. Chronic lung disease (CLD), which is often seen in these patients, leads to long-term respiratory impairment. Many of these individuals require a tracheostomy or chronic mechanical ventilation during infancy. In a cohort of patients with CLD who received early respiratory interventions, persistent complications such as tracheomalacia and restrictive lung patterns were observed well into adolescence and adulthood. These sequelae pose a heightened risk under general anesthesia and contribute to prolonged ventilatory support after surgery (2). Thus, preoperative respiratory evaluation and customized anesthetic strategies are necessary to mitigate intraoperative hypoxia and respiratory distress.

Neurodevelopmental outcomes also affect possible clinical risks. Pre-term birth, particularly among infants conceived via assisted reproductive technologies, has been linked to cognitive and behavioral impairments that persist into adolescence and adulthood. These deficits may include attention, executive function, and learning ability impairments, which could compromise comprehension of surgical procedures, adherence to perioperative instructions, and overall recovery (3). Additionally, heightened anxiety or impaired communication skills may hinder patient-provider interactions, which could impact surgical outcomes.

Sleep-disordered breathing (SDB), including obstructive sleep apnea, is more prevalent among individuals born pre-term, increasing the risk of complications during anesthesia and surgical procedures. A population-based study that followed individuals from childhood into mid-adulthood found that pre-term birth increased the risk of SDB independently, regardless of other comorbidities (4). This has substantial surgical implications. Patients with undiagnosed SDB are more susceptible to respiratory depression during surgery, especially when sedatives or opioids are administered. Therefore, it is crucial to screen patients with a history of pre-term birth for SDB preoperatively.

Lastly, individuals born even slightly early face an elevated risk of metabolic disorders later in life. Children born at early term (37–38 weeks) show an increased prevalence of obesity and type 2 diabetes in adulthood, and these risks rise with decreasing gestational age (5). These conditions are independently associated with worse surgical outcomes, including impaired wound healing, higher infection rates, and cardiovascular instability under anesthesia. Therefore, preoperative optimization of metabolic parameters is particularly crucial for this vulnerable group.

Pre-term birth has long-lasting effects that affect multiple organ systems and contribute to a distinctive and often complex surgical risk profile. From altered pain sensitivity and chronic respiratory disease to neurodevelopmental delays, sleep disturbances, and metabolic dysfunction, adults born pre-term require careful, individualized perioperative planning. Awareness of these risks and early screening can significantly improve surgical outcomes and patient safety.

References

1. Walker SM, Melbourne A, O’Reilly H, et al. Somatosensory function and pain in extremely preterm young adults from the UK EPICure cohort: sex-dependent differences and impact of neonatal surgery. Br J Anaesth. 2018;121(3):623-635. doi:10.1016/j.bja.2018.03.035
2. Koltsida G, Konstantinopoulou S. Long term outcomes in chronic lung disease requiring tracheostomy and chronic mechanical ventilation. Semin Fetal Neonatal Med. 2019;24(5):101044. doi:10.1016/j.siny.2019.101044
3. Roychoudhury S, Lodha A, Synnes A, et al. Neurodevelopmental outcomes of preterm infants conceived by assisted reproductive technology. Am J Obstet Gynecol. 2021;225(3):276.e1-276.e9. doi:10.1016/j.ajog.2021.03.027
4. Crump C, Friberg D, Li X, Sundquist J, Sundquist K. Preterm birth and risk of sleep-disordered breathing from childhood into mid-adulthood. Int J Epidemiol. 2019;48(6):2039-2049. doi:10.1093/ije/dyz075
5. Paz Levy D, Sheiner E, Wainstock T, Sergienko R, Landau D, Walfisch A. Evidence that children born at early term (37-38 6/7 weeks) are at increased risk for diabetes and obesity-related disorders. Am J Obstet Gynecol. 2017;217(5):588.e1-588.e11. doi:10.1016/j.ajog.2017.07.015