Peer and sibling relationships


Vaillancourt T, Hymel S, Wolke D, van Wassenaer-Leemhuis A

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Target group

Infants born very preterm or those infants with risk factors (see preamble TEG Follow-up & continuing care, and standard on Cognitive development) and parents

User group

Healthcare professionals, neonatal units, hospitals, follow-up teams, and health services

Statement of standard

Peer and sibling relationships are evaluated as part of a standard follow-up programme.


The goal is to ensure that children who have problems in peer relationships are identified and their needs met.

Belonging is a fundamental, biologically-based, human need that operates across the lifespan. (1) As children grow up, peers contribute increasingly to both belonging and socialisation. (2) Children who experience difficulties in peer relationships, including those who are bullied, excluded, rejected, and/or disliked by peers, are at significant risk for major developmental difficulties, including mental and physical health problems, academic challenges, absenteeism and truancy. (3,4) The negative impact of poor peer relations is both far reaching, touching virtually all aspects of functioning, and enduring, impacting health and well-being long after the poor treatment from peers has ended. (5,6) Very preterm children are especially vulnerable for experiencing peer difficulties. (7,8) Their increased risk for altered cognitive and physical development contributes to difficulties with interpersonal relationships (7,8) and increases victimisation by peers, even when they do not have obvious motor, cognitive, or sensory issues. (9) Peer relationships characterised by high levels of intimacy and prosocial behaviour play a positive role in children’s health and well-being. (10) Friendships (11) and sibling relationships (12) serve as powerful protective factors against peer victimisation and help mitigate the negative effects of peer abuse.

Using a comprehensive, developmentally appropriate, short screening assessment of socio-emotional development and peer relationships, an annual screening for peer relationship problems from school entry should be developed. (13,14) Children with peer relationship difficulties should be referred to appropriate health and education teams.


Short-term benefits

Long-term benefits

  • Early identification and referral of very preterm children with mental and physical health problems stemming from peer and sibling relationship problems (7,8)
  • Provides feedback about peer and sibling relationships (15)
  • Provides support and advocacy (3)
  • Reduced risk of secondary mental health, physical health, and academic problems associated with peer and sibling relationship problems (3,13–15)
  • Increased social integration (3,13,14)


Components of the standard

Component Grading of evidence Indicator of meeting the standard
For parents and family    
1. Parents are informed about and invited by healthcare professionals to attend follow-up programme including peer and sibling relationships. B (High quality) Patient information sheet
2. Children receive screening for peer and sibling relationship problems. (16–20) A (High quality) Audit report, parent feedback
3. Parents of children identified at risk for peer and sibling relationship difficulties receive help about appropriate interventions and monitoring of progress. (13–15) A (High quality) Parent feedback
For healthcare professionals    
4. A unit guideline on follow-up including peer and sibling relationships is adhered to by all healthcare professionals. B (High quality) Guideline
5. Training on peer and sibling relationships is attended by all responsible healthcare professionals. (16–18) A (High quality)
B (High quality)
Training documentation
6. Screening for peer and sibling relationship problems using standardised tools is carried out. (16–18) B (Moderate quality) Audit report
For neonatal unit and follow-up team    
7. A unit guideline on follow-up including peer and sibling relationships is available and regularly updated. B (High quality) Guideline
For hospital and follow-up team    
8. Training on peer and sibling relationships is ensured. B (High quality) Training documentation
For health service    
9. A national guideline on follow-up including peer and sibling relationships is available and regularly updated. B (High quality) Guideline

Where to go

Further development Grading of evidence
For parents and family  
  • Easily available information on peer and sibling relations for families are developed.
B (Moderate quality)
For healthcare professionals  
  • Identify precursors of peer and sibling relationship problems. (3,21)
A (High quality)
For neonatal unit  
For hospital  
For health service  
  • Assess the impact of healthcare providers screening for social development and peer and sibling relations.
B (Low quality)

Getting started

Initial steps
For parents and family
  • Parents are informed by healthcare professionals about peer and sibling relationships of preterm born infants.
For healthcare professionals
  • Attend training on the evaluation of peer and sibling relationships.
  • Raise awareness of the importance of peer relationships for developmental outcomes.
For neonatal unit and follow-up team
  • Develop and implement a unit guideline on follow-up including peer and sibling relationships.
  • Develop information material about peer and sibling relationships of preterm born infants for parents.
For hospital and follow-up team
  • Support healthcare professionals to participate in training on peer and sibling relationships.
For health service
  • Develop and implement a national guideline on follow-up including peer and sibling relationships.


The importance of social relationships in health and well-being is underscored by a meta-analytic review demonstrating a “50% increase in odds of survival as a function of social relationships”. (22) Social relationships include social network integration, received social support, and perceived social support. Although the quality of caregiver-child relationships has long been emphasised in the promotion of positive cognitive, emotional, and behavioural responses (23), there is strong and growing evidence that peers are an important developmental context that also impacts adaptation across the life span. Bullying (being the target of repeated, intentional abuse by peers who hold more power) is especially problematic for children’s health and development. Bullying begins early in life, when children enter peer groups, contributes to loneliness, sadness, and anger, and is predictive of future peer relationship problems. (24) Bullying peaks around early adolescence (age 10-12) and declines in late adolescence, but never goes away completely. (25,26)

To date, healthcare providers have been at the periphery of efforts to prevent, educate, and address peer relation difficulties despite being important stakeholders in promoting child health. (18,27) Given that poor peer relationships are associated with significant health problems and positive social relationships are associated with wellness, the role of healthcare providers in promoting positive social interpersonal relationships is vital. Many children report being hesitant to disclose problematic peer interactions like bullying to adults because they feel adults will be ineffective, but there is emerging evidence that children would not only disclose to physicians, but that they want physicians to ask them about their peer relationships. (16) Although healthcare providers may not directly observe such interpersonal difficulties, they are often in a position to treat the symptoms of the problem and can identify root causes and contributing factors, including difficulties with peer relationships. Healthcare providers can help children by (a) validating that their social development is an important health issue worthy of attention, (b) being aware of symptoms and signs of peer relationship problems which may prove important for effective treatment of associated conditions, and (c) screening for peer relationship difficulties in clinical settings and intervene if and when needed.


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November 2018 / 1st edition / next revision: 2023

Recommended citation

EFCNI, Vaillancourt T, Hymel S et al., European Standards of Care for Newborn Health: Peer and sibling relationships. 2018.

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