CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Updates on an At-Risk Population:Late-Preterm and Early-Term InfantsDan L. Stewart, MD, FAAP,a Wanda D. Barfield, MD, MPH, FAAP, RADM, USPHS,b COMMITTEE ON FETUS AND NEWBORN

abstractThe American Academy of Pediatrics published a clinical report on late-preterm (LPT) infants in 2007 that was largely based on a summary of a 2005workshop convened by the Eunice Kennedy Shriver National Institute ofChild Health and Human Development, at which a change in terminology from“near term” to “late preterm” was proposed. This paradigm-shiftingrecommendation had a remarkable impact: federal agencies (the Centers forDisease Control and Prevention), professional societies (the AmericanAcademy of Pediatrics and American College of Obstetricians andGynecologists), and organizations (March of Dimes) initiated nationwidemonitoring and educational plans that had a significant effect on decreasingthe rates of iatrogenic LPT deliveries. However, there is now an evolvingconcern. After nearly a decade of steady decreases in the LPT birth rate thatlargely contributed to the decline in total US preterm birth rates, the birthrate in LPT infants has been inching upward since 2015. In addition, evidencerevealed by strong population health research demonstrates that being bornas an early-term infant poses a significant risk to an infant’s survival, growth,and development. In this report, we summarize the initial progress anddiscuss the potential reasons for the current trends in LPT and early-termbirth rates and propose research recommendations.

INTRODUCTION

The American Academy of Pediatrics (AAP) published a clinical report onlate-preterm (LPT) infants (born between 34 0/7 weeks’ gestation and36 6/7 weeks’ gestation; Fig 1) in 20071 that was largely based ona summary of the 2005 workshop convened by the Eunice Kennedy ShriverNational Institute of Child Health and Human Development.2 At thisworkshop, a change in terminology from “near term” to “late preterm” wasproposed. This shift in the paradigm recommendation led to a remarkableimpact: federal agencies (the Centers for Disease Control and Prevention),professional societies (the AAP and American College of Obstetrics andGynecology), and organizations (March of Dimes) initiated nationwide

aSchool of Medicine, University of Louisville, Louisville, Kentucky; andbCenters for Disease Control and Prevention, Atlanta, Georgia

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

Dr Stewart and the members of the Committee on Fetus and Newbornconceived the concept of updating the previous American Academy ofPediatrics publication on late-preterm infants, collaborated with DrsBarfield and Raju, and reviewed the manuscript; Drs Barfield and Rajucollaborated with Dr Stewart and members of the Committee on Fetusand Newborn and reviewed the manuscript; and both authorsapproved the final manuscript as submitted and agree to beaccountable for all aspects of the work.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

The findings and conclusions in this article are those of the authorsand do not necessarily represent the official position of the Centers forDisease Control and Prevention.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

DOI: https://doi.org/10.1542/peds.2019-2760

Address correspondence to Dan L. Stewart, MD, FAAP. E-mail:dan.stewart@louisville.edu

To cite: Stewart DL, Barfield WD, AAP COMMITTEE ON FETUSAND NEWBORN. Updates on an At-Risk Population: Late-Preterm and Early-Term Infants. Pediatrics. 2019;144(5):e20192760

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monitoring and educational plansthat had a significant effect ondecreasing the rates of iatrogenic LPTdeliveries, as noted in numerouspublications.

Evidence revealed by strongpopulation health researchdemonstrated that LPT or early-term(ET) births (between 37 0/7 weeks’gestation and 38 6/7 weeks’gestation; Fig 1) pose a significantrisk to an infant’s survival, growth,and development because ofincreased morbidities and mortalityin these at-risk groups (Fig 2). The2007 AAP clinical report on LPTbirths was an important milestone inhelping health care providersunderstand the magnitude of theseuntimely births and their relativecontribution to overall preterm birthand disparities. Neonatologists andpediatricians should be aware of thecurrent and ongoing challengesinfants face after being born LPT orET. Understanding the currentterminology, factors contributing tothese early deliveries, and long-termimplications for growth anddevelopment will help in prevention,clinical management, and population-based quality-improvement efforts.

Because LPT infants account forapproximately 70% of preterm birthsin the United States, this is a costlyand important public health matter.3

LPTs represent 7% of all live births;ET infants represent 26% of all livebirths and 29% of all term infants4

(Fig 3). Recognition of these at-risksubsets of preterm and term infantshas affected perinatal care andlaunched a robust research endeavorto decrease the number ofnonmedically indicated deliveriesof infants born LPT and ET5 whileseeking methods to optimize careprovided to these patients. Therehave been more than 500publications investigating the reasonsfor LPT and ET while recognizing thatthere are a number of maternal, fetal,and placental complications for whicheither LPT or ET birth is warranted.5

After reaching a nadir of 9.57% in2014, the preterm birth rateincreased to 9.97% in quarter 3 of2018 (Fig 4).6 This report shows anemerging concern. After nearlya decade of steady decreases, thepreterm birth rate is inchingupward again. These trends arelargely attributable to increasesin the rate of LPT births,

predominantly among non-Hispanicblack and Hispanic women.4,7 In2018, the LPT birth rate rose to7.28% (Fig 5). These trends must becontinually monitored with anexploration of causality.8 In thisreport, the initial progress issummarized, the potential reasonsfor the current trends in LPT birthrates are discussed, and practice

FIGURE 1Definitions of gestational age periods from LPT to postterm. (Reprinted with permission from EngleWA, Kominiarek M. Late preterm infants, early term infants, and timing of elective deliveries. ClinPerinatol. 2008;35(2):325–341.)

FIGURE 2Neonatal and infant mortality by gestational age. Adapted from Reddy UM, Ko CW, Raju TN, WillingerM. Delivery indications at late-preterm gestations and infant mortality rates in the United States.Pediatrics. 2009;124(1):234–240. (Reprinted with permission from Kardatzke MA, Rose RS, Engle WA.Late preterm and early term birth: at-risk populations and targets for reducing such early births.NeoReviews. 2017;18(5):e265–e276.)

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and research recommendations areproposed.

CURRENT DEFINITIONS

The national emphasis on reducingpreterm births and the increase inscheduled deliveries has createdconfusion around the definition ofterm gestation.9 The concept of“term” gestation provides guidance toclinicians and influences the public’sperceptions about the optimal timingof delivery for a healthy pregnancy.9

This nomenclature acknowledgedthat fetal maturation is a continuum,yet the use of the label of term forpregnancies spanning 37 weeks’0 days gestation through 41 weeks 6days’ gestation remained unchanged.Recent data demonstrate thatmaternal and neonatal adverseoutcome rates are not the sameacross the 5-week gestational agerange that constitutes term.9 Rather,the frequency distribution of adverseoutcomes is U shaped, with the nadirbeing between 39 weeks 0 days’gestation and 40 weeks 6 days’gestation.9 The Defining “Term”Pregnancy workshop recommendedthat births occurring between37 weeks 0 days’ gestation and

38 weeks 6 days’ gestation bedesignated as ET, those between39 weeks 0 days’ gestation and40 weeks 6 days’ gestation bedesignated as term, and thoseoccurring at 41 weeks 0 days’gestation through 41 weeks 6 days’gestation be designated as lateterm.9,10

According to the American College ofObstetricians and Gynecologists(ACOG), accurate dating of pregnancyis important to improve outcomesand is a research and public healthimperative. As soon as data from thelast menstrual period, the firstaccurate ultrasound examination, orboth are obtained, the gestational ageand the estimated due date should bedetermined, discussed with thepatient, and documented clearly inthe medical record. A pregnancywithout an ultrasound examinationthat confirms or revises the estimateddue date before 22 0/7 weeks’gestation should be consideredsuboptimally dated. For the purposesof research and surveillance, the bestobstetric estimate, rather thanestimates based on the last menstrualperiod alone, should be used as themeasure for gestational age.11

“Implicit in any definition orsubclassification of preterm or termbirth is the need for accurate dating,which would likely lead to a lowerproportion of deliveries categorizedas postterm or early term.”8 TheACOG considers first-trimesterultrasonography to be the mostaccurate method to establish orconfirm gestational age. Pregnancieswithout an ultrasonographicexamination confirming or revisingthe estimated due date before 22 0/7weeks’ gestation should beconsidered suboptimally dated. Thereis no role for elective delivery ina woman with a suboptimally datedpregnancy. Although guidelines forindicated LPT and ET deliveriesdepend on an accurate determinationof gestational age, women withsuboptimally dated pregnanciesshould be managed according tothese same guidelines because of thelack of a superior alternative.12

After the 2005 Eunice KennedyShriver National Institute of ChildHealth and Human Developmentworkshop, there were concernsabout unintended consequences,including an increase in stillbirths13

and increasing the risks for themother and her fetus by theavoidance of indicated LPTdeliveries. Current ACOG and Societyfor Maternal-Fetal Medicinerecommendations state that thereare a number of maternal, fetal, andplacental complications for whicheither an LPT or ET delivery iswarranted. The timing of delivery insuch cases must balance thematernal and newborn risks of LPTand ET delivery with the risksassociated with further continuationof pregnancy. Deferring delivery tothe 39th week is not recommended ifthere is a medical or obstetricindication for earlier delivery.

PATHOGENESIS OF PRETERM BIRTHS

The pathogenesis of preterm birth isnot completely understood. Two-thirds of preterm deliveries occur as

FIGURE 3Percentage of births by gestational age at birth: United States 2017. (Adapted from Martin JA,Hamilton BE, Osterman MJ, Driscoll AK, Drake P. Births: final data for 2017. Natl Vital Stat Rep. 2018;67:8.)

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a result of spontaneous preterm laborand/or premature rupture ofmembranes.14 Risk factors that maycontribute to these events includea history of a previous pretermdelivery (risk is 1.5–2.0 timeshigher)15; infection; inflammation;maternal stress (acute and/orchronic); uterine, placental, and/orfetal anomalies; short cervix; as wellas multifetal pregnancies.16

Newnham et al17 recently reviewedcurrent strategies for prevention ofpreterm birth, which includedecreasing smoking duringpregnancy, cervical cerclage, judicioususe of fertility treatments, preventionof nonmedically indicated deliveries,and the establishment of high-riskobstetric clinics. Public health effortsalso contributed, using theCollaboration on Innovation andImprovement Network to reduceinfant mortality. In these efforts,

states focused on policies andpractices to reduce tobacco use inpregnancy and reduce nonindicatedpreterm delivery.18,19 State perinatalquality collaboratives, whichconsisted of teams of clinical andpublic health members, have alsohelped to reduce the rates ofnonmedically indicated LPT and ETbirths.20 Progress has been made inthe rate for triplet and higher-order–multiple births, which hasbeen on the decline since 1998 andpresently is the lowest in more than 2decades.3,21–23 In part from theefforts from the March of Dimesprogram that no infant be deliveredelectively before 39 weeks’ gestation,the cesarean delivery rate is down3% from a peak of 32.9% in 2009.3

In a large randomized controlled trial,the benefits of a single course ofantenatal betamethasone was

investigated in women anticipated todeliver between 34 and 37 weeks ofpregnancy.24 Infants of womentreated had significantly lower ratesof respiratory complications.However, 35 women needed to betreated to improve outcomes in 1infant, and 24% of steroid-exposedinfants developed hypoglycemiacompared with 14.9% of those in theplacebo group. Thus, despiteendorsements by the obstetricprofessional societies,25–27 severalexperts have raised concerns aboutthe routine use of antenatal steroidsin women during LPT gestations.27–29

Pediatric providers, too, need toreview a history of antenatal steroidexposure while evaluating LPTinfants, including checking forneonatal hypoglycemia.

Use of progesterone for women witha previous history of spontaneous

FIGURE 4Quarterly preterm birth rates 2017 to quarter 1 of 2019. (Adapted from Rossen LM, Osterman MJK, Hamilton BE, Martin JA. Quarterly ProvisionalEstimates for Selected Birth Indicators, 2017–quarter 1, 2019. Hyattsville, MD: National Center for Health Statistics NVSS, Vital Statistics Rapid ReleaseProgram; 2019.)

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preterm birth decreases mortalityand the need for admission to theNICU. Unfortunately, thisimprovement is limited to singletonpregnancies, not multiples.15,30,31

Likewise, 17-hydroxyprogesteronehas shown efficacy in women witha short cervix documented byultrasonography.32 Screening ofwomen with a previous preterm birthat less than 34 weeks’ gestation mayidentify women with a cervical length,25 mm before 24 weeks’ gestationwho might potentially benefit froma cervical cerclage.33,34 Variableaccess to 17-hydroxyprogesterone,antenatal steroids, prenatalultrasonography, and early treatmentand/or management of pretermprolonged rupture of membranesand/or signs of infection may becontributing to racial disparities inpreterm birth rates.35,36 In addition,lack of adequate prenatal care maydelay appropriate management ofconditions that develop before andduring pregnancies, such as diabetes,hypertension, preeclampsia, andothers.23

Since the birth of the first US infantconceived with assisted reproductivetechnology (ART) in 1981, the use of

advanced technologies to overcomeinfertility has resulted in millions ofpregnancies and subsequent livebirths.37 Since 1995, the number ofART procedures performed in theUnited States and the number ofinfants born as a result of theseprocedures have nearly tripled.22

Because many ART proceduresinvolve transferring multipleembryos, ART results in multiple-gestation pregnancies and multiplebirths. The percentage of infants bornpreterm and very preterm is higheramong ART-conceived infants thanamong infants in the total birthpopulation even with elective single-embryo transfers, which involves thetransfer of a single embryo. The

contribution of ART to pretermbirths, the majority of which are alsolow birth weight, is a factor in theincreases observed in the LPT and ETpopulation (Table 1).38,39

SHORT- AND LONG-TERM MEDICAL ANDNEURODEVELOPMENTAL SEQUELAE FORLPT AND ET INFANTS

LPT infants are at increased risk fora number of adverse events, includingrespiratory distress, hypoglycemia,feeding difficulties, hypothermia,hyperbilirubinemia, apnea, seizures,and a higher rate of readmission afterinitial discharge.40,41 In addition, LPTinfants have higher rates ofpulmonary disorders duringchildhood and adolescence, learning

FIGURE 5Preterm birth rates: United States, overall and by race and ethnicity, 2014 and 2018. Source: National Center for Health Statistics, National Vital StatisticsSystem–Natality.

TABLE 1 The Percentage of Preterm Births by Gestational Age Groups Attributable to ART, 2015

Region Preterm (,37 wk)Births Attributable

toART, %

Very Preterm (,32wk) Births

Attributable toART, %

LPT Births (34 1 0/7–36 1 6/7 wk)Attributable to

ART, %

ET Births (37 1 0/7–38 1 6/7 wk)Attributable to

ART, %

UnitedStatesandPuertoRico

5.3 5.4 5.0 2.1

Preterm:,37 wk; very preterm:,32 wk; LPT: 34 0/7–36 6/7 wk; ET: 37 0/7–38 6/7 wk. Source: Analyses of the National ARTSurveillance System (NASS) data. Written communication with the Division of Reproductive Health, National Center forChronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, April 19, 2018.

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difficulties, and subtle, minor deficitsin cognitive function.42 As adults, LPTand ET infants have higher bloodpressure and more often requiretreatment of diabetes.43 In a Swedishcohort, former LPT infants at 18 to36 years of age showed an increasedmortality rate compared with infantsborn at 37 to 42 weeks’ gestation(hazard ratio, 1.31; 95% confidenceinterval, 1.13–1.5).44 Several studieshave described an increased risk ofneurologic, psychiatric, anddevelopmental conditions in thissubset as they mature into adulthood(Table 2).45 The United States doesnot have registries tracking outcomesof infants born at LPT gestations intoadult age groups. However, on thebasis of its national registry, theSwedish National Cohort Studyreported a stepwise increase indisability rates in young adulthood,which increased with the degree ofpreterm birth.46

LENGTH OF STAY AND DISCHARGECRITERIA

The duration of birth hospitalizationcorrelates with gestational age atbirth.47,48 Among 235 LPTs at 1 birthcenter, the length of the birthhospitalization (mean 6 SD) was 12.66 10.6 days at 34 weeks’ gestation,6.1 6 5.8 days at 35 weeks’ gestation,and 3.8 6 3.6 days at 36 weeks’gestation. The usual hospital stay fora term infant is 2 days for a vaginaldelivery and 3 days for a cesareandelivery. In addition, hospital

readmission rates are increased forLPT (3.5%) versus term (2.0%)infants.49 Even among infants whowere never in a NICU, thereadmission rate was threefold higherin LPT than in term infants.50 ManyLPT infants are discharged early butrequire readmission for jaundice,feeding problems, respiratorydistress, and proven or suspectedsepsis because of physiologic andmetabolic immaturity.

Early discharge among LPT infantsaffected by discharge criteriaestablished for term infants show anincrease in morbidities. In statewidedata from Massachusetts, all state-resident infants discharged aftera hospital stay of less than 2 nightswere analyzed. In the LPT group(1004 infants), 4.3% were readmittedor required an observational stayversus 2.7% of the term infants (n =24 320). LPT infants were also1.5 times more likely to requirehospital-related care. This studysuggested that LPT infants dischargedearly experience significantly moreneonatal morbidity than term infants;however, this may be true only forbreastfed infants. The authorsconcluded that evidence-basedrecommendations for appropriatedischarge timing and postdischargefollow-up are needed.49

Moderately preterm infants are alsoat increased risk for acute bilirubinencephalopathy. Clinicalmanifestations may be more subtle inthe LPT infant versus the term

infant.51,52 Chronic bilirubinencephalopathy (kernicterus)secondary to high concentrations ofunconjugated bilirubin can result inpermanent neurologic damage. Evenexposure to moderate concentrationsof bilirubin may lead to more subtleyet permanent neurodevelopmentalimpairment, which is labeled asbilirubin-induced neurologicdysfunction.51 Auditory neuropathyspectrum disorder is a commonmanifestation of bilirubin-inducedneurologic dysfunction in the LPTinfant.53

Quinn et al54 recently publisheda review of the literature concerningdischarge criteria for the LPT infant.They found few differences indischarge criteria between infantsin the newborn nursery and thosein the NICU.55 Previously publisheddischarge criteria from the AAPevolved over time and includephysiologic stability and completedscreenings for hearing loss,hyperbilirubinemia, car seat safety,hypoglycemia, critical congenitalheart disease, and sepsis. Parentaleducation was also a majorcomponent of discharge planning,including umbilical cord care,feeding, voiding and/or stooling,and weight gain. In addition, Quinnet al54 recommended maternalscreening assessments fordepression, drug use, a safe homeenvironment, and the existence ofa support system.

A major difference between newborndischarge and discharge criteria forthe LPT infant is the transition tosafe sleep before discharge (supineposition). Given that LPT and ETinfants are at an increased risk ofmorbidity and mortality, greaterefforts are needed to ensure safe andhealthy posthospitalization andhome care practices for thesevulnerable infants.56 Finally,standardized criteria for dischargemay improve outcomes and reducematernal stress in these high-riskgroups.

TABLE 2 Neurologic, Psychiatric, and Developmental Disorders in LPT Infants as Adults

Neurologic and Psychiatric Conditions Relative Risk of LPT Versus Term (95%CI)

Attention-deficit/hyperactivity disorder 1.7 (1.2–2.5)Any psychiatric disorder 3.74 (1.59–8.78)Any anxiety disorder 3.85 (1.52–9.52)Cerebral palsy 2.7 (2.2–3.3)Cognitive disability 1.6 (1.4–1.8)Schizophrenia 1.3 (1.0–1.7)Any disorder of psychological development, behavior, andemotion

1.4 (1.3–1.5)

Adapted from Moster D, Lie RT, Markestad T. Long-term medical and social consequences of preterm birth. N Engl J Med.2008;359(3):262–273; and Kardatzke MA, Rose RS, Engle WA. Late preterm and early term birth: at-risk populations andtargets for reducing such early births. NeoReviews. 2017;18(5):e265–2376. CI, confidence interval.

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Evaluating 161 804 infants in Floridabetween 34 and 41 weeks’ gestationwith a length of stay of #72 hoursrevealed that LPT infants, comparedwith term infants, had a 36% higherrisk for developmental delay ordisability and a 19% higher risk ofsuspension in kindergarten afteradjustment for 15 potentialconfounders. Disability inprekindergarten at 3 and 4 years ofage, exceptional student education,and retention in kindergarten allcarried a 10% to 13% increased riskamong LPT infants. “Not ready tostart school” was borderlinesignificant. The authors concludedthat healthy LPT infants havea greater risk for developmentaldelay and school problems than terminfants through the first 5 years oflife.57

School performance is also a concernin LPT and ET infants. Schoolperformance in this group wasevaluated in a cohort study at 7 yearsof age in the population-basedprospective UK Millennium CohortStudy with .6000 children. Thisstudy used the statutory key stage 1teacher assessment performed in thethird school year in England. Theprimary outcome was not achievingthe expected level ($2) in reading,writing, and mathematics. There wasa statistically significant increasedrisk of poor performance in thoseborn LPT (adjusted relative risk, 1.36;95% confidence interval, 1.09–1.68).ET infants performed statisticallysignificantly worse than the termchildren in 4 of 5 individual subjectdomains but not in the primaryoutcome. This study concluded thatLPT, and to a lesser extent ET, birthnegatively affected academicoutcomes at 7 years of age asmeasured by key stage 1assessments.58

After review of 126 publications, Rajuet al concluded that theoverwhelming majority of adults bornat preterm gestation remain healthyand well, but adult outcomes in

a small but significant fraction ofinfants born preterm are concerning.This population is at a slightly higherrisk for neuropsychological andbehavioral problems, hypertensivedisorders and metabolic syndrome,and developing at an earlier age whencompared with term infants. Pretermbirth should be considered a chroniccondition, and the primary carephysician should glean thisinformation; this would potentiateearly diagnoses and timelyintervention.59 Because of theresearch gaps that exist, the USNational Institutes of Healthconvened a multidisciplinaryconference with experts on adultdiseases in infants born preterm andproposed a research agenda.60

PRACTICAL CONSIDERATIONS

Acceptance that early birth is not aninevitable and natural feature ofhuman reproduction is the first stepin ameliorating the societal burden ofLPT and ET births.17 LPT and ETbirths are not caused by a singleentity but are the result ofa heterogeneous group of conditionsthat affect the mother and/or fetus.61

Potential interventions to reduce LPTbirths include the following:

1. prevention of exposure ofpregnant women to cigarettesmoke,19

2. judicious use of non-ART fertilitytreatments and ART treatments(eg, elective single-embryotransfer),39

3. improvement of preconceptionhealth to reduce chronic medicalconditions such as diabetes,obesity, and poor nutrition,15 and

4. encouragement of longerinterpregnancy interval becausea short interpregnancy interval of,6 months poses a higher risk ofLPT delivery.62–64

Further success can be anticipated inthe future as other researchdiscoveries are translated into clinicalpractice, including new approaches to

treating intrauterine infection,improving maternal nutrition, andlifestyle modifications to decreasestress.17

RECOMMENDATIONS

Accounting for approximately 32%of nearly 4 million live birthsannually, LPT and ET births remaina challenge, with a recent increaseseen in rates in the United States.Pediatricians can continue to play animportant role in the reduction ofthese at-risk births.

1. LPT and ET infants have increasedrisks of adverse medical,neurodevelopmental, behavioral,and social sequelae into andthrough adulthood. Neonatologistsand pediatricians can continue tounderstand these risks and informparents, educators, and adult careclinicians.

2. Continued use of population datawithin hospitals, states, regions,and networks will help to monitorrates of LPT and ET births fortrends, changes in practice, andneed for intervention.

3. Promising interventions existto prevent LPT and ET births,but these interventions need tobe adopted and disseminatedequitably and financed bypayers adequately to reducedisparities.

4. Multidisciplinary discussions andplanning with obstetric providerswill improve the understanding ofthe causes of and indications forLPT and ET deliveries with theintention of preventing iatrogenicdeliveries.18, 65

5. Health care providers for all agegroups should consider obtaininga patient’s birth history to includegestational age asa comprehensive means ofevaluating and predicting currentand future health.48,49

6. Because these at-risk populationsof LPT and ET infants are at risk

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for adverse health outcomes, thesegroups should be added topayment models that betterfinance practitioners who have toincrease their outreach, screening,and treatment to provideappropriate care to these patients.

LEAD AUTHORS

Dan L. Stewart, MD, FAAPWanda D. Barfield, MD, MPH, FAAP, RADMUSPHS

COMMITTEE ON FETUS AND NEWBORN,2018–2019

James J. Cummings, MD, FAAP, ChairpersonIra S. Adams-Chapman, MD, FAAP

Susan Wright Aucott, MD, FAAPJay P. Goldsmith, MD, FAAPIvan L. Hand, MD, FAAPSandra E. Juul, MD, PhD, FAAPBrenda Bradley Poindexter, MD, MS, FAAPKaren Marie Puopolo, MD, PhD, FAAPDan L. Stewart, MD, FAAP

LIAISONS

Wanda D. Barfield, MD, MPH, FAAP, RADMUSPHSYasser El-Sayed, MDErin L. Keels, DNP, APRN, NNP-BC – NationalAssociation of Neonatal NursesMeredith Mowitz, MD, MS, FAAPMichael Ryan Narvey, MD, FAAP – CanadianPaediatric SocietyTonse N. K. Raju, MD, DCH, FAAP – NationalInstitutes of Health

Kasper S. Wang, MD, FACS, FAAP – Section onSurgery

STAFF

Jim Couto, MA

ABBREVIATIONS

AAP: American Academy ofPediatrics

ACOG: American College of Obste-tricians and Gynecologists

ART: assisted reproductivetechnology

ET: early-termLPT: late-preterm

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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