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Apgar score and risk of cause-specific infant mortality

2015; Elsevier BV; Volume: 385; Issue: 9967 Linguagem: Inglês

10.1016/s0140-6736(15)60196-9

1474-547X

Mario Rüdiger, Dimitrios Konstantelos,

Neonatal and fetal brain pathology

More than 60 years ago, Virginia Apgar proposed a score to describe the postnatal condition of every newborn.1Apgar V A proposal for a new method of evaluation of the newborn infant.Curr Res Anesth Analg. 1953; 32: 260-267Crossref PubMed Scopus (1318) Google Scholar Despite Virginia Apgar's warnings not to overinterpret the score for predicting outcome,1Apgar V A proposal for a new method of evaluation of the newborn infant.Curr Res Anesth Analg. 1953; 32: 260-267Crossref PubMed Scopus (1318) Google Scholar many research papers reported an association between Apgar score and long-term outcome (up to 18 years of age).2Odd DE Rasmussen F Gunnell D Lewis G Whitelaw A A cohort study of low Apgar scores and cognitive outcomes.Arch Dis Child Fetal Neonatal Ed. 2008; 93: F115-F120Crossref PubMed Scopus (85) Google Scholar Stamatina Iliodromiti and colleagues3Iliodromiti S Mackay DF Smith GCS Pell JP Nelson SM Apgar score and the risk of cause-specific infant mortality: a population-based cohort study.Lancet. 2014; 384: 1749-1755Summary Full Text Full Text PDF PubMed Scopus (151) Google Scholar reported a strong association between low Apgar score at 5 min and the risk of neonatal and infant death. Several studies have questioned the reliability and validity of the Apgar score. At present, use of this score in clinical routine shows great inter-observer and intra-observer variability.4O'Donnell CP Kamlin CO Davis PG Carlin JB Morley CJ Interobserver variability of the 5-minute Apgar score.J Pediatr. 2006; 149: 486-489Summary Full Text Full Text PDF PubMed Scopus (137) Google Scholar Centres scoring case descriptions with a low Apgar score also had lower Apgar scores for preterm infants than did centres giving case descriptions higher Apgar scores.5Rüdiger M Küster H Herting E et al.Variations of Apgar score of very low birth weight infants in different neonatal intensive care units.Acta Paediatr. 2009; 98: 1433-1436Crossref PubMed Scopus (26) Google Scholar The present poor reliability of the Apgar score is attributable to changes in the care of newborn infants during the past 60 years. Very immature infants who might previously have died now survive and their condition is assessed by the Apgar score. However, approaches to score immature muscle tone and reflex responses of infants differ in and between single centres. Furthermore, many infants now receive medical interventions during the first minutes of life, but how to score an infant receiving medical support is not standardised. To establish the risk of death or the need for further interventions, the newborn's actual condition should be scored according to the Apgar score (irrespective of the intervention needed). For example, the chance of survival in an infant with apnoea (eg, respiration scored zero) will differ if it receives sufficient mechanical ventilation, ineffective respiratory support, or no respiratory support. To overcome this problem, we previously suggested specifying the Apgar score to describe an infant's condition irrespective of gestational age or interventions received. Furthermore, the American Academy of Pediatrics suggested an expansion of the score to describe the interventions an infant received.6American Academy of PediatricsCommittee on Fetus and NewbornAmerican College of Obstetricians and GynecologistsCommittee on Obstetric PracticeThe Apgar score.Pediatrics. 2006; 117: 1444-1447Crossref PubMed Scopus (184) Google Scholar This Combined-Apgar (specified and expanded) describes both an infant's condition and the interventions needed.7Rüdiger M Braun N Gurth H Bergert R Dinger J Preterm resuscitation I: clinical approaches to improve management in delivery room.Early Hum Dev. 2011; 87: 749-753Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar In the Combined-Apgar, a maximum of 17 points describes an infant who received no intervention and had undisturbed vital parameters, whereas an infant with a score of zero received all necessary interventions, but did not respond to them. The TEST-APGAR study consortium tested the Combined-Apgar score in more than 2000 preterm infants in a prospective, international, multicentre study. Findings showed this modified score to be useful in prediction of short-term outcome of infants; but our manuscript was not accepted for publication (including by The Lancet). Whereas Iliodromiti and colleagues3Iliodromiti S Mackay DF Smith GCS Pell JP Nelson SM Apgar score and the risk of cause-specific infant mortality: a population-based cohort study.Lancet. 2014; 384: 1749-1755Summary Full Text Full Text PDF PubMed Scopus (151) Google Scholar summarised their findings of an association to “support its [Apgar score] continued usefulness in contemporary practice”, we question this conclusion. The conventional Apgar might be useful to describe an association in groups of infants; however, changes to perinatal care necessitate a reformation of the conventional Apgar, and the Combined-Apgar represents a chance to do so. We declare no competing interests. Apgar score and the risk of cause-specific infant mortality: a population-based cohort studyLow Apgar score at 5 min was strongly associated with the risk of neonatal and infant death. Our findings support its continued usefulness in contemporary practice. Full-Text PDF Apgar score and risk of cause-specific infant mortality – Authors' replyWe acknowledge the concerns of Caren Lanting and Jacobus van Wouwe; the mothers' age of 10 years was an a priori threshold established before the analysis on the basis of biological plausibility that there might be no records of births by mothers younger than this age. Full-Text PDF