The Journal of Pediatrics
Volume 149, Issue 4 , Page 440, October 2006

The Apgar challenge

  • William Keenan, MD

      Affiliations

    • Corresponding Author InformationReprint requests: William Keenan, MD, Cardinal Glennon Children’s Hospital, Neonatal-Perinatal Medicine, 1465 South Grand Boulevard, St. Louis, MO 63104.

Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, St. Louis, MO

Article Outline

 

Virginia Apgar’s most enduring contribution is the Apgar score for neonatal assessment, which is used in virtually every country in the world. Apgar developed a simple method to evaluate the newly born infant. She hoped that the score would provide additional focus on the infant’s well being, generate a systematic, easily done evaluation to facilitate a number of perinatal comparisons, and serve as an index of the effects of resuscitation.1 Although the Apgar score at 1 minute has been used to determine whether active resuscitation should be initiated, Apgar herself stated characteristically that “this, of course, is wrong.”2

See related article, p 486

The usefulness of the Apgar score has been questioned because of its limited, but not negligible, predictive value for early neonatal acidosis, mortality, asphyxial syndrome, and long-term outcome.3, 4 Others, including Apgar, have stated that color as part of the score has little predictive value and that prematurity influences the vigor of respiratory effort, muscle tone, and reflex responses, which make up a significant portion of the score.5 Parent and provider expectations are known to significantly inflate the score, and the lack of contemporaneous assessment likely contributes to considerable variability.

The continuing value of the Apgar score was recently examined in 2 large neonatal cohorts.6, 7 The relative mortal risks of newborns with low 5-minute scores compared with newborns with high 5-minute scores were 14.4 and 59 in these studies.

The difficulties that individual professionals have with Apgar assessment itself have been pointed out often. Paneth and Fox8 identified a 10-fold overestimate of the impact of a low 5-minute score on handicap by 172 maternal and other health care professionals. Clark and Hakason9 used descriptive cases to test Apgar score assignments by 223 providers of neonatal care and found that only 40% of those tested accurately characterized all 8 case senarios. Lopriore et al10 used 3 case descriptions to test 166 pediatric professionals; correct responses ranged from 16% to 68% for the 3 groups.

In their study reported in this issue of The Journal, O’Donnell et al11 assessed the assignment of 5-minute Apgar scores in a tertiary care setting. Post hoc assessments using video recordings taken 5 minutes after delivery were compared with the clinical assessments made by a neonatal care provider. Color, which Apgar felt was the least useful score component, was not used. A maximum score under these circumstances was 8. The variability among the 42 video scorers was substantial, the reliability was poor for all 4 elements of the score, and the standard deviation of the total video scores was 1.9. The scores determined clinically varied significantly from the video assessments, with only 9 of the 30 clinical assessments included within the interquartile range of the video assessments. Twenty of the 30 clinical assessments were 2 or more points higher than the corresponding video assessment, with greater deviation at lower scores.

How are we to respond to these appalling data, which, although gathered uniquely, are consistent with previous observations? Should fiction or fantasy be tolerated at the bedside? Do we give up? A 1998 editorial in Lancet called for the Apgar score to “… be pensioned off.”12 On the other hand, the Apgar score’s overall usefulness has been well demonstrated, and it still has value in systemic assessment of the newborn.

In view of this current study and others cited, the sustained value of the Apgar score requires improved reliability, confrontation of sources of variance, unequivocal performance expectations, better training, and investment in quality control. We can do better, and improved neonatal assessment in the delivery setting is the minimum we owe to the vulnerable neonatal population and to honor the lady of the score, Virginia Apgar.

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References 

  1. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32:260–267
  2. Apgar V. The newborn (Apgar) scoring system. Ped Clin North Am. 1960;13:645–650
  3. Sykes GS, Johnson P, Ashworth F, Malloy PM, Gu W, Stirral G. Do Apgar scores indicate asphyxia?. Lancet. 1982;1:494–496
  4. Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics. 1981;68:36–44
  5. Catlin EA, Carpenter MW, Brann BS, Mayfield SR, Shaul PW Goldstein M, et al. The Apgar score revisted: influence of gestational age. J Pediatr. 1986;109:865–868
  6. Thorngren-Jerneck K, Herbst A. Low 5-minute Apgar score: a population-based register study of 1 million term births. Obstet Gynecol. 2001;98:65–70
  7. Casey BM, McIntyre DD, Leveno KJ. The continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med. 2001;344:467–471
  8. Paneth N, Fox HE. The relationship of Apgar score to neurologic handicap: a survey of clinicians. Obstet Gynecol. 1983;61:547–550
  9. Clark DA, Hakanson DO. The inaccuracy of Apgar scoring. J Perinatol. 1988;8:203–205
  10. Lopriore E, van Burk GF, Walther FJ, de Beaufort AJ. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ. 2004;329:143–144
  11. O’Donnell CPF, Kamlin COF, Davis PG, Carlin JB, Morley CJ. Interobserver variability of the 5-minute Apgar score. J Pediatr. 2006;149:486–489
  12. Is the Apgar score outmoded?. Lancet. 1989;1:591–592

PII: S0022-3476(06)00788-8

doi:10.1016/j.jpeds.2006.08.023

Refers to article:

  • Interobserver variability of the 5-minute Apgar score

    Colm P.F. O’Donnell, C. Omar F. Kamlin, Peter G. Davis, John B. Carlin, Colin J. Morley
    The Journal of Pediatrics October 2006 (Vol. 149, Issue 4, Pages 486-489)

The Journal of Pediatrics
Volume 149, Issue 4 , Page 440, October 2006

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