AAP/ACOG Revise Statement on Use of Apgar Score

Diana Phillips

September 29, 2015

The Apgar score does not predict individual neonatal mortality or neurological outcomes, and thus should not be used for that purpose, according to a joint policy statement issued by the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG), published online September 28 in Pediatrics.

The revised statement reflects an effort by the AAP and ACOG to place the Apgar score "in its proper perspective," the authors write.

"We want to keep the Apgar score in the forefront of the clinicians' minds: what it can and cannot do," Kristi L. Watterberg, MD, FAAP, chairwoman of the 2014-2015 AAP Committee on Fetus and Newborn, told Medscape Medical News. "It cannot predict individual outcomes but is a useful tool for communication between professionals and for overall population studies."

For the updated policy statement, the authors revised the 2006 ACOG Committee Opinion/AAP Policy Statement to include guidance from the 2014 ACOG/AAP collaborative report "Neonatal Encephalopathy and Neurologic Outcomes." "We incorporated the language of this document as it relates to asphyxia and the Apgar score," Dr Watterberg said.

The five-component Apgar score "is an expression of the infant's physiologic condition at 1 point in time," the authors write. As such, it continues to be an accepted and convenient method for evaluating and reporting newborn infant status immediately after birth and for reporting infant response to resuscitation when resuscitation is required.

However, it should not be used "to determine the need for initial resuscitation, what resuscitation steps are necessary, or when to use them," the authors stress, as resuscitation must be initiated before the 1-minute score is assigned.

When properly applied, the Apgar score is a tool for standardized assessment, and it provides a mechanism to record fetal-to-neonatal transition. It is not predictive of long-term developmental outcomes.

"The healthy preterm infant with no evidence of asphyxia may receive a low score only because of immaturity," the authors write.

"A 5-minute Apgar score of 0 to 3 correlates with neonatal mortality in large populations but does not predict individual future neurologic dysfunction."

Misinterpretation of research efforts focused on establishing a correlation between developmental outcomes and individual Apgar scores has in some cases led to the use of Apgar scores to predict long-term outcomes, according to Dr Watterberg. This practice, which is not supported by scientific evidence, "is not appropriate as the Apgar score is currently defined."

In addition to the recommendation that the Apgar score not be used to predict individual neonatal mortality or neurologic outcome, the revised guidelines also state that:

  • The Apgar score alone should not be used to diagnose asphyxia. "The term asphyxia, which describes a process of varying severity and duration rather than an end point, should not be applied to birth events unless specific evidence of markedly impaired intrapartum or immediate postnatal gas exchange can be documented on the basis of laboratory test results," the authors write.

  • Umbilical arterial blood gas samples from a clamped section of the umbilical cord should be obtained for infants with an Apgar score of 5 or less at 5 minutes. In such cases, there may be value in submitting the placenta for pathologic examination.

  • Perinatal healthcare professionals should be consistent in assigning an Apgar score during resuscitation. Because there is currently no accepted standard for reporting an Apgar score in infants undergoing resuscitation after birth, "[t]o correctly describe such infants and provide accurate documentation and data collection, an expanded Apgar score reporting form is encouraged," the authors write.

The expanded Apgar score reporting form provides space for recording Apgar scores at 1, 5, 10, 15, and 20 minutes as well as resuscitation efforts at those times and a space for additional information.

"We want to reiterate the utility of the Apgar score," according to Dr Watterberg. "Additionally, we want to remind people that the expanded Apgar scoring table can include the resuscitative efforts ongoing, to give a better picture of what's being done for the baby and how the baby is responding."

Pediatrics. Published online September 28, 2015. Full text

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