BACKGROUND AND PURPOSE:

• There is data associated with lower Apgar scores and poor neurologic outcomes
• The Apgar Score is named after Dr. Virginia Apgar
  • Skin color (0=blue or pale; 1=blue at extremities; 2=no cyanosis)
  • Pulse rate (0=absent; 1=<100 bpm; 2=>100 bpm)
  • Reflex irritability w/ stimulation (0=no response; 1= grimace; 2=cry)
  • Activity (0=none; 1=some flexion; 2=flexion/resists extension)
  • Respiratory effort (0=absent; 1=weak/irregular; 2+strong, robust cry)
• Apgar scoring in general is as follows
  • 7-10: Normal
  • 4-6: Low
  • ≤3: Critically Low
• However, there is limited data on
  • Full range of Apgar scores from 1-10
  • Whether the change in scores between 5 to 10 minute Apgars (including among normal scores) is relevant and has any influence on risk for cerebral palsy (CP) and epilepsy
• Persson et al. (BMJ 2018) investigated whether there is an association between Apgar scores at five and ten minutes and risk of childhood CP or epilepsy

METHODS:

• Population-based cohort study
• Data on maternal and pregnancy characteristics and diagnoses of cerebral palsy and epilepsy were obtained by individual record linkages
• All patients received Apgar scores at 5 and 10 minutes
• The primary outcome was cerebral palsy and epilepsy diagnosed up to 16 years of age
• Adjusted hazard ratio (HR) was used, along with 95% confidence intervals

RESULTS:

• Data was collected from 1,213,470 live, term singleton infants without malformations
  • 1,221(0.1%) children were diagnosed as having cerebral palsy
  • 3,957(0.3%) were diagnosed with epilepsy
• Compared with children with an Apgar score of 10 at five minutes, the adjusted HR for cerebral palsy increased steadily with decreasing Apgar score
  • Risk increased from 1.9 (95% CI, 1.6 to 2.2) for an Apgar score of 9 to 277.7 (95% CI, 154.4 to 499.5) for an Apgar score of 0
• A similar correlation was observed to a stronger degree between Apgar scores at 10 minutes
• Associations between Apgar scores and epilepsy were less pronounced
  • Increased HRs were noted in infants with a 5 minute Apgar score of 7 or less and a 10 minute Apgar score of 8 or less

When comparing the change between 5 and 10 minutes scores

• Highest HRs were seen in offspring with a very low Apgar score at both five and 10 minutes
• Increasing Apgar scores from five to 10 minutes were associated with decreasing HR of CP
• Children with a score of 7-8 at both five and 10 minutes had a higher risk for CP than children with an Apgar score of 9-10 at both five and 10 minutes (HR of 5.3)
• HRs for CP were also significantly higher among children with five minutes Apgar score of 9 and a 10 minute Apgar score of 10 compared with infants who had an Apgar score of 10 at both five and 10 minutes
  • Adjusted HR 1.3, 95% CI, 1.0 to 1.5

CONCLUSION:

• Risk of cerebral palsy and epilepsy are inversely related to Apgar score
• The authors suggest that

[t]he finding that children with five minute Apgar scores of 7-8 and 10 minute Apgar scores of 7-8 have higher hazard ratios of cerebral palsy and epilepsy (hazard ratios were 5.3 and 1.5, respectively) is concerning and warrants critical attention from the resuscitation community.

Learn More – Primary Sources:

Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden

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