POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

The Apgar ScoreAMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON FETUS AND NEWBORN,AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE

abstractThe Apgar score provides an accepted and convenient method for reportingthe status of the newborn infant immediately after birth and the response toresuscitation if needed. The Apgar score alone cannot be considered asevidence of, or a consequence of, asphyxia; does not predict individualneonatal mortality or neurologic outcome; and should not be used for thatpurpose. An Apgar score assigned during resuscitation is not equivalent toa score assigned to a spontaneously breathing infant. The American Academyof Pediatrics and the American College of Obstetricians and Gynecologistsencourage use of an expanded Apgar score reporting form that accounts forconcurrent resuscitative interventions.

INTRODUCTION

In 1952, Dr Virginia Apgar devised a scoring system that was a rapidmethod of assessing the clinical status of the newborn infant at 1 minuteof age and the need for prompt intervention to establish breathing.1

Dr Apgar subsequently published a second report that included a largernumber of patients.2 This scoring system provided a standardizedassessment for infants after delivery. The Apgar score comprises 5components: (1) color; (2) heart rate; (3) reflexes; (4) muscle tone; and(5) respiration. Each of these components is given a score of 0, 1, or 2.Thus, the Apgar score quantitates clinical signs of neonatal depression,such as cyanosis or pallor, bradycardia, depressed reflex response tostimulation, hypotonia, and apnea or gasping respirations. The score isreported at 1 minute and 5 minutes after birth for all infants, and at5-minute intervals thereafter until 20 minutes for infants with a score lessthan 7.3 The Apgar score provides an accepted and convenient method forreporting the status of the newborn infant immediately after birth and theresponse to resuscitation if it is needed; however, it has beeninappropriately used to predict individual adverse neurologic outcome.

The purpose of the present statement was to place the Apgar score in itsproper perspective. This statement revises the 2006 College CommitteeOpinion/American Academy of Pediatrics policy statement to includeupdated guidance from the 2014 report Neonatal Encephalopathy andNeurologic Outcome (second edition)4 published by the American College

This document is copyrighted and is the 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.

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

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

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

Also published in Obstetrics & Gynecology. Copyright October 2015 bythe American College of Obstetricians and Gynecologists, 409 12thStreet, SW, PO Box 96920, Washington, DC 20090-6920 and the AmericanAcademy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk GroveVillage, IL 60009-0927. All rights reserved. ISSN 1074-8613

The American College of Obstetricians and Gynecologists CommitteeOpinion no. 644: The Apgar score. Obstet Gynecol. 2015;126:e52–e55.Accepted for publication Jul 22, 2015

www.pediatrics.org/cgi/doi/10.1542/peds.2015-2651

DOI: 10.1542/peds.2015-2651

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

Copyright © 2015 by the American Academy of Pediatrics

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of Obstetricians and Gynecologists incollaboration with the AmericanAcademy of Pediatrics, along with newguidance on neonatal resuscitation.The guidelines of the NeonatalResuscitation Program state that theApgar score is useful for conveyinginformation about the newborninfant’s overall status and response toresuscitation. However, resuscitationmust be initiated before the 1-minutescore is assigned. Therefore, the Apgarscore is not used to determine theneed for initial resuscitation, whatresuscitation steps are necessary, orwhen to use them.3

An Apgar score that remains0 beyond 10 minutes of age may,however, be useful in determiningwhether continued resuscitativeefforts are indicated because very fewinfants with an Apgar score of 0 at10 minutes have been reported tosurvive with a normal neurologicoutcome.3,5,6 In line with thisoutcome, the 2011 NeonatalResuscitation Program guidelinesstate that “if you can confirm that noheart rate has been detectable for atleast 10 minutes, discontinuation ofresuscitative efforts may beappropriate.”3

The Neonatal Encephalopathy andNeurologic Outcome report definesa 5-minute Apgar score of 7 to 10 asreassuring, a score of 4 to 6 asmoderately abnormal, and a score of0 to 3 as low in the term infant andlate-preterm infant.4 In that report,an Apgar score of 0 to 3 at 5 minutesor more was considered a nonspecificsign of illness, which “may be one ofthe first indications ofencephalopathy.” However,a persistently low Apgar score aloneis not a specific indicator forintrapartum compromise.Furthermore, although the score iswidely used in outcome studies, itsinappropriate use has led to anerroneous definition of asphyxia.Asphyxia is defined as the markedimpairment of gas exchange, which, ifprolonged, leads to progressive

hypoxemia, hypercapnia, andsignificant metabolic acidosis. Theterm asphyxia, which describesa process of varying severity andduration rather than an end point,should not be applied to birth eventsunless specific evidence of markedlyimpaired intrapartum or immediatepostnatal gas exchange can bedocumented on the basis oflaboratory test results.

LIMITATIONS OF THE APGAR SCORE

It is important to recognize thelimitations of the Apgar score. It is anexpression of the infant’s physiologiccondition at 1 point in time, whichincludes subjective components.There are numerous factors that caninfluence the Apgar score, includingmaternal sedation or anesthesia,congenital malformations, gestationalage, trauma, and interobservervariability.4 In addition, thebiochemical disturbance must besignificant before the score isaffected. Elements of the score, suchas tone, color, and reflex irritability,can be subjective and partiallydepend on the physiologic maturity ofthe infant. The score may also beaffected by variations in normaltransition. For example, lower initialoxygen saturations in the first fewminutes need not promptimmediate supplemental oxygenadministration; the NeonatalResuscitation Program targets foroxygen saturation are 60% to 65% at 1minute and 80% to 85% at 5 minutes.3

The healthy preterm infant with noevidence of asphyxia may receive a lowscore only because of immaturity.7,8

The incidence of low Apgar scores isinversely related to birth weight, anda low score cannot predict morbidityor mortality for any individualinfant.8,9 As previously stated, it is alsoinappropriate to use an Apgar scorealone to diagnose asphyxia.

APGAR SCORE AND RESUSCITATION

The 5-minute Apgar score, andparticularly a change in the score

between 1 minute and 5 minutes, isa useful index of the response toresuscitation. If the Apgar score isless than 7 at 5 minutes, the NeonatalResuscitation Program guidelinesstate that the assessment should berepeated every 5 minutes for up to20 minutes.3 However, an Apgar scoreassigned during resuscitation is notequivalent to a score assigned toa spontaneously breathing infant.10

There is no accepted standard forreporting an Apgar score in infantsundergoing resuscitation after birthbecause many of the elementscontributing to the score are alteredby resuscitation. The concept of anassisted score that accounts forresuscitative interventions has beensuggested, but the predictivereliability has not been studied. Tocorrectly describe such infants andprovide accurate documentation anddata collection, an expanded Apgarscore reporting form is encouraged(Fig 1). This expanded Apgar scoremay also prove useful in the setting ofdelayed cord clamping, in which thetime of birth (ie, complete delivery ofthe infant), the time of cord clamping,and the time of initiation ofresuscitation can all be recorded inthe comments box.

The Apgar score alone cannot beconsidered to be evidence of ora consequence of asphyxia. Manyother factors, includingnonreassuring fetal heartrate–monitoring patterns andabnormalities in umbilical arterialblood gas results, clinical cerebralfunction, neuroimaging studies,neonatal electroencephalography,placental pathology, hematologicstudies, and multisystem organdysfunction, need to be considered indiagnosing an intrapartumhypoxic–ischemic event.6 Whena category I (normal) or category II(indeterminate) fetal heart ratetracing is associated with Apgarscores of 7 or higher at 5 minutes,a normal umbilical cord arterial bloodpH (61 SD), or both, it is not

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consistent with an acutehypoxic–ischemic event.4

PREDICTION OF OUTCOME

A 1-minute Apgar score of 0 to 3 doesnot predict any individual infant’soutcome. A 5-minute Apgar score of0 to 3 correlates with neonatalmortality in large populations11,12

but does not predict individual futureneurologic dysfunction. Populationstudies have uniformly reassured usthat most infants with low Apgarscores will not develop cerebral palsy.However, a low 5-minute Apgar scoreclearly confers an increased relativerisk of cerebral palsy, reported to beas high as 20- to 100-fold over that ofinfants with a 5-minute Apgar scoreof 7 to 10.9,13–15 Although individualrisk varies, the population risk ofpoor neurologic outcomes alsoincreases when the Apgar score is 3or less at 10 minutes, 15 minutes, and20 minutes.16 When a newborn infanthas an Apgar score of 5 or less at5 minutes, umbilical arterial bloodgas samples from a clamped sectionof the umbilical cord should beobtained, if possible.17 Submitting theplacenta for pathologic examinationmay be valuable.

OTHER APPLICATIONS

Monitoring of low Apgar scores froma delivery service may be useful.Individual case reviews can identifyneeds for focused educationalprograms and improvement insystems of perinatal care. Analyzingtrends allows for the assessment ofthe effect of quality improvementinterventions.

CONCLUSIONS

The Apgar score describes thecondition of the newborn infantimmediately after birth and, whenproperly applied, is a tool forstandardized assessment.18 It alsoprovides a mechanism to record fetal-to-neonatal transition. Apgar scoresdo not predict individual mortality oradverse neurologic outcome.However, based on populationstudies, Apgar scores of less than 5 at5 and 10 minutes clearly confer anincreased relative risk of cerebralpalsy, and the degree of abnormalitycorrelates with the risk of cerebralpalsy. Most infants with low Apgarscores, however, will not developcerebral palsy. The Apgar score isaffected by many factors, includinggestational age, maternal

medications, resuscitation, andcardiorespiratory and neurologicconditions. If the Apgar score at5 minutes is 7 or greater, it is unlikelythat peripartum hypoxia–ischemiacaused neonatal encephalopathy.

RECOMMENDATIONS

1. The Apgar score does not predictindividual neonatal mortality orneurologic outcome and shouldnot be used for that purpose.

2. It is inappropriate to use the Apgarscore alone to establish the di-agnosis of asphyxia. The term as-phyxia, which describes a processof varying severity and durationrather than an end point, shouldnot be applied to birth events un-less specific evidence of markedlyimpaired intrapartum or immedi-ate postnatal gas exchange can bedocumented.

3. When a newborn infant has anApgar score of 5 or less at 5minutes, umbilical arterial bloodgas samples from a clamped sec-tion of the umbilical cord shouldbe obtained. Submitting the pla-centa for pathologic examinationmay be valuable.

4. Perinatal health care professionalsshould be consistent in assigningan Apgar score during re-suscitation; therefore, the Ameri-can Academy of Pediatrics and theAmerican College of Obstetriciansand Gynecologists encourage useof an expanded Apgar scorereporting form that accounts forconcurrent resuscitativeinterventions.

AAP COMMITTEE ON FETUS AND NEWBORN,2014–2015

Kristi L. Watterberg, MD, FAAP, ChairpersonSusan Aucott, MD, FAAPWilliam E. Benitz, MD, FAAPJames J. Cummings, MD, FAAPEric C. Eichenwald, MD, FAAPJay Goldsmith, MD, FAAPBrenda B. Poindexter, MD, FAAPKaren Puopolo, MD, FAAPDan L. Stewart, MD, FAAPKasper S. Wang, MD, FAAP

FIGURE 1Expanded Apgar score reporting form. Scores should be recorded in the appropriate place atspecific time intervals. The additional resuscitative measures (if appropriate) are recorded at thesame time that the score is reported by using a checkmark in the appropriate box. The commentbox is used to list other factors, including maternal medications and/or the response to re-suscitation between the recorded times of scoring. ETT, endotracheal tube; PPV/NCPAP, positivepressure ventilation/nasal continuous positive airway pressure.

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LIAISONS

Captain Wanda D. Barfield, MD, MPH, FAAP – Centers

for Disease Control and Prevention

James Goldberg, MD – American College of

Obstetricians and Gynecologists

Thierry Lacaze, MD – Canadian Pediatric Society

Erin L. Keels, APRN, MS, NNP-BC – National

Association of Neonatal Nurses

Tonse N.K. Raju, MD, DCH, FAAP – National Institutes

of Health

STAFF

Jim Couto, MA

ACOG COMMITTEE ON OBSTETRIC PRACTICE,2014–2015

Jeffrey L. Ecker, MD, ChairpersonJoseph R. Wax, MD, Vice ChairpersonAnn Elizabeth Bryant Borders, MDYasser Yehia El-Sayed, MDR. Phillips Heine, MDDenise J. Jamieson, MDMaria Anne Mascola, MDHoward L. Minkoff, MDAlison M. Stuebe, MDJames E. Sumners, MDMethodius G. Tuuli, MDKurt R. Wharton, MD

LIAISONS

Debra Bingham, DrPh, RN – Association of Women’s

Health Obstetric Neonatal Nurses

Sean C. Blackwell, MD – Society for Maternal–Fetal

Medicine

William M. Callaghan, MD – Centers for Disease

Control and Prevention

Julia Carey-Corrado, MD – US Food and Drug

Administration

Beth Choby, MD – American Academy of Family

Physicians

Joshua A. Copel, MD – American Institute of

Ultrasound in Medicine

Nathaniel DeNicola, MD, MS – American Academy of

Pediatrics Council on Environmental Health (ACOG

liaison)

Tina Clark-Samazan Foster, MD – Committee on

Patient Safety and Quality Improvement – Ex-Officio

William Adam Grobman, MD – Committee on Practice

Bulletins-Obstetrics – Ex-Officio

Rhonda Hearns-Stokes, MD – US Food and Drug

Administration

Tekoa King, CNM, FACNM – American College of Nurse-

Midwives

Uma Reddy, MD, MPH – National Institute of Child

Health and Human Development

Kristi L. Watterberg, MD – American Academy of

Pediatrics

Cathy H. Whittlesey – Executive Board – Ex-Officio

Edward A. Yaghmour, MD – American Society of

Anesthesiologists

STAFF

Gerald F. Joseph, Jr, MDMindy Saraco, MHADebra Hawks, MPHMargaret VillalongaAmanda Guiliano

REFERENCES

1. Apgar V. A proposal for a new method ofevaluation of the newborn infant. CurrRes Anest Anal. 1953;32(4):260–267

2. Apgar V, Holaday DA, James LS, WeisbrotIM, Berrien C. Evaluation of the newborninfant; second report. J Am Med Assoc.1958;168(15):1985–1988

3. American Academy of Pediatrics andAmerican Heart Association. Textbook ofNeonatal Resuscitation. 6th ed. Elk GroveVillage, IL: American Academy ofPediatrics and American HeartAssociation; 2011

4. American College of Obstetrics andGynecology, Task Force on NeonatalEncephalopathy, American Academy ofPediatrics. Neonatal Encephalopathy andNeurologic Outcome. 2nd ed.Washington, DC: American College ofObstetricians and Gynecologists; 2014

5. Jain L, Ferre C, Vidyasagar D, Nath S,Sheftel D. Cardiopulmonary resuscitationof apparently stillborn infants: survivaland long-term outcome. J Pediatr. 1991;118(5):778–782

6. Kasdorf E, Laptook A, Azzopardi D, JacobsS, Perlman JM. Improving infant outcomewith a 10 min Apgar of 0. Arch Dis ChildFetal Neonatal Ed. 2015;100(2):F102–F105

7. Catlin EA, Carpenter MW, Brann BS IV,et al. The Apgar score revisited:

influence of gestational age. J Pediatr.1986;109(5):865–868

8. Hegyi T, Carbone T, Anwar M, et al. TheApgar score and its components in thepreterm infant. Pediatrics. 1998;101(1 pt1):77–81

9. Ehrenstein V. Association of Apgarscores with death and neurologicdisability. Clin Epidemiol. 2009;1:45–53

10. Lopriore E, van Burk GF, Walther FJ, deBeaufort AJ. Correct use of the Apgarscore for resuscitated and intubatednewborn babies: questionnaire study.BMJ. 2004;329(7458):143–144

11. Casey BM, McIntire DD, Leveno KJ. Thecontinuing value of the Apgar score forthe assessment of newborn infants. NEngl J Med. 2001;344(7):467–471

12. Li F, Wu T, Lei X, Zhang H, Mao M, Zhang J.The Apgar score and infant mortality.PLoS One. 2013;8(7):e69072

13. Moster D, Lie RT, Irgens LM, Bjerkedal T,Markestad T. The association of Apgarscore with subsequent death andcerebral palsy: a population-based studyin term infants. J Pediatr. 2001;138(6):798–803

14. Nelson KB, Ellenberg JH. Apgar scores aspredictors of chronic neurologicdisability. Pediatrics. 1981;68(1):36–44

15. Lie KK, Grøholt EK, Eskild A. Association ofcerebral palsy with Apgar score in lowand normal birthweight infants:population based cohort study. BMJ.2010;341:c4990

16. Freeman JM, Nelson KB. Intrapartumasphyxia and cerebral palsy. Pediatrics.1988;82(2):240–249

17. Malin GL, Morris RK, Khan KS. Strength ofassociation between umbilical cord pHand perinatal and long term outcomes:systematic review and meta-analysis.BMJ. 2010;340:c1471

18. Papile LA. The Apgar score in the 21stcentury. N Engl J Med. 2001;344(7):519–520

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