The Apgar Score – Time to Retire, Revamp Or Replace Henry J

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The Apgar Score – Time to Retire, Revamp or Replace Henry J. Rozycki, MD Professor of Pediatrics (or Retain)? Division of Neonatal Medicine The Miracle of Modern Birth Quiz

What does virtually every newborn receive in the delivery room in the US and most other countries? 1. A hat 2. A slap on a body part 3. A social security number 4. An Apgar Score Virginia Apgar

• 1929 – AB from Mt. Holyoke magna cum laude, having played 7 sports, reported for the newspaper, acted, played violin in the orchestra … • 1933 –Graduated 4th in class at Columbia P&S • 1933‐34 ‐ After first year surgical internship, she was directed to the surgical subspecialty of anesthesiology as a better career for women • 1938 – became first director of Division of Anesthesiology at Columbia • 1949 – Passed over for Department Chair Virginia Apgar Why did Virginia Apgar Develop a Score? • While infant mortality rates improved between 1930 and 1950, deaths in first 24 hours of life did not. “It became clear to Apgar that in many cases, newborns could be saved if anyone bothered to examine them closely just after birth” National Library of Medicine • “Nine months’ observation of the mother surely warrants one minute observation of the baby.”

• Original Intent – Pay attention to the baby – To predict survival – Compare methods of resuscitation – Compare perinatal experience across hospitals • Later Added – For neonatal research – For predicting neuromuscular deficit in early childhood

Apgar V. The newborn (Apgar) scoring system; Reflections and advice. Pediatr Clin N Am 1966; 13: 645 Virginia Apgar Current Researches in Anesthesia and Analgesia 32, ([July‐August The Original Apgar Score Paper 1953]): 260‐267. The Apgar Score First use – Distribution and Mortality

• 15,348 newborns Sloane Hospital NYC – Recommended slapping the foot if couldn’t use nasal catheter for reflex irritability • Score Distribution 0‐3 4‐6 7‐10 % 7.9 13.1 68.1 • Mortality rate 0‐3 4‐6 7‐10 % 11.3 2.0 0.4

APGAR V, HOLADAY DA, JAMES LS, WEISBROT IM, BERRIEN C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958 Dec 13;168(15):1985‐8. Collaborative Perinatal Study of Cerebral Palsy (CPP) CPP

• Jan 1 1959 – Dec 31, 1965 • 55,908 pregnancies enrolled, 4% loss leaving 49,434 • Sponsored by NINDS – 500,000 with CP, 5,000,000 with ‘Mental Retardation’, 1.5 million with Epilepsy • CNS injuries presumed to represent “reproductive wastage” • Dedicated nurse with stopwatch in L&D

Niswander, KR, Gordon M. The Women and Their Pregnancies. WB Saunders, Philadelphia. 1972 Apgar Score Results ‐ Collaborative Perinatal Project

• N = 17,534 • Related to Apgar and birthweight

0 ‐ 3 4 ‐ 8 9‐10 1 min 5 min 1 min 5 min 1 min 5 min < 2 kg 64.0% 77.9% 16.3% 29.9% 2.0% 5.9% Obstet Gynecol 1964; 24: 222‐230 > 2.5 kg 3.2% 15.4% 0.5% 1.2% 0.3% 0.3%

• N = 14,114 examined at 1 year • Related to Apgar and birthweight

0 ‐ 3 4 ‐ 6 7 ‐ 10

< 2 kg 23.5% 26.7% 13.3%

> 2.5 kg 4.3% 3.4% 2.4%

Dev Med Child Neurol. 1966 Apr;8(2):141‐8. It spreads

• 1970 NICU manual from Hammersmith Hospital, London “We do not use the Apgar score” • Nelson’s Pediatrics 10th Edition, 1975 – Apgar not in the index • Nelson’s Pediatrics 11th Edition, 1979 – Apgar in the index – 2 paragraphs • Pubmed search for – “Apgar Score” and country And beyond the delivery room • Smilkstein G. The Family APGAR: A proposal for a family Function Test and Its Use by Physicians. J Fam Prac 1978; 6; 1231‐39 – 540 citations to date

• Gawande AA, et al. An Apgar Score for Surgery. J Am Coll Surg 2007;204:201–208 – > 225 citations to date

• Bernstein J, et al. The New APGAR Score: A checklist to Enhance Quality of Life in Geriatric Patients with Hip Fracture. J Bone Joint Surg 2017; 99: e77. The New Therapy Curve

0.9

0.8 First Studies 0.7

0.6

0.5 Reality

0.4

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0.2 Problem Studies

0.1

0 024681012 Limitations 1 – Predictive Ability • CPP data from 1959‐66. n = 49,000 singletons with Apgar scores and follow‐up to 7 years. CP diagnosed in 120

• Death • 59% with 1 Min Apgar > 3 • 71% with 5 Min Apgar > 3 • CP • 88% with 1 Min Apgar > 3 • 85% with 5 Min Apgar > 3 • Death or CP • 65% with 1 Min Apgar > 3 • 72% with 5 Min Apgar > 3 • Only at 20 mins is CP risk > 50% • In >2500 g in survivors • 10/18

Nelson KB, Ellenberg J. Apgar scores as predictors of chronic neurologic disability. Pediatr 1981; 68: 36‐44 Limitation 1 ‐ Predictive Ability ‐ Modern data • 0‐3 vs 10 at 10 minutes (n = 267 vs 1,150,993) – RR 176.1 (CI 127.8‐242.9) for CP • 34/267 i.e. 87% with low score did not – 68% of children with CP had 10 minute Apgar 0

(Persson M, et al. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden. BMJ 2018; 360: k207) • Score of 0 at 10 minutes in cooling study subjects (n = 90) – 24.4% survived with normal outcome at 18 – 22 months

(Kasdorf E, et al. Improving infant outcome with a 10 min Apgar of 0. Arch Dis Child Fetal Neonatal Ed 2015;100: F102–F105.)

• Useful as a risk factor, not a prognosticator Limitations 2 ‐ Interobserver Variability

Figure. Boxplots of 5‐minute Apgar scores given by 42 observers of 30 videos of neonatal resuscitation (ASvideo). Each box plot displays Range = 2‐3 median and interquartile range, with outlying values shown as small circles. Box plots are ordered by increasing mean ASvideo as proxy for illness severity. 5‐minute Apgar score given by staff who attended delivery (ASdel) is indicated by solid black boxes.

Range = 6‐7

Range = 2‐3

Kappa for elements: 0.43 – 0.53

O’Donnell CPF et al. Interobserver variability of the 5‐minute Apgar score. J Pediatr 2006; 149: 486‐89 Limitations 2 ‐ Interobserver Variability

Bashambu MT, et al. Evaluation of Interobserver Agreement of Apgar Scoring in Preterm Infants. Pediatr 2012; 130: e982‐987 Limitations 2 ‐ Interobserver Variability

C1 = Color C2 = Heart Rate N1 = Reflex Irritability N2 = Tone R1 = Respirations

21/50 < 0.6

Jurdi S, et al. Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score: A Pilot Study. Glob Pediatr Health 2015; 2: 1‐8 Limitations 3 ‐ Prematurity • Catlin et al. The Apgar score revisited: influence of gestational age. J Pediatr 1986;109:865‐8

Bashambu MT, et al. Evaluation of Interobserver Agreement of Apgar Scoring in Preterm Infants. Pediatr 2012; 130: e982‐987 Limitations 4 ‐ International

5‐min score = 10 Latvia vs France

5‐min score < 4 Lithuania vs Iceland

Siddiqui A, et al. Can the Apgar Score be Used for International Comparisons of Newborn Health? Paediatr Perinat Epidemiol. 2017;31:338‐345 Limitations 5 – Accounting for Assistance

25 weeks @ 5 minutes Intubated, HR 120, acrocyanosis, normal tone, and response to stimulation for age

Total Score 40

0 % 7 8 9 10

Lopriore E, van Burk F, Walther F, Arnout J. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ 2004;329:143–144. Limitations ‐ Summary

• Dispassionate scorers • Predictive use not great for indivudal patients • Inconsistent scoring – By persons – Across borders • Prematurity • Intervention NRP • 11/87 – First national faculty • 1991 – First textbook

• 2001 – 4th Ed – “The scores should be recorded in the baby’s birth record”

• 2015 – 7th Ed – Only mention: “We suggest that, in infants with an Apgar score of 0 after ten minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop assisted ventilation.” NRP – WHERE IS THE APGAR SCORE?

Saturation guidelines : 60% at 1 minute and 80% at 5 minutes Lower Color Score?

4 Steps, 2 assessments by 1 Minute!

No routine suctioning: Assess reflex irritability? Continued Endorsement • Lu‐Anne Papile, New England Journal 2001 – Although the Apgar score is considered by many to be an obsolete measure of the condition of neonates, few will deny that its application at one minute of age accomplishes Dr. Apgar's goal of focusing attention on the condition of the infant immediately after birth. Moreover, until a more useful tool for assessing neonates is developed, the five-minute Apgar score … is still valid as a rapid method for assessing the effectiveness of resuscitative efforts and the vitality of the infant

• AAP – ACOG 2015 – The Apgar score describes the condition of the newborn infant immediately after birth and, when properly applied, is a tool for standardized assessment. It also provides a mechanism to record fetal‐to‐neonatal transition … Alternatives

• Specified Apgar • Expanded Apgar • Combined Apgar • NRAS The Specified Apgar Intervention‐ and Gestation‐independent • Change Respiration to Chest Movement – Good expansion = 2 – No movement = 0 – Intervention neutral • Skin color estimated regardless of oxygen supplementation • Reflex irritability judged according to gestational age • Muscle tone judged according to gestational age – Preterm infants with age‐appropriate muscle tone should receive a score of 2 despite being limp compared with term infants.

Rudiger M et al. Pediatr 2006; 118: 1314 The Expanded Apgar Including Interventions

• Add points for NO interventions • Confusing

American Academy of Pediatrics; American College of Obstetricians and Gynecologists. The Apgar score. ACOG Committee Opinion No. 333. Obstet Gynecol 2006; 107:1209–12. The Combined Apgar – Best of each a) Account for prematurity and ignore interventions ‐ SPECIFIED + b) Record Interventions ‐ Expanded

COMBINED

Rudiger M et al. Neonatal assessment in the delvery room – Trial to Evaluate a Specified Type of Apgar (TEST‐Apgar). BMC Pediatr 2015: 18 TEST‐Apgar (Rudiger M, et al. BMC Pediatr 2015; 15: 18)

• 1855 infants < 32 weeks from 20 NICUs in 12 countries • Compared Combined to Specified or Expanded for – Mortality, morbidity (mod‐severe BPD, any IVH, cystic PVL or ROP) AUC Specified Expanded Combined 1 min 0.63 0.64 0.66 5 min 0.63 0.70 0.69 10 min 0.61 0.70 0.70 • Only prematures and premature‐specific outcomes • Small n Modified Apgar Scores and Birth Asphyxia

• 435 infants > 25 weeks gestation admitted to hospital in Teheran • Outcome was birth asphyxia – 5 minute score

• Small n, 53% were < 37 weeks, birth asphyxia in 10%

Dalili H et al. Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PLOS One 2015; 10: e0122116 Conventional vs Combined

• Prospective score for all newborns > 25 weeks over 6 months in Teheran hospital n = 942 AUC Conventional < 7 Combined < 10 Mechanical Ventilation 0.84 0.98* * P < 0.05 Hyperbilirubinemia 0.52 0.58 IVH 0.75 0.83 Death 0.90 0.97 • 53% < 37 weeks, mortality rate 2.4% • Basket of outcomes Neonatal Resuscitation and Adaptation (NRAS)

• Goals: Simple, familiar, gestation‐independent, intervention inclusive • 1, and 5 minutes

• Five 15 second videos at 1 and 5 minutes with HR, FiO2, O2 sat – 23, 24, 27, 32 and 40 weeks • Scored x 2 by 39 providers (Neo, NNPs. RNs, residents) in random order

8/50 < 0.6) P = 0.0082 NRAS – Clinical Application • Apgar and NRAS for newborns attended by resuscitation team • Outcomes – death, need for resuscitation, admission temp < 36oC, NICU admission if > 35 weeks – In first 48 hrs ‐ blood glucose < 40 mg/dl, platelets < 100k, PMNs < 1000, use of vasopressors, EOS, seizures, need for respiratory support > 1 hour, abnormal head US N = 340 Birthweight (g) Mean ± SEM 2780.9 ± 51.7 th th Gestational Age (wk) Median (25 and 75 percentile) 38 2/7 (35 2/7 – 40 0/7) Late preterm (34 – 36 weeks)/Premature (< 34 weeks) 50 (14.7%)/68 (20%) Male/Female 181 (53.2%)/159 (46.8%) Vaginal/C‐section/Emergency C‐section 146 (42.9%)/156 (45.9%)/38 (11.2%)

AGA/SGA/LGA 282 (82.9%/30 (8.8%)/25 (7.4%) Cord ph (n = 302) , Mean ± SEM 7.266 ± 0.005 Congenital anomalies 36 (10.6%) NRAS – Clinical Application

1 Minute 5 Minute Apgar NRAS Apgar NRAS n 0‐3 4‐6 7‐10 0‐3 4‐6 7‐10 0‐3 4‐6 7‐10 0‐3 4‐6 7‐10 < 32 58 34.5 29.3 36.2 17.2 36.2 44.8 12.1 24.1 63.8 3.4 25.9 70.7 wks 33–35 41 14.6 7.3 78.1 5 10 85 4.9 4.9 90.2 0 7.3 92.7 wks > 36 241 13.7 12.9 73.4 1.3 13.5 85.2 1.7 2.9 95.4 0.4 2.1 97.5 wks

• Small n • Selected population So … where are we?

1. Apgar Score is old – Validated on outdated population 2. Uses have been corrupted 3. Correlation with long term outcomes – Applicable to population, not individuals 4. Resuscitation has changed 5. Several proposed alternatives – Tested on small, selected populations

IS THE TIME RIGHT TO STUDY DELIVERY ROOM SCORING? DO WE EVEN NEED A SCORE?

• NRP doesn’t use it • Other markers of birth asphyxia (> 20 in last 5 years) – Blood • IL‐6, IL‐8, IL‐16, lactate, copeptin, advanced protein oxidation products, non‐protein bound Fe – Cord blood • Angiogenin, pH, base deficit, IL‐16, mir‐181b, mir‐374a‐5p, CK‐BB, GFAP, NSE, Tau protein, UCHL‐1, GFAP – Urine • S100b, Lactate/creatinine, Uric acid/creatinine Critical First Question

Why Score?

• Pay attention to the baby • Resuscitation QI – e.g. delayed cord clamping • Identify at‐risk population – Long term • Need for Early Intervention, close follow‐up? – Short term • NRP Post‐resuscitation care based only on need for oxygen or PPV A Modest Proposal

1. Define outcomes (Thanks to Bloodnet) • Expert panel – Survey – Expert Panel 2. Multicenter multicountry (Thanks to Support, BOOST and COT) . 4 – 6 national studies . > 20,000 infants each . > 5 hospitals each . 1 year enrollment . Real world scorers (competency validated by online video test) . Short term outcomes by chart review . Nested consented long term outcome 3. Apgar vs Combined vs NRAS vs ? Quiz

What will virtually every newborn receive in the delivery room in the US and most other countries? 1. A hat 2. A slap on a body part 3. An embedded chip 4. A score – or not Everyone should be a 10 References:

Apgar V. The newborn (Apgar) scoring system; Reflections and advice. Pediatr Clin N Am 1966; 13: 645 Current Researches in Anesthesia and Analgesia 32, ([July-August 1953]): 260-267. APGAR V, HOLADAY DA, JAMES LS, WEISBROT IM, BERRIEN C. Evaluation of the newborn infant; second report. J Am Med Assoc. 1958 Dec 13;168(15):1985-8. Niswander, KR, Gordon M. The Women and Their Pregnancies. WB Saunders, Philadelphia. 1972 Dev Med Child Neurol. 1966 Apr;8(2):141-8. Smilkstein G. The Family APGAR: A proposal for a family Function Test and Its Use by Physicians. J Fam Prac 1978; 6; 1231-39 Gawande AA, et al. An Apgar Score for Surgery. J Am Coll Surg 2007;204:201–208 Bernstein J, et al. The New APGAR Score: A checklist to Enhance Quality of Life in Geriatric Patients with Hip Fracture. J Bone Joint Surg 2017; 99: e77. Nelson KB, Ellenberg J. Apgar scores as predictors of chronic neurologic disability. Pediatr 1981; 68: 36- 44 (Persson M, et al. Five and 10 minute Apgar scores and risks of cerebral palsy and epilepsy: population based cohort study in Sweden. BMJ 2018; 360: k207) (Kasdorf E, et al. Improving infant outcome with a 10 min Apgar of 0. Arch Dis Child Fetal Neonatal Ed 2015;100: F102–F105.) O’Donnell CPF et al. Interobserver variability of the 5-minute Apgar score. J Pediatr 2006; 149: 486-89 Bashambu MT, et al. Evaluation of Interobserver Agreement of Apgar Scoring in Preterm Infants. Pediatr 2012; 130: e982-987 Jurdi S, et al. Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score: A Pilot Study. Glob Pediatr Health 2015; 2: 1-8 Bashambu MT, et al. Evaluation of Interobserver Agreement of Apgar Scoring in Preterm Infants. Pediatr 2012; 130: e982-987 Catlin et al. The Apgar score revisited: influence of gestational age. J Pediatr 1986;109:865-8 Siddiqui A, et al. Can the Apgar Score be Used for International Comparisons of Newborn Health? Pediatric Perinat Epidemiol. 2017;31:338-345 Lopriore E, van Burk F, Walther F, Arnout J. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ 2004;329:143–144. Rudiger M et al. Pediatr 2006; 118: 1314 American Academy of Pediatrics; American College of Obstetricians and Gynecologists. The Apgar score. ACOG Committee Opinion No. 333. Obstet Gynecol 2006; 107:1209–12. Rudiger M et al. Neonatal assessment in the delivery room – Trial to Evaluate a Specified Type of Apgar (TEST-Apgar). BMC Pediatr 2015: 18 Dalili H et al. Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes. PLOS One 2015; 10: e0122116 Jurdi S, et al. Evaluation of a Comprehensive Delivery Room Neonatal Resuscitation and Adaptation Score (NRAS) Compared to the Apgar Score: A Pilot Study. Glob Pediatr Health 2015; 2: 1-8