POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children The Apgar Score AMERICAN ACADEMY OF PEDIATRICS COMMITTEE ON FETUS AND NEWBORN, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS COMMITTEE ON OBSTETRIC PRACTICE The Apgar score provides an accepted and convenient method for reporting abstract the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered as evidence of, or a consequence of, asphyxia; does not predict individual neonatal mortality or neurologic outcome; and should not be used for that purpose. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists encourage use of an expanded Apgar score reporting form that accounts for concurrent resuscitative interventions. This document is copyrighted and is the property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of INTRODUCTION Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of In 1952, Dr Virginia Apgar devised a scoring system that was a rapid Pediatrics has neither solicited nor accepted any commercial method of assessing the clinical status of the newborn infant at 1 minute involvement in the development of the content of this publication. of age and the need for prompt intervention to establish breathing.1 Policy statements from the American Academy of Pediatrics benefit Dr Apgar subsequently published a second report that included a larger from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American number of patients.2 This scoring system provided a standardized Academy of Pediatrics may not reflect the views of the liaisons or the assessment for infants after delivery. The Apgar score comprises 5 organizations or government agencies that they represent. components: (1) color; (2) heart rate; (3) reflexes; (4) muscle tone; and The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking (5) respiration. Each of these components is given a score of 0, 1, or 2. into account individual circumstances, may be appropriate. Thus, the Apgar score quantitates clinical signs of neonatal depression, fl All policy statements from the American Academy of Pediatrics such as cyanosis or pallor, bradycardia, depressed re ex response to automatically expire 5 years after publication unless reaffirmed, stimulation, hypotonia, and apnea or gasping respirations. The score is revised, or retired at or before that time. reported at 1 minute and 5 minutes after birth for all infants, and at Also published in Obstetrics & Gynecology. Copyright October 2015 by 5-minute intervals thereafter until 20 minutes for infants with a score less the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 and the American 3 than 7. The Apgar score provides an accepted and convenient method for Academy of Pediatrics, 141 Northwest Point Blvd, PO Box 927, Elk Grove reporting the status of the newborn infant immediately after birth and the Village, IL 60009-0927. All rights reserved. ISSN 1074-8613 response to resuscitation if it is needed; however, it has been The American College of Obstetricians and Gynecologists Committee inappropriately used to predict individual adverse neurologic outcome. Opinion no. 644: The Apgar score. Obstet Gynecol. 2015;126:e52–e55. Accepted for publication Jul 22, 2015 The purpose of the present statement was to place the Apgar score in its www.pediatrics.org/cgi/doi/10.1542/peds.2015-2651 proper perspective. This statement revises the 2006 College Committee DOI: 10.1542/peds.2015-2651 Opinion/American Academy of Pediatrics policy statement to include updated guidance from the 2014 report Neonatal Encephalopathy and PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Neurologic Outcome (second edition)4 published by the American College Copyright © 2015 by the American Academy of Pediatrics Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 136, number 4, October 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS of Obstetricians and Gynecologists in hypoxemia, hypercapnia, and between 1 minute and 5 minutes, is collaboration with the American significant metabolic acidosis. The a useful index of the response to Academy of Pediatrics, along with new term asphyxia, which describes resuscitation. If the Apgar score is guidance on neonatal resuscitation. a process of varying severity and less than 7 at 5 minutes, the Neonatal The guidelines of the Neonatal duration rather than an end point, Resuscitation Program guidelines Resuscitation Program state that the should not be applied to birth events state that the assessment should be Apgar score is useful for conveying unless specific evidence of markedly repeated every 5 minutes for up to information about the newborn impaired intrapartum or immediate 20 minutes.3 However, an Apgar score infant’s overall status and response to postnatal gas exchange can be assigned during resuscitation is not resuscitation. However, resuscitation documented on the basis of equivalent to a score assigned to must be initiated before the 1-minute laboratory test results. a spontaneously breathing infant.10 score is assigned. Therefore, the Apgar There is no accepted standard for score is not used to determine the LIMITATIONS OF THE APGAR SCORE reporting an Apgar score in infants need for initial resuscitation, what undergoing resuscitation after birth It is important to recognize the resuscitation steps are necessary, or because many of the elements limitations of the Apgar score. It is an when to use them.3 contributing to the score are altered expression of the infant’s physiologic An Apgar score that remains condition at 1 point in time, which by resuscitation. The concept of an 0 beyond 10 minutes of age may, includes subjective components. assisted score that accounts for however, be useful in determining There are numerous factors that can resuscitative interventions has been whether continued resuscitative influence the Apgar score, including suggested, but the predictive efforts are indicated because very few maternal sedation or anesthesia, reliability has not been studied. To infants with an Apgar score of 0 at congenital malformations, gestational correctly describe such infants and 10 minutes have been reported to age, trauma, and interobserver provide accurate documentation and survive with a normal neurologic variability.4 In addition, the data collection, an expanded Apgar outcome.3,5,6 In line with this biochemical disturbance must be score reporting form is encouraged outcome, the 2011 Neonatal significant before the score is (Fig 1). This expanded Apgar score Resuscitation Program guidelines affected. Elements of the score, such may also prove useful in the setting of state that “if you can confirm that no as tone, color, and reflex irritability, delayed cord clamping, in which the heart rate has been detectable for at can be subjective and partially time of birth (ie, complete delivery of least 10 minutes, discontinuation of depend on the physiologic maturity of the infant), the time of cord clamping, resuscitative efforts may be the infant. The score may also be and the time of initiation of appropriate.”3 affected by variations in normal resuscitation can all be recorded in transition. For example, lower initial the comments box. The Neonatal Encephalopathy and oxygen saturations in the first few Neurologic Outcome report defines The Apgar score alone cannot be minutes need not prompt a 5-minute Apgar score of 7 to 10 as considered to be evidence of or immediate supplemental oxygen reassuring, a score of 4 to 6 as a consequence of asphyxia. Many administration; the Neonatal moderately abnormal, and a score of other factors, including Resuscitation Program targets for 0 to 3 as low in the term infant and nonreassuring fetal heart oxygen saturation are 60% to 65% at 1 late-preterm infant.4 In that report, rate–monitoring patterns and minute and 80% to 85% at 5 minutes.3 an Apgar score of 0 to 3 at 5 minutes abnormalities in umbilical arterial The healthy preterm infant with no or more was considered a nonspecific blood gas results, clinical cerebral evidence of asphyxia may receive a low sign of illness, which “may be one of function, neuroimaging studies, score only because of immaturity.7,8 the first indications of neonatal electroencephalography, The incidence of low Apgar scores is encephalopathy.” However, placental pathology, hematologic inversely related to birth weight, and a persistently low Apgar score alone studies, and multisystem organ a low score cannot predict morbidity is not a specific indicator for dysfunction, need to be considered in or mortality for any individual diagnosing an intrapartum intrapartum compromise. infant.8,9 As previously stated, it is also hypoxic–ischemic event.6 When Furthermore, although the score is inappropriate to use an Apgar score a category I (normal) or category II widely used in outcome studies, its alone to diagnose asphyxia. inappropriate use has