Predicting the neurodevelopment of preterm born children: Is a low Apgar score associated with impaired development?

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The Apgar score is a tool to quickly evaluate a newborn’s health status right after birth. It helps healthcare professionals to quickly make treatment decicions for the infant only minutes after birth.  It is an important tool for determining neonatal health because a low Apgar score is associated with higher mortality and morbidity. A study conducted by the EPICE-SHIPS research group examined nearly 1,000 preterm born children at age five to find out more about the long-term concequences of being born with a low Apgar score.

The Apgar score is an assessment tool for healthcare professionals to quickly evaluate the infant’s health status immediately after birth. For example, it measures wether the newborn is breathing regularly, is active or has a pale or pink skin colour. (More information on the Apgar score is also available here.) Using these quickly observable indicators helps medical professionals to assess the need for resuscitation measures right after birth and significantly improves neonatal outcomes. The score is measured three times, namely at 0, 5 and 10 minutes of life. Lower Apgar scores are associated with higher rates of mortality and morbidity and impaired neurological development. Preterm infants with a low Apgar score have been found to be at additional risk to fall ill with bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP) and cerebral palsy.


 How informative is a low Apgar score for preterm infants?

The Apgar score was originally developed to examine at-term babies. It is therefore unclear in how far it can be used for preterm infants. This is what the EPICE-SHIPS (Effective Perinatal Intensive Care in Europe-Screening to Improve health in Very Preterm Infants in Europe) research group aimes to investigate. The research group specialised in examining the health status of very preterm children across Europe. For this purpose, the Apgar score was determined after 5 minutes of life, and the health status of these children was followed up 5 years later.

Observing the study participants, more male infants were classified with a low Apgar score than female newborns. Further risk factors were multiparity, lower gestational age and being small for one’s gestational age. Additionally, parents of children with a low Apgar score tended to have higher unemployment rates or an immigration background compared to parents of children with higher Apgar scores, initially suggesting a relation between socioeconomic background and Apgar score.


A lower Apgar score at birth does not correlate with impared neurological development

The promising outcome of the study reveals that children with a low Apgar score neither showed a lower IQ than children with high scores nor worse motoric development at age 5. This suggests that low Apgar scores for very preterm infants do not sufficiently explain or predict long-term outcomes. It appears that the Apgar score is helpful in estimating in-hospital mortality but not long-term neurodevelopmental outcomes. Similarly, the apparent connection between a low Apgar score and a family’s socioeconomic background does not adequately account for the complex influence of socioeconomic forces on child development. However, it remains a valuable assessment tool for rapid triage after birth to improve postnatal care.


Paper available at: Apgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm

Full list of authors: Harald Ehrhardt, Adrien Aubert, Ulrika Ådén, Elizabeth Draper, Anna Gudmundsdottir, Heili Varendi, Tom Weber, Michael Zemlin, Rolf Maier, Jennifer Zeitlin

DOI: 10.1001/jamanetworkopen.2023.32413