Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1314-1315 (doi:10.1542/peds.2006-1254)
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LETTER TO THE EDITOR

The Apgar Score

Mario Rüdiger, MD
Abteilung für Neonatologie
Medizinische Universität Innsbruck
6020 Innsbruck, Austria

Roland R. Wauer, MD
Klinik für Neonatologie
Charité-Universitätsmedizin Berlin
Campus Mitte
10098 Berlin, Germany

Katerina Schmidt
Abteilung für Kinder- und Jugendheilkunde
Landeskrankenhaus Feldkirch
A-6807 Feldkirch, Austria

Helmut Küster, MD
Abteilung für Neonatologie und Pädiatrische Intensivmedizin der Kinderklinik
Ernst-Moritz-Arndt Universität Greifswald
17487 Greifswald, Germany

To the Editor.—

The Apgar score is a simple and rapid method to evaluate the condition of a newborn infant.1 As shown recently by Lopriore et al,2 its value is hampered because of nonuniform definitions used by individual caregivers, causing great variations when scoring ventilated infants.

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recently suggested an expanded version of the Apgar score reporting form3 for infants on resuscitation. This form allows a more detailed description of resuscitation efforts, but the problem of inconsistencies in definitions is not solved. Even with the expanded version, it will be difficult to compare Apgar scores between infants or NICUs.

Using previously published written case descriptions,2 we also found a great variation (up to 5 points for the total Apgar score) for the same "patient" (answers from 96 physicians from 12 university-based neonatal departments in Germany, Austria, and Switzerland). Ventilation, muscle tone, and reflexes showed the highest variation. When compared with junior staff (n = 44), the scores given by neonatologists (n = 52) had a significantly larger variation. In only 1 of 12 units did all caregivers score the same value.

To elucidate the clinical relevance of these variations, Apgar scores given for very low birth weight infants (born between January 2004 and December 2005) were compared between 4 different units (members of the Vermont Oxford Neonatal Network). Despite the similar population and description, the mean Apgar score was higher in unit 1 when compared with the other units (Table 1). Our data show that the policy to score infants differs systematically between units, especially during resuscitation. The most likely explanation is a difference in local guidelines regarding how to score these infants as a result of missing general consent in Apgar definitions.1


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  		TABLE 1. Apgar Scores of Very Low Birth Weight Infants and Written Case Descriptions Obtained From 4 Different Units

 
Therefore, we suggest specifications of the Apgar score, which will slightly change the Apgar score perspective; however, the changes will not alter the number of its components. As a result, the Apgar score will not express the efforts of the infant but will describe his or her condition independently of the requirements needed to achieve this condition.

The term "respiration" should be substituted by "chest movements" regardless of its origin. Infants with an expanding chest (spontaneous or by ventilation) should receive a score of 2, and those with no chest movement should receive a score of 0. Skin color should be estimated regardless of oxygen supplementation. Reflex irritability and muscle tone should be 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.

Such a specified score would be in accordance with Apgar's initial idea of a simple, rapid, standardized, and reproducible tool.1 Alone or in combination with the expansion,3 these specifications could increase the prognostic value of the Apgar score.

ACKNOWLEDGMENTS

We appreciate the supply of data by Egbert Herting (Universitätsklinikum Schleswig-Holstein), Christian F. Poets (Universitätsklinikum Tübingen), and Roland Hentschel (Universitätsklinikum Freiburg, Deutschland).

REFERENCES

  1. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32 :260 –267[Medline]
  2. Lopriore E, von Burk F, Walther FJ, de Beaufort AJ. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ. 2004;329 :143 –144[Free Full Text]
  3. American Academy of Pediatrics, Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. The Apgar score. Pediatrics. 2006; 117: 1444–1447[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics




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