PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1315-1316 (doi:10.1542/peds.2006-1558)
LETTER TO THE EDITOR |
The Apgar Score: In Reply
Gilbert I. Martin, MDAnn R. Stark, MD
for the American Academy of Pediatrics Committee on Fetus and Newborn
We read with interest the letter by Whelan concerning the joint American Academy of Pediatrics Committee on Fetus and Newborn and American College of Obstetricians and Gynecologists Committee on Obstetric Practice policy statement on the Apgar score.1 Whelan is correct to state that some confusion exists concerning the Apgar score as a predictor of outcome, and we cited both sides of this discussion. In addition, as we point out in the statement, misuse of the Apgar score may lead to an erroneous definition of asphyxia. However, we take issue with her assertion that this statement was "[c]learly driven by an effort to oppose the use of low Apgar scores as litigious weapons." We wished to point out the problems of prediction with either low or high scores. Nelson and Ellenberg2,3 have demonstrated that an Apgar score of 0 to 3 at 5 minutes correlated poorly with future neurologic outcome and that a score of 0 to 3 at 5 minutes was associated with an increased risk of cerebral palsy in only 0.3% to 1.0% of term infants. On the other hand, a score that may be high because of the assistance of resuscitation may lead to the erroneous prediction of a neurologically normal infant. The committees chose not to discuss the Apgar score at 10, 15, and 20 minutes, because extended low scores have high positive predictive values for neurologic disability.
We thank Rüdiger et al for their letter, also. We agree that the subjective assessments of 3 components of the score (color, reflex irritability, and tone) can lead to the variations in scoring that they describe. Because the components of the Apgar score are the most consistent part of any labor and delivery summary throughout the world, we elected not to alter its components, as Rüdiger et al propose. We are hopeful that our proposed expanded reporting form and the term "assisted Apgar score" will help in both data collection and prognosis and look forward to studies that will test their value.
Iyer's proposal to stop using the Apgar score to evaluate the newborn has been suggested before,4 and a review elsewhere5 contains observations that remain valid despite widespread adoption of the evidence-based Neonatal Resuscitation Program. We think that the Apgar score remains useful, and we hope that use of the expanded scoring sheet will add to the information necessary for evaluation of long-term outcomes.
REFERENCES
1. 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
2. Nelson KB, Ellenberg JH. Antecedents of cerebral palsy. I. Univariate analysis of risk.
Am J Dis Child. 1985;139
:1031
–1038
3. Nelson KB, Ellenberg JH. Antecedents of cerebral palsy: multivariate analysis of risk. N Engl J Med. 1986;315 :81 –86[Abstract]
4. Is the Apgar score outmoded? Lancet. 1989;1 :591 –592[Medline]
5. Martin GI. The Apgar score...revisited. J Perinatol. 1989;9 :338 –346[Medline]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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