Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Sep 5;6(9):e2332413.
doi: 10.1001/jamanetworkopen.2023.32413.

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

Harald Ehrhardt  1 , Adrien M Aubert  2 , Ulrika Ådén  3 , Elizabeth S Draper  4 , Anna Gudmundsdottir  3 , Heili Varendi  5 , Tom Weber  6 , Michael Zemlin  7 , Rolf F Maier  8 , Jennifer Zeitlin  2 ; EPICE-SHIPS Research Group
Collaborators, Affiliations

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

Harald Ehrhardt et al. JAMA Netw Open. .

Abstract

Importance: The Apgar score is used worldwide as an assessment tool to estimate the vitality of newborns in their first minutes of life. Its applicability to estimate neurodevelopmental outcomes in infants born extremely preterm (EPT; <28 weeks' gestation) is not well established.

Objective: To investigate the association between the Apgar score and neurodevelopmental outcomes in infants born EPT.

Design, setting, and participants: This cohort study was conducted using data from the Effective Perinatal Intensive Care in Europe-Screening to Improve Health in Very Preterm Infants in Europe (EPICE-SHIPS) study, a population-based cohort in 19 regions of 11 European countries in 2011 to 2012. Clinical assessments of cognition and motor function at age 5 years were performed in infants born EPT and analyzed in January to July 2023.

Exposures: Apgar score at 5 minutes of life categorized into 4 groups (0-3, 4-6, 7-8, and 9-10 points).

Main outcomes and measures: Cognitive and motor outcomes were assessed using the Wechsler Preschool and Primary Scale of Intelligence test of IQ derived from locally normed versions by country and the Movement Assessment Battery for Children-Second Edition. Parents additionally provided information on communication and problem-solving skills using the Ages and Stages Questionnaire, third edition (ASQ-3). All outcomes were measured as continuous variables.

Results: From the total cohort of 4395 infants born EPT, 2522 infants were live born, 1654 infants survived to age 5 years, and 996 infants (478 females [48.0%]) followed up had at least 1 of 3 outcome measures. After adjusting for sociodemographic variables, perinatal factors, and severe neonatal morbidities, there was no association of Apgar score with IQ, even for scores of 3 or less (β = -3.3; 95% CI, -10.5 to 3.8) compared with the score 9 to 10 category. Similarly, no association was found for ASQ-3 (β = -2.1; 95% CI, -24.6 to 20.4). Congruent results for Apgar scores of 3 or less were obtained for motor function scores for all children (β = -4.0; 95% CI, -20.1 to 12.1) and excluding children with a diagnosis of cerebral palsy (β = 0.8, 95% CI -11.7 to 13.3).

Conclusions and relevance: This study found that low Apgar scores were not associated with longer-term outcomes in infants born EPT. This finding may be associated with high interobserver variability in Apgar scoring, reduced vitality signs and poorer responses to resuscitation after birth among infants born EPT, and the association of more deleterious exposures in the neonatal intensive care unit or of socioeconomic factors with greater changes in outcomes during the first 5 years of life.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ehrhardt reported receiving grants from the German Research Foundation (DFG), Federal Ministry of Education and Research, von Behring-Röntgen-Foundation, and Chiesi Research Foundation outside the submitted work and being a member of the European Neonatal Research Consortium of the European Society for Paediatric Research and European Association of Perinatal Medicine special interest group of preterm delivery. Dr Gudmundsdottir reported receiving grants from Sällskapet Barnavård, Sweden and Stiftelsen Samariten, Sweden during the conduct of the study. Drs Varendi, Maier, and Zeitlin reported receiving grants from the Effective Perinatal Intensive Care in Europe-Screening to Improve Health in Very Preterm Infants in Europe (EPICE-SHIPS) project from the European Union during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
ASQ-3 indicates Ages and Stages Questionnaire, third edition; MABC-2, Movement Assessment Battery for Children–Second Edition.
Figure 2.
Figure 2.. Association of Apgar Score Group and Cognitive Outcome
The association of the Apgar score at 5 minutes of life and A, IQ as determined by Wechsler Preschool and Primary Scale of Intelligence–Revised, Third, or Fourth Edition and B, caregiver-reported Ages and Stages Questionnaire, third edition (ASQ-3) results was investigated using multinomial logistic regression with inverse probability weighting and multiple imputation. Data were analyzed without adjustments except for country as a fixed effect, with additional adjustment on sociodemographic factors, plus adjustment on perinatal factors and with additional adjustment on severe neonatal morbidities. The reference group is Apgar score 9 and 10.
Figure 3.
Figure 3.. Association of Apgar Score Group and Motor Outcome
The association of the Apgar score at 5 minutes of life and movement difficulties as determined by the Movement Assessment Battery for Children–Second Edition (MABC-2) and caregiver-reported questionnaires was investigated for A, global movement difficulties and B, movement difficulties not related to cerebral palsy using multinomial logistic regression with inverse probability weighting and multiple imputation. Data were analyzed without adjustments except for country as fixed effect, with additional adjustment on sociodemographic factors, plus adjustment on perinatal factors and with additional adjustment on severe neonatal morbidities. The reference group is Apgar score 9 and 10.
See this image and copyright information in PMC

References

    1. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32(4):260-267. doi:10.1213/00000539-195301000-00041 - DOI - PubMed
    1. American Academy of Pediatrics Committee on Fetus And Newborn; American College of Obstetricians and Gynecologists Committee on Obstetric Practice . The Apgar score. Pediatrics. 2015;136(4):819-822. doi:10.1542/peds.2015-2651 - DOI - PubMed
    1. Razaz N, Cnattingius S, Joseph KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ. 2019;365:l1656. doi:10.1136/bmj.l1656 - DOI - PMC - PubMed
    1. Razaz N, Cnattingius S, Persson M, Tedroff K, Lisonkova S, Joseph KS. One-minute and five-minute Apgar scores and child developmental health at 5 years of age: a population-based cohort study in British Columbia, Canada. BMJ Open. 2019;9(5):e027655. doi:10.1136/bmjopen-2018-027655 - DOI - PMC - PubMed
    1. Iliodromiti S, Mackay DF, Smith GCS, Pell JP, Nelson SM. Apgar score and the risk of cause-specific infant mortality: a population-based cohort study. Lancet. 2014;384(9956):1749-1755. doi:10.1016/S0140-6736(14)61135-1 - DOI - PubMed

Publication types