Can the 5-minute Apgar score be used to predict developmental outcomes?

The Apgar score, invented by Dr Virginia Apgar in 1952, is a fast, non-invasive measure of a baby’s health at birth, and their need for immediate medical intervention. It was never intended to measure long-term health, intelligence, or developmental outcomes. However, recent evidence from Canada and Sweden suggests that as Apgar scores decrease, children’s risk of poor neurodevelopmental outcomes increase.

Almost 98% of Australian newborns had a ‘normal’ Apgar score in the 7-10 range in 2019 according to the Australian Institute of Health and Welfare. By grouping the majority of children together as ‘normal’ we may be overlooking risk factors and missing opportunities for early intervention.

At one and five minutes after birth, a doctor or midwife administers the Apgar test. Every newborn is scored from 0 to 2 points five factors; their Appearance (skin color), Pulse (heart rate), Grimace response (reflexes), Activity (muscle tone), and Respiration (breathing rate and effort). A score of 7 -10 shows the baby is adapting well to their new environment. A score below seven indicates complications. Otherwise healthy babies may have low scores due to a high-risk pregnancy, complicated delivery, C-section, or premature birth.

To investigate the links between Apgar scores and neurodevelopmental outcomes in Australia, researchers turned to data from the Mothers and their Children’s Health (MatCH) study. In 2016, mothers from the 1973-78 cohort of the Australian Longitudinal Study on Women’s Health were invited to participate in the MatCH substudy. They answered questions on their children’s communication and gross motor development from the Ages and Stages Questionnaire – a widely used neurodevelopmental assessment tool for children aged zero to five and a half. The Australian state-based Perinatal Data Collections linked data from the ALSWH and MatCH studies to provide Apgar scores for the MatCH children.

The 809 boys and girls included in the study ranged in age from eight months to five and half years old. In this group, 7.1% of children had a gross motor delay, and 4.2% had a communications delay. Of these children:

Children who scored a 7-8, traditionally considered in the ‘healthy’ range, were at an increased risk of gross motor delays compared to those with a score of 10. The risk of communication delays was not significant.

The Apgar score is not currently recommended as a tool for predicting individual developmental outcomes in Australia or elsewhere. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists discourages the use of Apgar score for the prediction of individual developmental outcomes. However, they included the following in their 2015 statement regarding other applications of the score: “Monitoring of low Apgar scores from a delivery service can be useful. Individual case reviews can identify needs for focused educational programs and improvement in systems of perinatal care”.

This research adds to a growing body of recent evidence from large population-based studies showing the applicability of the Apgar score to predicting children’s developmental outcomes. The Apgar test should be considered as a useful tool to support referral for ongoing assessment and intervention. Less than 2% of newborns receiving an Apgar score in the traditionally low 0-6 range.  To provide at risk children with early intervention, clinicians need to consider the full range of Apgar scores and provide follow up for children with Apgar scores in the 7-8 range.

This paper is open access and free to read at https://doi.org/10.3390/ijerph18126450

Tahir Ahmed Hassen, University of Newcastle

Professor Deborah Loxton, University of Newcastle

Cath Chojenta, University of Newcastle

Hassen TA, Chojenta C, Egan N, Loxton D. The Association between the Five-Minute Apgar Score and Neurodevelopmental Outcomes among Children Aged 8−66 Months in Australia. International Journal of Environmental Research and Public Health. 2021; 18(12):6450.