Introduction

• The APGAR score evaluates the clinical status of the newborn at birth based on five objective signs.
• Each clinical sign is evaluated and assigned a score of 0, 1, or 2.
• Total scores are routinely recorded at 1 minute and 5 minutes after birth.
• If the 5-minute score is 6 or less, the score must be documented at successive 5-minute intervals.
• APGAR scoring must not stop at 10 minutes if the infant remains unstable.
• The score must be documented continuously until the neonate is stabilized with a score greater than 6, up to at least 20 minutes of life.

Components And Scoring

• The conventional APGAR score comprises five parameters evaluating physiological transition.

(Table: APGAR Scoring Parameters)

Documentation And The Expanded APGAR Score

• Pediatricians frequently assign the APGAR score by recall after the event has occurred.
• Recall-based scoring is associated with a high risk of errors.
• The resuscitation team must document the actual observations and resuscitation efforts in real time.
• The American Academy of Pediatrics (AAP) currently recommends the use of an expanded APGAR score reporting form.
• The expanded form details both the numeric APGAR score and all concurrent resuscitative interventions at each time interval.
• Interventions documented alongside the score include oxygen delivery, positive pressure ventilation (PPV), CPAP, endotracheal intubation, chest compressions, and epinephrine administration.
• This expanded APGAR sheet is considered a critical medico-legal statement.

Combined APGAR Score

• A specific Combined APGAR score incorporates therapeutic interventions into the numerical evaluation.
• The interventions evaluated include CPAP, Oxygen, Mask and Bag, Intubation, Neonatal chest compressions, Exogenous surfactant, and Drugs.
• Each of these interventions is assigned a score of 0 if performed and 1 if not performed.
• This intervention score is calculated in combination with the standard APGAR score out of a total maximum of 17 points.
• A combined score of less than 10 out of 17 serves as a strong indicator for high neonatal morbidity and mortality.

Prognostic Value And Limitations

• The 1-minute APGAR score is useful for predicting immediate mortality.
• However, the 1-minute score does not correlate with long-term neurodevelopmental outcomes and should not be used to guide prognostication.
• A low APGAR score at 5 minutes significantly increases the risk of developing cerebral palsy (CP).
• The association with severe neurodisability is highest when the APGAR score is evaluated at 20 minutes of life.
• A prolonged period of severe depression, defined as an APGAR score of 3 for more than 15 minutes, indicates a high likelihood of abnormal long-term neurologic outcomes.
• Despite this statistical risk, many newborns with prolonged depression beyond 15 minutes are completely normal on follow-up.
• A 10-minute APGAR score of 5 or less is utilized as a diagnostic criterion for fetal distress to initiate therapeutic hypothermia in neonates with moderate-to-severe encephalopathy.

Differential Diagnosis Of A Low APGAR Score

• A low APGAR score and the need for resuscitation in the delivery room are not sufficient to definitively diagnose perinatal asphyxia or hypoxic-ischemic encephalopathy (HIE).
• Many infants fail to cry at birth or experience an ineffective transition due to reasons entirely unrelated to asphyxia.
• Differential diagnoses for a term newborn with a persistently low APGAR score include respiratory depression from maternal anesthesia or analgesia.
• Birth trauma, congenital infections, and severe cardiac or pulmonary disorders can present with identical low scores.
• Underlying neuromuscular disorders and other central nervous system (CNS) abnormalities must also be excluded.