Apgar score and the risk of cause-specific infant mortality: a population-based cohort study
Open accessAbstract
Background The Apgar score has been used worldwide as an index of early neonatal condition for more than 60 years. With advances in health-care service provision, neonatal resuscitation, and infant care, its present relevance is unclear. The aim of the study was to establish the strength of the relation between Apgar score at 5 min and the risk of neonatal and infant mortality, subdivided by specific causes.Methods We linked routine discharge and mortality data for all births in Scotland, UK between 1992 and 2010. We restricted our analyses to singleton livebirths, in women aged over 10 years, with a gestational age at delivery between 22 and 44 weeks, and excluded deaths due to congenital anomalies or isoimmunisation. We calculated the relative risks (RRs) of neonatal and infant death of neonates with low (0-3) and intermediate (4-6) Apgar scores at 5 min referent to neonates with normal Apgar score (7-10) using binomial log-linear modelling with adjustment for confounders. Analyses were stratified by gestational age at birth because it was a significant effect modifier. Missing covariate data were imputed.Findings Complete data were available for 1,029,207 eligible livebirths. Across all gestational strata, low Apgar score at 5 min was associated with an increased risk of neonatal and infant death. However, the strength of the association (adjusted RR, 95% CI referent to Apgar 7-10) was strongest at term (p<0·0001). A low Apgar (0-3) was associated with an adjusted RR of 359·4 (95% CI 277·3-465·9) for early neonatal death, 30·5 (18·0-51·6) for late neonatal death, and 50·2 (42·8-59·0) for infant death. We noted similar associations of a lower magnitude for intermediate Apgar (4-6). The strongest associations were for deaths attributed to anoxia and low Apgar (0-3) for term infants (RR 961·7, 95% CI 681·3-1357·5) and preterm infants (141·7, 90·1-222·8). No association between Apgar score at 5 min and the risk of sudden infant death syndrome was noted at any gestational age (RR 0·6, 95% CI 0·1-4·6 at term; 1·2, 0·3-4·8 at preterm).Interpretation Low Apgar score at 5 min was strongly associated with the risk of neonatal and infant death. Our findings support its continued usefulness in contemporary practice.Funding None.
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Umbilical blood gas data was not included in the Iliodromiti study.
“Yet, umbilical blood gas data was not included in this study.”
From Neonatal outcome of infants with umbilical cord arterial <scp>pH</scp> less than 7 (2023) · cites this paper as [21]
Iliodromiti et al. found that a low AS5 was associated with a higher infant mortality rate.
“Iliodromiti et al., in their large Scottish population cohort study of 1 million deliveries, found that a low AS5 was associated with a higher infant mortality rate.”
From Neonatal outcome of infants with umbilical cord arterial <scp>pH</scp> less than 7 (2023) · cites this paper as [21]
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“Although a low Apgar score at 5 min is associated with increased risk of neonatal and infant death a large majority of these children are healthy (18).”
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“► 1 min and 5 min Apgar scores: an Apgar score >7 was defined as normal, whereas a score <7 was considered to indicate moderate or severe hypoxia.(23) ► Birth weight: neonatal birth weight is presented in grams.”
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Low Apgar scores at both one and five minutes are associated with long‐term neurological morbidity
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“It has been shown that the risk of neonatal and infant mortality increased when the five-minute Apgar score was low (4).”
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Self-citationObsa, M. S., Shanka, G. M., Menchamo, M. W., Fite, R. O., & Abrar, M. (2020) · Journal of Pregnancy · doi:10.1155/2020/5986269 · Cited by 28 · see citing works
“The test is simple and repeatable method to quickly and summarily assess the health of newborn physical condition immediately after delivery and to determine any immediate need for extra emergency care [2, 3].”
MethodGetachew, B., Etefa, T., Asefa, A., Tesfaye, B. T., & Dereje, D. (2020) · International Journal of Pediatrics · doi:10.1155/2020/9896127 · Cited by 28 · see citing works
“Low Apgar scores was associated with increased perinatal morbidity and mortality [4]; neonatal and infant death had a strong association with low Apgar score (<3) [5].”
BackgroundThe Health Impacts of Hospital Delivery Practices
Card, D., Fenizia, A., & Silver, D. W. (2023) · American Economic Journal Economic Policy · doi:10.1257/pol.20210034 · Cited by 28 · see citing works
Review of the Reliability and Validity of the Apgar Score
Michel, A. (2021) · Advances in Neonatal Care · doi:10.1097/anc.0000000000000859 · Cited by 28 · see citing works
Sun, J., Zheng, Z., Li, Y., Zou, L., Li, G.-H., Wang, X.-G., She, B.-Z., Huang, X., & Li, Y. (2019) · Journal of International Medical Research · doi:10.1177/0300060519865063 · Cited by 27 · see citing works
“Spinal anesthesia is the most common type of anesthesia in cesarean section surgery with an incidence of 30% to 55% for intraoperative shivering.(1) Shivering, which is a thermoregulatory response to hypothermia or muscle activity with tonic or clonic patterns,(2) mainly occurs in the upper limbs, neck, and jaw muscle…”
Hong, J. G. S., Crawford, K., Jarrett, K., Triggs, T., & Kumar, S. (2024) · The Lancet Regional Health - Western Pacific · doi:10.1016/j.lanwpc.2024.101011 · Cited by 28 · see citing works
Ensing, S., Abu–Hanna, A., Roseboom, T. J., Repping, S., van der Veen, F., Mol, B. W., & Ravelli, A. C. J. (2015) · Fertility and Sterility · doi:10.1016/j.fertnstert.2015.04.035 · Cited by 26 · see citing works
Severe Maternal Morbidity and Infant Mortality in Canada
Aoyama, K., Park, A. L., Davidson, A. J. F., & Ray, J. G. (2020) · PEDIATRICS · doi:10.1542/peds.2019-3870 · Cited by 26 · see citing works
“Recognized risk factors for neonatal mortality at birth include extreme preterm weight, severe growth restriction, and a low 5-minute Apgar score.(29,30) Sepsis, lethal congenital or chromosomal anomalies, and sudden infant death syndrome are causes of postneonatal death.”
BackgroundDie Versorgung und Reanimation des Neugeborenen
Wyllie, J. P., Bruinenberg, J., Roehr, C. C., Rüdiger, M., Trevisanuto, D., & Urlesberger, B. (2015) · Notfall + Rettungsmedizin · doi:10.1007/s10049-015-0090-0 · Cited by 26 · see citing works
Gillette, E., Boardman, J. P., Calvert, C., John, J. R., & Stock, S. J. (2022) · PLoS Medicine · doi:10.1371/journal.pmed.1004040 · Cited by 26 · see citing works
“Apgar’s original use of the score to predict neonatal mortality and support the use of the 5-minute Apgar score in research [4,7,26].”
MethodResultFuka, F., Osuagwu, U. L., Agho, K., Gyaneshwar, R., Naidu, S., Fong, J., & Simmons, D. S. (2020) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-020-2821-6 · Cited by 25 · see citing works
Neonatal outcome of infants with umbilical cord arterial <scp>pH</scp> less than 7
Lau, S. L., Lok, Z. L. Z., Hui, S. Y. A., Fung, G. P. G., Lam, H. S., & Leung, T. Y. (2023) · Acta obstetricia et gynecologica Scandinavica · doi:10.1111/aogs.14494 · Cited by 23 · see citing works
Abate, K. H., Chojenta, C., Egan, N., & Loxton, D. J. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18126450 · Cited by 23 · see citing works
“A low Apgar score, commonly defined as a score of less than seven, has been associated with an increased risk of neonatal morbidity, mortality [9,10], and neurodevelopmental outcomes, such as motor, language, and educational outcomes [11–13].”
BackgroundLeybovitz‐Haleluya, N., Wainstock, T., Sheiner, E., Segal, I., Landau, D., & Walfisch, A. (2017) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2017.1411475 · Cited by 23 · see citing works
Utility of the 5-Minute Apgar Score as a Research Endpoint
Bovbjerg, M. L., Dissanayake, M. V., Cheyney, M. J., Brown, J., & Snowden, J. M. (2019) · American Journal of Epidemiology · doi:10.1093/aje/kwz132 · Cited by 22 · see citing works
Association of Gestational Age and Severe Neonatal Morbidity with Mortality in Early Childhood
Stephens, A. S., Lain, S. J., Roberts, C. L., Bowen, J. R., & Nassar, N. (2016) · Paediatric and Perinatal Epidemiology · doi:10.1111/ppe.12323 · Cited by 21 · see citing works
Yeagle, K. P., O’Brien, J. M., Curtin, W. M., & Ural, S. (2018) · International Journal of Women s Health · doi:10.2147/ijwh.s170090 · Cited by 21 · see citing works
“Lower Apgar scores were shown to be associated with an increased risk of mortality and perinatal complications in preterm infants.(7) correspondence: Kevin P Yeagle Penn state college of Medicine, 500 University Drive, 3rd Floor north, Hershey, Pa 17033, Usa Tel +1 717 531 8142 email kyeagle@pennstatehealth.”
Identification of risk factors in infants participating in a Follow-up program
Formiga, C. K. M. R., da Silva, L. P., & Linhares, M. B. M. (2018) · Revista CEFAC · doi:10.1590/1982-021620182038817 · Cited by 20 · see citing works
Wake, G. E., Chernet, K., Getu, A. A., Yenealem, F., Fitie, G. W., Tizazu, M. A., Mittiku, Y. M., Chekole, M. S., & Behulu, G. K. (2022) · Frontiers in Public Health · doi:10.3389/fpubh.2022.979402 · Cited by 20 · see citing works
“The supply of oxygen through the placenta increases with the course of gestation according to the fetal needs (40, 41).”
BackgroundApgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm
Ehrhardt, H., Aubert, A. M., Ådén, U., Draper, E. S., Guðmundsdóttir, A., Varendi, H., Weber, T., Zemlin, M., Maier, R. F., Zeitlin, J. A., et al. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.32413 · Cited by 21 · see citing works
Ernest, E., Wainstock, T., Sheiner, E., Segal, I., Landau, D., & Walfisch, A. (2019) · European Journal of Pediatrics · doi:10.1007/s00431-018-03311-6 · Cited by 19 · see citing works
Neuraxial analgesia in labour and the foetus
Kearns, R. J., & Lucas, D. N. (2023) · Best Practice & Research Clinical Anaesthesiology · doi:10.1016/j.bpa.2023.02.005 · Cited by 21 · see citing works
Varela, A. R., Schneider, B. C., Bubach, S., da Silveira, M. F., Bertoldi, A. D., Morón-Duarte, L. S., Menezes, A. M. B., Domingues, M. R., & Bassani, D. G. (2019) · Cadernos de Saúde Pública · doi:10.1590/0102-311x00072918 · Cited by 18 · see citing works
Five-minute Apgar score ≤ 5 and Molar Incisor Hypomineralisation (MIH) – a case control study
Sidaly, R., Schmalfuss, A., Skaare, A. B., Sehic, A., Stiris, T., & Espelid, I. (2016) · BMC Oral Health · doi:10.1186/s12903-016-0253-5 · Cited by 18 · see citing works
“Also low Apgar score at 5 min has been demonstrated to have some predictive value on neurodevelopmental outcome [13, 14] and a recent publication [15] showed that low Apgar score at 5 min was strongly associated with the risk of neonatal and infant death.”
Backgroundon behalf of the ERC Guidelines 2015 Writing Group, Monsieurs, K. G., Nolan, J. P., Bossaert, L. L., Greif, R. T., Maconochie, I. K., Nikolaou, N. I., Perkins, G. D., Soar, J., Truhlář, A., et al. (2015) · Notfall + Rettungsmedizin · doi:10.1007/s10049-015-0097-6 · Cited by 16 · see citing works
Perinatal complications and executive dysfunction in early-onset schizophrenia
Teigset, C. M., Mohn, C., & Rund, B. R. (2020) · BMC Psychiatry · doi:10.1186/s12888-020-02517-z · Cited by 17 · see citing works
Birhane, B. M., Bayih, W. A., Alemu, A. Y., Belay, D. M., & Demis, A. (2021) · PLoS ONE · doi:10.1371/journal.pone.0249365 · Cited by 17 · see citing works
Predictive macrosomia birthweight thresholds for adverse maternal and neonatal outcomes
Wang, D., Zhu, L., Zhang, S., Wu, X., Wang, X., Lv, Q., Gan, D., Liu, L., Wen, L., Zhou, Q., et al. (2016) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.3109/14767058.2016.1147549 · Cited by 17 · see citing works
“anoxia, which is an important cause of neonatal neurological diseases [27].”
BackgroundLow Five-Minute Apgar Score and Neurological Morbidities: Does Prematurity Modify the Association?
Wainstock, T., & Sheiner, E. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11071922 · Cited by 16 · see citing works
“The score given at one minute (Apgar 1) is considered an indicator of antepartum complications associated with infant mortality, morbidity, and development, especially in the short term [6,7].”
BackgroundDoes Health-Care Consolidation Harm Patients? Evidence from Maternity Ward Closures
Avdic, D., Lundborg, P., & Vikström, J. (2024) · American Economic Journal Economic Policy · doi:10.1257/pol.20200734 · Cited by 19 · see citing works
Cao, W., Ni, X., Wang, Q., Li, J., Li, Y., Chen, T., & Wang, X. (2020) · Experimental and Therapeutic Medicine · doi:10.3892/etm.2020.8548 · Cited by 16 · see citing works
Evaluation of Health in Pregnancy grants in Scotland: a natural experiment using routine data
Leyland, A. H., Ouédraogo, S., Nam, J., Bond, L. M., Briggs, A. H., Gray, R., Wood, R., & Dundas, R. (2017) · Public Health Research · doi:10.3310/phr05060 · Cited by 15 · see citing works
Five-minute Apgar score and outcomes in neonates of 24–28 weeks’ gestation
Shah, P. S., Norman, M., Rusconi, F., Kusuda, S., Reichman, B. L., BATTIN, M. R., Bassler, D., Modi, N., Håkansson, S., Yang, J., et al. (2021) · Archives of Disease in Childhood Fetal & Neonatal · doi:10.1136/archdischild-2021-322230 · Cited by 15 · see citing works
Jindal, S., Steer, P. J., Savvidou, M. D., Draycott, T. J., Dixon‐Woods, M., Wood, A., & Kim, L. G. (2023) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.17531 · Cited by 15 · see citing works
“20 22 Secondly, we used a composite outcome comprising any one of (i) 5-minute Apgar score 7, (ii) neonatal resuscitation by intubation and positive pressure ventilation (with or without cardiac massage) and (iii) perinatal death (intra-partum and early neonatal death), a rare but important…”
MethodPersson, M., Johansson, S., & Cnattingius, S. (2016) · PLoS Medicine · doi:10.1371/journal.pmed.1002033 · Cited by 15 · see citing works
“The validity of this definition is supported by the fact that an infant with an Apgar score of 4–6 at 5 min has a 45 times higher risk of neonatal death and a 31 times higher risk of cerebral palsy compared to infants with an Apgar score of 7–10 at 5 min [41,42].”
BackgroundFatores de risco de óbito neonatal em região do interior paulista, Brasil
Sleutjes, F. C. M., Pàrada, C. M. G. D. L., Carvalhães, M. A. D. B. L., & Jamas, M. T. (2018) · Ciência & Saúde Coletiva · doi:10.1590/1413-81232018238.15142016 · Cited by 15 · see citing works
Arterial blood gas and acid‑base balance in patients with pregnancy‑induced hypertension syndrome
Cao, Y., Wang, M.-C., Yuan, Y., Li, C., Bai, Q., & Li, M. (2018) · Experimental and Therapeutic Medicine · doi:10.3892/etm.2018.6893 · Cited by 15 · see citing works
“In this study, according to the Apgar scoring criteria reported by Iliodromiti et al (10), 7-10 points indicated normal neonates, 4-6 points indicated neonates with mild asphyxia, and <4 points indicated neonates with severe asphyxia.”
Zewude, S. B., Ajebe, T. M., Gessesse, S. S., & Wassie, T. H. (2021) · International Journal of Africa Nursing Sciences · doi:10.1016/j.ijans.2021.100322 · Cited by 15 · see citing works
Ogunyemi, D. A., Jovanovski, A. P., Friedman, P., Sweatman, B., & Madan, I. (2018) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2018.1456523 · Cited by 15 · see citing works
“The primary outcome was a composite neonatal adverse outcome comprised of 5-minute Apgar score <4 [9] umbilical arterial pH< 7.”
BackgroundDragon year superstition, birth timing, and neonatal health outcomes
Huang, C., Zhang, S., Zhao, Q., & Lin, Y. (2021) · China Economic Review · doi:10.1016/j.chieco.2021.101594 · Cited by 14 · see citing works
Abdullahi, I., Wong, K., Glasson, E. J., Mutch, R. C., de Klerk, N. H., Downs, J. A., Cherian, S., & Leonard, H. (2019) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-019-2437-x · Cited by 14 · see citing works
“A Scottish study found that a low Apgar score at 5 min was strongly associated with the risk of neonatal and infant death [6].”
BackgroundLiu, L.-C., Tsai, Y.-H., Chou, Y., Jheng, Y.-C., Lin, C., Lyu, N.-Y., Chien, Y., Yang, Y., Chang, K.-J., Chang, K.-H., et al. (2020) · Journal of the Chinese Medical Association · doi:10.1097/jcma.0000000000000416 · Cited by 14 · see citing works
“18 Because 1-and 5-minute Apgar scores were related to neonatal resuscitation and mortality, 18 we recorded the 1-and 5-minute Apgar scores for each delivery and analyzed them using both clinical practice and the AI model.”
Ma, S., Wu, L., Yu, Q., Chen, D., Geng, C., Peng, H. Y., Yu, L., & Zhang, M. (2021) · Risk Management and Healthcare Policy · doi:10.2147/rmhp.s318956 · Cited by 14 · see citing works
Lorthe, E., Kayem, G., on behalf of the TOCOPROM Study Group and the GROG (Groupe de Recherche en Obstétrique et Gynécologie), Kayem, G., Lorthe, E., Ancel, P., Abdoul, H., Briand, N., Lehmann, B., Cabanne, C., et al. (2021) · BMC Pregnancy and Childbirth · doi:10.1186/s12884-021-04047-2 · Cited by 14 · see citing works
Apgar score at 10 minutes and adverse outcomes among low-risk pregnancies
Chen, H.-Y., & Chauhan, S. P. (2021) · The Journal of Maternal-Fetal & Neonatal Medicine · doi:10.1080/14767058.2021.1943659 · Cited by 13 · see citing works
Infant death prediction using machine learning: A population-based retrospective study
Zhang, Z., Xiao, Q., & Luo, J. (2023) · Computers in Biology and Medicine · doi:10.1016/j.compbiomed.2023.107423 · Cited by 13 · see citing works
Clinical Features and Antibiotic Treatment of Neonatal Listeriosis: A Hospital-Based Study
Zhang, S., Li, J., Wan, L., Yu, J., Chen, S., & Jin, Z. (2023) · Infection and Drug Resistance · doi:10.2147/idr.s431402 · Cited by 13 · see citing works
“Some studies proved that low Apgar score at 5 minutes was associated with an increased risk of neonatal death, across all gestational strata.(24,25) The same conclusion was observed in our study.”
- Authors
- Iliodromiti, S., Mackay, D. F., Smith, G. C. S., Pell, J. P., & Nelson, S. M.
- Affiliations
- Glasgow Royal Infirmary (GB)
- University of Glasgow (GB)
- University of Cambridge (GB)
- Corresponding author
- Nelson, Scott M
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2014-11
- Volume
- 384
- Issue
- 9956
- Pages
- 1749-1755
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- OpenAlex
- W2061760881
- Cited by
- 282
- References
- 27
- Citations by year
- 2026: 12 · 2025: 20 · 2024: 24 · 2023: 27 · 2022: 34 · 2021: 27 · 2020: 36 · 2019: 18 · 2018: 21 · 2017: 20 · 2016: 18 · 2015: 23 · 2014: 1 · 2013: 1
- FWCI
- 37.42
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet (publishedVersion)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
- Topics
- Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Infant Development and Preterm Care
- Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
- Keywords
- Apgar score, neonatal mortality, infant mortality, cause-specific mortality, neonatal anoxia, preterm infants, gestational age, term infants, neonatal resuscitation, neonatal assessment, mortality risk stratification, neonatal intensive care admission, neonatal sepsis, neonatal jaundice, neonatal hypoglycemia, neonatal respiratory distress
- MeSH terms
- Adult, Apgar Score, Cause of Death, Female, Humans, Infant, Infant Mortality, Infant, Newborn, Infant, Premature, Male, Retrospective Studies, Scotland, Cohort Studies, Confidence Intervals, Likelihood Functions, Linear Models, Databases, Factual, Risk Assessment, Term Birth, Young Adult
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