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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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“Yet, umbilical blood gas data was not included in this study.”
From Neonatal outcome of infants with umbilical cord arterial pH less than 7 (2023) · cites this paper as [21]
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“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 pH less than 7 (2023) · cites this paper as [21]
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“In full-term and mature infants, a low Apgar score is associated with poor neurological outcomes (2) and an increased risk of neonatal and infant death (3,4).”
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“Characteristics Total (n=666) Median maternal age (range), years 24 (15-45) Gender Male, n (%) 301 (45.”
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“[18] confirmed the usefulness of the Apgar score in modern day practice - both in term and preterm neonates.”
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“In recent years, an increasing number of studies found that low Apgar scores, especially low Apgar score at 5 min, were associated with increased risk of death in preterm or full-term infants (6,7).”
BackgroundHidden in plain sight in the delivery room – the Apgar score is biased
Grunebaum, A. N., Bornstein, E., Dudenhausen, J. W., Lenchner, E., Jones, M. D. F., Varrey, A., Lewis, D., & Chervenak, F. A. (2023) · Journal of Perinatal Medicine · doi:10.1515/jpm-2022-0550 · Cited by 10
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“4/1000 live births for a 5-minute Apgar score under 7 [5], while a study including 23 countries or regions participating in the Euro-Peristat project reported that scores < 7 ranged from 3 to 24 per 1000 live births [11].”
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“This is in line with studies conducted in Scotland [36], Cameron [37], and Ethiopia [38].”
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“…fathers have been and will continue to be involved with them, and who receive more maternal investment prenatally, should be less likely to have low Apgar scores, a widely used measure of child well-being immediately after delivery that is predictive of infant mortality (Iliodromiti et al. 2014).”
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“Although APGAR score methods are not intended to predict individual neurologic outcomes of the neonate, babies with low APGAR scores have 4.02 odds of adverse neurologic outcomes such as cerebral palsy [11], epilepsy, mental retardation, and lower academic achievement in secondary school [12].”
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Neonatal Depression Is Associated With 1‐Year Mortality in Critical Congenital Heart Disease
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“27,28,42 In a Scottish registry study including >1 million live births, after adjustment for multiple confounders, a low AS (0– 3) was associated with mortality in the first 7 days of life (adjusted RR, 359.4 [95% CI, 277.3– 465.9]), first 28 days of life (adjusted RR, 177.8 [95% CI, 145.0–…”
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“An Apgar score > 7 was defined as normal, while a score ≤ 7 was considered indicative of moderate or severe hypoxia [21].”
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“The adverse pregnancy conditions of patients in the two groups were compared, including the Apgar score (12), birth weight and adverse conditions of the newborns, and postpartum hemorrhage and postpartum hospital stays of the research group were recorded.”
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“Severity of birth asphyxia was categorized based on Apgar 5-minute scores of > 7 (normal) ， 4–7 (mild) and ≤ 3 (severe) [9].”
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“%) had five-minute Apgar scores of less than 7, which compares favourably with incidences reported in large recent UK studies (Iliodromiti et al. 2014).”
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Apgar Score Plus Umbilical Artery pH and Adverse Neonatal Outcomes in Very Preterm Infants
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“It has been reported that low 5 minutes Apgar score is associated with short-term infant morbidity and mortality [30], as well as an increased risk of long-term pediatric gastro-intestinal morbidity of the offspring [31] In our study, the Pearson correlation coefficients manifested that S/D, RI, and PI of MCA were pos…”
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“Low Apgar scores have been associated with neo-natal death and long-term neurological impairment such as cerebral palsy, epilepsy, sensorineural defects, intellectual disability, and attention deficit hyperactivity disorder [5–11].”
BackgroundResuscitation outcomes for weekend deliveries of very low birthweight infants
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Predicting Neonatal Condition at Birth through Ensemble Learning Methods in Pregnancy Care
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“Each of the signals is assigned a score of 0 to 2 according to the observed condition [Iliodromiti et al. 2014].”
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“Nevertheless, recent scientific evidence demonstrates that antenatal GCS treatment may eventually be ineffective, lead to adverse outcomes or to epigenetic changes in a variety of homeostatic mechanisms [23] by mimicking a stress response during a gestational period in which the fetus is normally protected from high s…”
BackgroundLiu, J., Liu, C., Zuo, X., & Teng, Y. (2019) · Journal of International Medical Research · doi:10.1177/0300060519886991 · Cited by 4
“The birth weight of the neonate was 1110 g, which was compatible with the gestational age of 27þ6 weeks, but the Apgar scores were 7-7-8, which were much lower than average for neonates born at a similar gestational age, indicating unfavorable intrauterine conditions for the fetus.(11) Pernicious placenta previa coexi…”
MethodApgar score and risk of cause-specific infant mortality
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The Role of Prenatal Care in Fetal and Infant Development in Brazil: A Narrative Review
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“Magalh ã es and collaborators analyzed 5,680,092 live births, Cnattingius and coworkers evaluated 113,000 preterm infants, and Santos and collaborators examined 9135 newborns [24,46,85].”
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“Within the NICU, several patient risk and severity indicators exist, such as birth weight, gestational age [37–39], CRIB score [40], and Apgar score [41].”
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“Other studies also indicated that a low APGAR score at 5 min is highly associated with neonatal deaths [23, 24].”
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Apgar Score at Various Gestational Ages
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Índice de morte neonatal precoce: Uma análise do perfil materno
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Neonatal near miss in the intensive care unit
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“Nonetheless, the score at 1 minute can predict the prognosis of early or late neonatal mortality(17,20-24).”
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Oxygen saturation after birth in resuscitated neonates in Uganda: a video-based observational study
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Apgar score and risk of cause-specific infant mortality – Authors' reply
Nelson, S. M., Iliodromiti, S., Mackay, D., Pell, J. P., & Smith, G. C. S. (2015) · The Lancet · doi:10.1016/s0140-6736(15)60197-0 · Cited by 3
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“The 5-minute Apgar score is considered a better reflection of sustained perinatal compromise and correlates more strongly with adverse neonatal outcomes than the 1-or 10-minute scores 31 .”
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“Large population-based studies have shown that low five-minute Apgar scores are associated with increased neonatal mortality [ 11 , 13 , 14 ], and there is epidemiological evidence that low five-minute Apgar scores are associated with adverse neurodevelopmental outcomes [ 15 ].”
Fallout and health: Chernobyl’s legacy, early-life exposure, and protective behavior
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“Low Apgar Score: Apgar score less than 7 at either 1 or 5 min after birth, indicating potential neonatal compromise [41].”
Study of Some Predictors of Neonatal Mortality among Preterm Newborn at Zagazig University Hospital
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“…(de fi ned as birth before 37 complete weeks of gestation), low Apgar score at 5 min (de fi ned as an Apgar score 7 at 5 min after birth [13, 14]), and congenital anomalies (de fi ned as having any type of congenital anomalies at birth, including cyanotic congenital heart disease,…”
BackgroundKristbergsdóttir, H., Valdimarsdottir, H. B., Steingrímsdóttir, Þ., Sigurvinsdóttir, R., Skúlason, S., Lýðsdóttir, L. B., Jónsdóttir, S. S., Ólafsdóttir, H., & Sigurðsson, J. F. (2023) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2023.10.010 · Cited by 2
Impact of villitis of unknown etiology and adverse acute neonatal outcomes in Eastern Ontario
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Metadata
- 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
- 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 › Medicine › Pediatrics, Perinatology and Child Health › 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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