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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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Characterization of language profile in children with critical congenital heart disease
Faria-Lefort, M., Hurtrel, C., Piller, A.-G., Garnier, É., Schweitzer, E., Ferré, S., & Lefort, B. (2026) · Archives de Pédiatrie · doi:10.1016/j.arcped.2026.105588
Siame, L., Mupeta, G., Mbasela, N., Kabidiki, C., Muyombu, A., Mandumbwa, K., Mutalange, M., Chakulya, M., Ngosa, M., Luyando, M., et al. (2026) · Discover Pediatrics · doi:10.1007/s44571-026-00002-8
“Low Apgar scores are commonly linked to perinatal asphyxia and poor early adaptation, both of which increase the risk of death [34, 35 ].”
Arnovitz, E., MacFarlane, S., Kugler, A., & Balayla, J. (2026) · Early Human Development · doi:10.1016/j.earlhumdev.2026.106644
Kabasubabo, F. K., Bézanahary, H., Magné, J., & Akilimali, P. Z. (2026) · PLOS Global Public Health · doi:10.1371/journal.pgph.0005989
“These results are consistent with the original use of the score created by Dr. Apgar to predict neonatal mortality and support the use of the 5-minute Apgar score in research [16,35,36].”
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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