Do we need an Apgar score?

The Apgar score in clinical research: for what, how and by whom it is used

OBJECTIVES

To review how the Apgar score is used in published clinical research as well as who uses it, and how this may have changed between 1989-90 and 2018-19.

METHODS

Pubmed search for English publications using MeSH Terms "apgar score" OR "apgar" AND "score" AND "humans" for epochs 1989-90 & 2018-19. The location and specialty of first author, primary purpose and how the Apgar score was used was recorded.

RESULTS

There was a 61% increase in number of publications in 2018-19 compared to 1989-90, from all regions except North America. The most common purpose for using the Apgar was to assess newborn status after pregnancy/delivery interventions. There were 50 different definitions of a significant score. Definition of significance was influenced by specialty in 2018-19 and by study purpose in both epochs.

CONCLUSIONS

Most studies using the Apgar score are focused on the mother. There is no consistent definition of a significant score. Development of any future newborn assessment tools should account for the multiple purposes for which the Apgar score is used.

Parâmetros utilizados na avaliação de bem-estar do bebê no nascimento

Objectivo: identificar parâmetros que se utilizan para evaluar el bienestar del recién nacido.Síntesis del contenido: revisión integrativa de la literatura, realizada en las bases PubMed y Biblioteca Virtual de Salud (bvs), que utilizó los descriptores “apgar score”, “neonatal outcomes”, “fetal vitality” y “health services evaluation”. El recorte temporal fue de enero del 2011 a diciembre del 2016. Se importaron los resúmenes para el software Endnote Web®, para la remoción de duplicados y los remanentes exportados para el software Covidence®, lo que permitió la selección de la muestra final por dos investigadoras, de forma independiente. La muestra final incluyó 17 estudios. Los parámetros más utilizados fueron admisión del neonato en Unidad de Cuidados Intensivos en las primeras 24 a 48 horas de vida y el índice de Apgar, pero hubo variaciones en la mensuración de esos parámetros entre los estudios. Otros parámetros fueron: peso al nacer, temperatura corporal, natimortalidad y mortalidad neonatal. El Apgar, a pesar de utilizado mundialmente, posibilita subjetividad en la evaluación de algunas variables; este puede evaluar la respuesta del bebé a las maniobras empleadas en el atendimiento en sala de parto, pero no debe ser un parámetro decisorio para instituir o no maniobras de reanimación.Conclusión: algunos parámetros fueron comunes entre los estudios, sin embargo pueden agregarse otros parâmetros al abordar patologías específicas. Se considera importante entrenar enfermeiros en la medición del Apgar, pues son professionales responsables por el cuidado de la madre y el bebé 24 horas del día y, en muchos servicios, por la primera atención del recién nacido.

Comparison of the Combined versus Conventional Apgar Scores in Predicting Adverse Neonatal Outcomes

Objectives

Assessing the value of the Combined-Apgar score in predicting neonatal mortality and morbidity compared to the Conventional-Apgar.

Methods

This prospective cohort study evaluated 942 neonates (166 very preterm, 233 near term, and 543 term) admitted to a tertiary referral hospital. At 1- and 5-minutes after delivery, the Conventional and Combined Apgar scores were recorded. The neonates were followed, and the following information was recorded: the occurrence of severe hyperbilirubinemia requiring medical intervention, the requirement for mechanical ventilation, the occurrence of intraventricular hemorrhage (IVH), and neonatal mortality.

Results

Before adjusting for the potential confounders, a low Conventional (<7) or Combined (<10) Apgar score at 5-minutes was associated with adverse neonatal outcomes. However, after adjustment for the gestational age, birth weight and the requirement for neonatal resuscitation in the delivery room, a depressed 5-minute Conventional-Apgar score lost its significant associations with all the measured adverse outcomes; after the adjustments, a low 5-minute Combined-Apgar score remained significantly associated with the requirement for mechanical ventilation (OR,18.61; 95%CI,6.75–51.29), IVH (OR,4.8; 95%CI,1.91–12.01), and neonatal mortality (OR,20.22; 95%CI,4.22–96.88). Additionally, using Receiver Operating Characteristics (ROC) curves, the area under the curve was higher for the Combined-Apgar than the Conventional-Apgar for the prediction of neonatal mortality and the measured morbidities among all the admitted neonates and their gestational age subgroups.

Conclusions

The newly proposed Combined-Apgar score can be a good predictor of neonatal mortality and morbidity in the admitted neonates, regardless of their gestational age and resuscitation status. It is also superior to the Conventional-Apgar in predicting adverse neonatal outcomes in very preterm, near term and term neonates.

Comparison of the four proposed Apgar scoring systems in the assessment of birth asphyxia and adverse early neurologic outcomes

OBJECTIVES

To compare the Conventional, Specified, Expanded and Combined Apgar scoring systems in predicting birth asphyxia and the adverse early neurologic outcomes.

METHODS

This prospective cohort study was conducted on 464 admitted neonates. In the delivery room, after delivery the umbilical cord was double clamped and a blood samples was obtained from the umbilical artery for blood gas analysis, meanwhile on the 1- , 5- and 10- minutes Conventional, Specified, Expanded, and Combined Apgar scores were recorded. Then the neonates were followed and intracranial ultrasound imaging was performed, and the following information were recorded: the occurrence of birth asphyxia, hypoxic Ischemic Encephalopathy (HIE), intraventricular hemorrhage (IVH), and neonatal seizure.

RESULTS

The Combined-Apgar score had the highest sensitivity (97%) and specificity (99%) in predicting birth asphyxia, followed by the Specified-Apgar score that was also highly sensitive (95%) and specific (97%). The Expanded-Apgar score was highly specific (95%) but not sensitive (67%) and the Conventional-Apgar score had the lowest sensitivity (81%) and low specificity (81%) in predicting birth asphyxia. When adjusted for gestational age, only the low 5-minute Combined-Apgar score was independently associated with the occurrence of HIE (B = 1.61, P = 0.02) and IVH (B = 2.8, P = 0.01).

CONCLUSIONS

The newly proposed Combined-Apgar score is highly sensitive and specific in predicting birth asphyxia and also is a good predictor of the occurrence of HIE and IVH in asphyxiated neonates.

Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990

BACKGROUND

Intrapartum hypoxic events ("birth asphyxia") may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.

METHODS

Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.

RESULTS

In 2010, 1.15 million babies (uncertainty range: 0.89-1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000-440,000) neonates with NE died in 2010; 233,000 (163,000-342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000-319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.

CONCLUSION

Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.

Preterm resuscitation I: clinical approaches to improve management in delivery room

Delivery room (DR-) management has a great potential to optimise quality of long term outcome in extremely preterm infants. However, a new conceptual framework that focuses on an individualised 'support of transition' rather than on 'resuscitation' is necessary. Video-recordings of DR-management represent a valuable tool to improve care. Recording combined with a structured feed-back should be introduced in step-wise approach in clinical routine. To describe the postnatal condition of groups of infants or to compare interventions in a research setting, a numerical score-- representing the sum of several objective findings--is required. The conventional Apgar-Score has severe limitations that restrict its applicability. The Specified-Apgar allows an assessment of infant's condition independent of interventions and regardless of gestational age. The Expanded-Apgar quantifies the interventions needed to achieve the condition described by the Specified-Apgar. In summary, beside a new conceptual framework an individualised monitoring and an objective assessment of DR-management are required.

Neonatal resuscitation and immediate newborn assessment and stimulation for the prevention of neonatal deaths: a systematic review, meta-analysis and Delphi estimation of mortality effect

BACKGROUND

Of 136 million babies born annually, around 10 million require assistance to breathe. Each year 814,000 neonatal deaths result from intrapartum-related events in term babies (previously "birth asphyxia") and 1.03 million from complications of prematurity. No systematic assessment of mortality reduction from tactile stimulation or resuscitation has been published.

OBJECTIVE

To estimate the mortality effect of immediate newborn assessment and stimulation, and basic resuscitation on neonatal deaths due to term intrapartum-related events or preterm birth, for facility and home births.

METHODS

We conducted systematic reviews for studies reporting relevant mortality or morbidity outcomes. Evidence was assessed using GRADE criteria adapted to provide a systematic approach to mortality effect estimates for the Lives Saved Tool (LiST). Meta-analysis was performed if appropriate. For interventions with low quality evidence but strong recommendation for implementation, a Delphi panel was convened to estimate effect size.

RESULTS

We identified 24 studies of neonatal resuscitation reporting mortality outcomes (20 observational, 2 quasi-experimental, 2 cluster randomized controlled trials), but none of immediate newborn assessment and stimulation alone. A meta-analysis of three facility-based studies examined the effect of resuscitation training on intrapartum-related neonatal deaths (RR= 0.70, 95%CI 0.59-0.84); this estimate was used for the effect of facility-based basic neonatal resuscitation (additional to stimulation). The evidence for preterm mortality effect was low quality and thus expert opinion was sought. In community-based studies, resuscitation training was part of packages with multiple concurrent interventions, and/or studies did not distinguish term intrapartum-related from preterm deaths, hence no meta-analysis was conducted. Our Delphi panel of 18 experts estimated that immediate newborn assessment and stimulation would reduce both intrapartum-related and preterm deaths by 10%, facility-based resuscitation would prevent a further 10% of preterm deaths, and community-based resuscitation would prevent further 20% of intrapartum-related and 5% of preterm deaths.

CONCLUSION

Neonatal resuscitation training in facilities reduces term intrapartum-related deaths by 30%. Yet, coverage of this intervention remains low in countries where most neonatal deaths occur and is a missed opportunity to save lives. Expert opinion supports smaller effects of neonatal resuscitation on preterm mortality in facilities and of basic resuscitation and newborn assessment and stimulation at community level. Further evaluation is required for impact, cost and implementation strategies in various contexts.

FUNDING

This work was supported by the Bill & Melinda Gates Foundation through a grant to the US Fund for UNICEF, and to the Saving Newborn Lives program of Save the Children, through Save the Children US.

Attendance of paediatricians at elective Caesarean sections performed under regional anaesthesia: is it warranted?

AIM

Whether or not a paediatric registrar or consultant paediatrician trained in advanced neonatal resuscitation is needed at elective Caesarean section (CS) deliveries remains controversial. The objective of this study was to provide recent population-based data comparing the need for resuscitation of babies born at >or=37 weeks gestation by elective CS under regional anaesthesia with those born by spontaneous, unassisted vertex vaginal delivery.

METHODS

We performed a population-based cohort study in Tasmania using data collected between January 1998 and December 2003 inclusive. Data on all singleton births>or=37 weeks gestation was analysed from the Tasmanian Obstetric and Neonatal Audit database to determine the number and type of resuscitations, and the number of low 1-min Apgar scores for each mode of delivery.

RESULTS

There were 31 820 singleton deliveries born at >or=37 weeks gestation over the 6-year period. Of these 21 733 (68.3%) were spontaneous unassisted vertex vaginal deliveries and 2918 (9.2%) were elective CSs performed under regional anaesthesia (2620 spinal and 298 epidural). The incidence of a 1-min Apgar score of <4 and a 1-min Apgar score of >or=4 and <7 for elective sections under spinal was significantly lower when compared with unassisted, spontaneous, vertex vaginal delivery at 0.57% and 11.8% respectively. The relative risks when compared with unassisted, spontaneous, vertex vaginal delivery were 0.36 (95% confidence interval (CI) 0.21-0.60, P<0.05) and 0.73 (95% CI 0.65-0.81, P<0.05), respectively. There was a small but statistically significant difference between unassisted, spontaneous, vertex vaginal delivery and elective CSs performed under regional anaesthesia in the requirement for resuscitation in the form of bag and mask ventilation. The relative risk for the need for bag and mask ventilation was 1.33 (95% CI 1.11-1.58, P<0.05) for spinal anaesthesia and 1.99 (95% CI 1.33-2.96, P<0.05) for epidural anaesthesia. There was no difference in the need for bag and mask ventilation or low 1-min Apgar scores between non-cephalic and cephalic presentation at elective CS under regional anaesthesia.

CONCLUSION

Elective CSs performed under regional anaesthesia are low-risk deliveries. The slight increased requirement for bag and mask ventilation is not practically significant. Such deliveries do not require the routine attendance of experienced paediatric medical staff.

[Neuropsychomotor development of infants born of mothers with gestational hypertension]

INTRODUCTION

Gestational hypertension is a major cause of maternal death in our country and may be associated with neonatal hypoxic-ischemic encephalopathy with serious neurological complications.

OBJECTIVE

To correlate gestational hypertension with risk factors of neuropsychomotor development in infants.

METHOD

This was a prospective study. We evaluated 30 consecutive infants born of mothers with gestational hypertension. The following risk factors were considered: small for gestational age; fetal asphyxia; age of onset of gestational hypertension; term/preterm newborn; Apgar scores; central cyanosis; O2 mask; meconium. The study followed two steps. In the first step, newborns underwent neurological examination soon after birth (48-72 hours of life). In the second step, children underwent another neurological assessment between 7 and 15 months of life.

RESULTS

Six newborns presented neurological signs on the first evaluation. The only risk factor that showed a significant correlation with the neurologic examination was the Apgar score. Other risk factors did not show any correlation. All children evaluated on the second step of the study showed normal neurological development and examination, which did not allow any correlation with risk factors.

CONCLUSION

Our data suggest that gestational hypertension per se is not sufficient to cause fetal neurological impairment.

A review of the Apgar score indicated that contextualization was required within the contemporary perinatal and neonatal care framework in different settings

OBJECTIVE

To triangulate the Apgar score by using a crossdisciplinary approach and highlighting the differences that exist between actual everyday practice and accepted standards of scoring in contrasting populations of the world.

STUDY DESIGN AND SETTING

Clinimetrics review of Apgar scoring.

RESULTS

The Apgar scoring has weighting problems, rigid categorization, redundancy and subjectivity in its variables. Poor inter-rater reliability and equivocal validity mark its use in the present milieu. The ceiling and floor effects further hamper the evaluative responsiveness of scoring. Moreover, despite some recent evidence in its favor, the Apgar score has poor calibration when used as an isolated criterion to predict mortality and long-term morbidity, particularly in preterms. Also, the vigor of resuscitation (nature and duration), in essence, is beyond the realm of the Apgar score in contemporary resuscitation guidelines. In developed nations, with rapidly decreasing age of viability, and alternative modes of childbearing, threats to Apgar are more ominous today than before. On the other hand, in developing countries, feasibility problems due to unattended home deliveries and barriers to effective scoring in the overburdened and understaffed hospitals cast doubts about its accuracy as a measure of neonatal well-being.

CONCLUSION

Use of the Apgar score definitely needs to be contextualized within the contemporary perinatal and neonatal care framework in different settings.

Resuscitation beyond 10 minutes of term babies born without signs of life

OBJECTIVE

To obtain population-based data on babies who were admitted to a neonatal intensive care unit despite having Apgar scores of 0 up to and including 10 min, and to document their outcomes. We aimed also to review other studies where outcomes following a 10-min Apgar score of 0 were described, and to combine them with own results. Current recommendations regarding the discontinuation of resuscitation will be reconsidered in light of these results.

METHODS

In order to obtain population-based data for babies born in New South Wales (NSW), a request was made to the NSW Neonatal Intensive Care Unit Study (NICUS) directors to allow identification of babies in the NICUS database with Apgar scores of 0 at both 1 and 5 minutes. Individual directors were then asked to determine from their hospital records, which of these babies had a 10-minute Apgar of 0, and to provide the results of follow-up assessments of any survivors in this subgroup.

RESULTS

Twenty-nine full-term newborns with a 10-minute Apgar score of 0 were identified. Twenty of the 29 babies died before leaving hospital. Of the 9 who were discharged alive, eight had severe disability and one had moderate disability. Thus death or severe disability occurred in 28/29 (97%), and death or any disability in 100%. Combining with other published studies, death or severe disability occurred in 63/64 (98%).

CONCLUSION

The above findings strongly support the discontinuation of resuscitation if a baby remains asystolic at 10 minutes.

The association of Apgar score with subsequent death and cerebral palsy: A population-based study in term infants

OBJECTIVE

To estimate the risk of adverse outcomes for newborns with a low Apgar score.

STUDY DESIGN

Population-based cohort study. All 235,165 children born between 1983 and 1987 in Norway with a birth weight of at least 2500 g and no registered birth defects were followed up from birth to age 8 to 12 years by linkage of 3 national registries. Outcomes were death and cerebral palsy (CP).

RESULTS

Five-minute Apgar scores of 0 to 3 were recorded for 0.1%, and scores of 4 to 6 were recorded for 0.6% of the children. Compared with children who had 5-minute Apgar scores of 7 to 10, children who had scores of 0 to 3 had a 386-fold increased risk for neonatal death (95% CI: 270-552) and an 81-fold (48-138) increased risk for CP. If Apgar scores at both 1 and 5 minutes were 0 to 3, the risks for neonatal death and CP were increased 642-fold (442-934) and 145-fold (85-248), respectively, compared with scores of 7 to 10.

CONCLUSION

The strong association of low Apgar scores with death and CP in this population with a low occurrence of low scores shows that the Apgar score remains important for the early identification of infants at increased risk for serious and fatal conditions.

Selection of babies for intervention after birth asphyxia

Based on animal experiments, the therapeutic window for neonates with signs of perinatal hypoxia-ischaemia is probably less than 6 h, and early selection of patients is of utmost importance. In term neonates, fetal heart rate and blood flow patterns, the Apgar score, and other clinical scoring systems are insufficient to select patients for intervention, whereas umbilical artery pH<7.0 combined with umbilical arteriovenous differences in PCO(2), lactate/pyruvate ratios in cord blood, and CSF interleukin-1beta have a better predictive value. At present, neurophysiological methods such as (amplitude-integrated) EEG and evoked potentials have the best predictive value. In preterm neonates, lactate/pyruvate and uric acid measurements in cord blood, as well as neurophysiology appear to be helpful to predict brain injury, and might be used to select patients for intervention.

[Definition of asphyxia neonatorum and incidence of neurologic and systemic complications in the full-term newborn]

PATIENTS AND METHODS

In a prospective multicentric study, 152 of 10,065 live term births had birth asphyxia, defined by the association of three indicators (fetal distress, depression at birth and metabolic acidosis).

RESULTS

The incidence of birth asphyxia was 1.5% of live term births when birth asphyxia was defined by the presence of at least two indicators, and 1% of live term births when birth asphyxia was defined by the association of metabolic acidosis and another indicator. Neurological complications were observed in 66 cases (43%). The incidence of post-asphyxial encephalopathy (PAE) was 5.9/1000 of live term births (mild PAE: 3/1000; moderate PAE: 2.7/1000; severe PAE: 0.2/1000). Systemic complications were observed in 87 patients (57%). Renal injury and coagulopathy were associated with moderate or severe PAE. Respiratory complications (39%), infections (17%) and gastro-intestinal intolerance (15%) often complicated the course. Severe complications were never seen in the absence of significant metabolic acidosis at 30 minutes of life.

CONCLUSION

Our study has many implications concerning the diagnosis of birth asphyxia and its complications. A terminology based on clinical observation and arterial pH evaluation is proposed in order to clarify the situation.

Outborn status with a medical neonatal transport service and survival without disability at two years. A population-based cohort survey of newborns of less than 33 weeks of gestation

OBJECTIVE

Prenatal events are thought to play an important role in long-term handicap, but the specific role of perinatal factors remains controversial. Our study, conducted in the context of this debate, aimed to break down the various components of perinatal management and to assess the relationship between these components and survival without disability at the age of two years.

STUDY DESIGN

A prospective geographically-defined study was conducted in 1985 in the Paris metropolitan area. It covered 53430 births (stillbirths and live births), including 539 that occurred between 25 and 32 weeks gestation. The relationship between perinatal management and survival without disability was studied by a multivariate analysis (logistic regression). The analysis was restricted to a group of 202 infants born at 31 or 32 week's gestation, to avoid indication bias.

RESULTS

An inborn status (delivery in a tertiary care facility) exerted a protective effect on survival without disability at the age of two years (Adjusted Odds Ratio (OR)=7.51 [1.51; 37.4]), even though the area we studied possessed an excellent Medical Neonatal Transport Service. Multiple pregnancies also seemed to have a protective effect (Adjusted OR=2.45 [0.96; 6.27]). No statistically significant association was seen between survival without disability at two years and the presence of a hospital staff paediatrician in the delivery room.

CONCLUSION

These results lead us to consider what the concept of inborn/outborn represents in the perinatal management of infants at high risk.

Outcome of resuscitation following unexpected apparent stillbirth

There are few data to inform a decision to resuscitate babies who are unexpectedly stillborn. The outcome for 42 successfully resuscitated stillborn children, of whom 62% survived to be discharged home, is reported. Of the survivors, a poor outcome with severe disability was found in 23% (including one postneonatal death), equivocal outcome was found in 15% (two mild hypertonia; two with mild hemiplegia and no associated other disability) and 62% were free of any impairment at follow up 20 months to 8 years later. In 39 (93%) fetal problems had been identified and the resuscitation team was present at delivery. Poor outcome was associated with late return of heart beat, delayed respirations, neonatal acidaemia and early onset of seizures. Of the unexpected apparent stillbirths successfully resuscitated, 52% died or survived severely disabled, 10% had an equivocal outcome, but 36% survived apparently intact. Therefore, vigorous resuscitation is clearly indicated in these circumstances.

Value of the urinary uric acid to creatinine ratio in term infants with perinatal asphyxia

The diagnosis of perinatal asphyxia is often inexact and present techniques for assessing its severity are unsatisfactory. The purpose of this study was to describe prospectively the value of the urinary uric acid to creatinine (UA/Cr) ratio in showing increased uric acid excretion in early spot urine samples for the identification of perinatal asphyxia, and to assess the relationship between the urinary UA/Cr ratio and the severity of hypoxic-ischemic encephalopathy. Twenty-seven fullterm infants with perinatal asphyxia were compared with 40 healthy controls. The UA/Cr ratio was higher in the asphyxiated group when compared with controls (2.11 +/- 0.83 vs 0.72 +/- 0.39 P < 0.001). Furthermore, there was a correlation between the UA/Cr ratio and the severity of the encephalopathy (r = 0.84; P < 0.001). The UA/Cr ratio was found to be a good, simple screening test for the early assessment of perinatal asphyxia.

Diagnostic and prognostic value of cerebral 31P magnetic resonance spectroscopy in neonates with perinatal asphyxia

The impact of depressed neonatal cerebral oxidative phosphorylation for diagnosing the severity of perinatal asphyxia was estimated by correlating the concentrations of phosphocreatine (PCr) and ATP as determined by magnetic resonance spectroscopy with the degree of hypoxic-ischemic encephalopathy (HIE) in 23 asphyxiated term neonates. Ten healthy age-matched neonates served as controls. In patients, the mean concentrations +/- SD of PCr and ATP were 0.99 +/- 0.46 mmol/L (1.6 +/- 0.2 mmol/L) and 0.99 +/- 0.35 mmol/L (1.7 +/- 0.2 mmol/L), respectively (normal values in parentheses). [PCr] and [ATP] correlated significantly with the severity of HIE (r = 0.85 and 0.9, respectively, p < 0.001), indicating that the neonatal encephalopathy is the clinical manifestation of a marred brain energy metabolism. Neurodevelopmental outcome was evaluated in 21 children at 3, 9, and 18 mo. Seven infants had multiple impairments, five were moderately handicapped, five had only mild symptoms, and four were normal. There was a significant correlation between the cerebral concentrations of PCr or ATP at birth and outcome (r = 0.8, p < 0.001) and between the degree of neonatal neurologic depression and outcome (r = 0.7). More important, the outcome of neonates with moderate HIE could better be predicted with information from quantitative 31P magnetic resonance spectroscopy than from neurologic examinations. In general, the accuracy of outcome predictability could significantly be increased by adding results from 31P magnetic resonance spectroscopy to the neonatal neurologic score, but not vice versa. No correlation with outcome was found for other perinatal risk factors, including Apgar score.

[Management of newborn infants in maternity-neonatal intensive care units]

BACKGROUND

Although in utero transfer seems actually the safest option when risk factors are identified, specialized transport teams remain important to consider for the neonatal overall management.

SUBJECTS

From January 1988 through December 1992, 692 transports of 838 neonates were prospectively studied to determine effectiveness and safety of the Hospital Lenval's neonatal transport team.

RESULTS

Neonatal transports were required respectively for prematurity (46.4%), acute fetal distress (13.8%), respiratory distress (10.1%), intrauterine growth retardation (7.8%), multiple pregnancies (5.2%), perinatal asphyxia (3.1%) and life-threatening congenital abnormalities (2%). Pediatric assistance was unplanned in most of the cases (80%). Assistance with a pediatrician before delivery was performed more frequently (70%) for premature babies (mean gestational age 34.1 +/- 3.1 wk) delivered by cesarean section in 66.4% of the cases; in this group, delivery room resuscitation was less aggressive. Assistance was performed after delivery less frequently (30%), approximately in one-half of the cases for neonatal distress: respiratory (33.9%) or neurologic (17.1%); in this group, delivery room resuscitation was more aggressive. In transit, ventilation support via endotracheal intubation was given to 17.9% of the babies. Neither death nor heavy complication occurred during transport. On arrival in the neonatal intensive care unit, hypothermia was noted in 9.6% of the cases, hypotension in 4.3%, hypoglycemia in 13.1% and metabolic acidosis in 10.4%. In our series, the overall mortality rate was 6%, and incidence of neurologic damage 3.3%.

CONCLUSION

A skilled person in neonatal resuscitation available at every referring maternity and regional high-risk obstetric/neonatal combined centre are two recommendations which could provide improved neonatal management.

Neonatal urinary uric acid/creatinine [correction of ceratinine] ratio as an additional marker of perinatal asphyxia

The diagnosis and evaluation of perinatal asphyxia can be problematic and objective means of assessing its severity are lacking. To study the validity of urinary uric acid as a marker of the degree of perinatal asphyxia, the ratio of urinary uric acid to creatinine (UA/Cr) in urine specimens obtained after birth was measured in two groups of infants. Eighteen term infants with Apgar scores < or = 5 at 5 min and/or an umbilical cord blood pH < or = 7.2, and a base deficit > or = 12 meq/l were compared to 50 healthy controls. The severity of the perinatal asphyxia was determined by using an ASPHYXIA SCORE. The UA/Cr was higher in the asphyxiated group when compared to controls. (2.06 +/- 1.12, vs. 0.64 +/- 0.48; P < 0.001). Within the perinatal asphyxia group, a significant correlation was found between the UA/Cr ratio and the asphyxia score. (r = 0.86, P < 0.01).

CONCLUSION

Infants with perinatal asphyxia have a significantly higher urinary UA/Cr ratio. This may be used as an indicator of the severity of perinatal asphyxia.

The validity of the Apgar scores in the assessment of asphyxia at birth

A prospective study was performed in 613 consecutively live born infants to investigate the validity of 1- and 5-min Apgar scores as an index for asphyxial assessment at birth. The independent and combined relationship between Apgar scores, metabolic acidemia, pulse oximeter (SaPO2) measurements and neonatal outcome were determined. In the term infants 1-min Apgar score was more influenced by the mode of delivery and by gestational age than by asphyxia. Instead, 5-min Apgar score had a high concordance with metabolic acidemia. Infants with low Apgar scores, metabolic acidemia and arterial desaturation have the highest incidence of neonatal intensive care unit admission and poor neonatal outcome. The study suggests that the 5-min Apgar score is useful for immediate clinical assessment and care of the neonate.

Introduction to the age-related diagnosis (ARD) index: an age at presentation related index for diagnostic use

Development and, therefore, age is important in paediatrics. Diagnostically useful data from this journal has been related to age and organized to form an age-related diagnostic (ARD) index. The ARD index is designed for non-expert clinical and laboratory workers to use in the early phases of diagnosis and as an addition to existing diagnostic schemes. Entry to the index is from the age at clinical presentation. Each entry is a sequence starting with clinical and laboratory presentations, clinical course, laboratory key investigations and finally diagnosis with volume and page numbers of the original article, the primary source. Within age groups, entries are grouped by diagnoses with the commonest diagnosis first; this has the effect of roughly but not precisely grouping similar clinical and laboratory findings.