This document summarizes a study examining the continued usefulness of the Apgar scoring system for assessing newborn infants. The study reviewed outcomes of over 145,000 live births and found that lower 5-minute Apgar scores (3 or less) were still strongly associated with higher risk of death in the first 28 days, regardless of gestational age. While technologies like umbilical cord pH levels are also useful, the 5-minute Apgar score remained the better predictor of neonatal survival. The document concludes that the Apgar scoring system established in 1953 remains pertinent today for predicting neonatal outcomes.

1. References
1. Krafchik B, et al. J Am Acad Dermatol. 1999;41:60-63.
2. Haroon TS, et al. Br J. Dermatol. 1996;135:86-88.
3. Gupta AK, et al. Pediatr Dermatol. 1998;15:56-58.
4. Rademaker M, et al. NZ Med J. 1998;111:55-57.
5. Elewski BE. J Am Acad Dermatol. 2000;42:1-20.
6. DragosV, et al. Pediatr Dermatol. 1997;14:46-48.
7. http://www.drugstore.com
Apgar Scores
Still Useful
Source: Casey BM, McIntire DD, Leveno KJ. The continuing
value of the Apgar score for the assessment of newborn infants.
N Engl J Med. 2001;344:467-471.
T
o examine whether the Apgar scoring system predicts
survival during the neonatal period and remains rele-
vant, researchers in Dallas reviewed the outcomes of
145,627 live-born, singleton infants without malformations
who were delivered at 26 weeks of gestation or later (based on
obstetrical estimate) between January 1988 and December
1998 at the University ofTexas Southwestern Medical Center.
Retrospective cohort analysis of paired Apgar scores and
umbilical artery pH values found the incidence of death dur-
ing the first 28 days after birth was highest for 5-minute Apgar
scores of 3 or less, regardless of gestational age. The severity
of acidemia did not appreciably modify the relative risk of
neonatal death.The authors conclude that the Apgar scoring
systemremainsaspertinenttodayforthepredictionofneona-
tal survival as it was almost 50 years ago.
Commentary by Mike Dubik,MD,FAAP
General Pediatrics, Naval Medical Center, Portsmouth,VA
In 1953, Dr. Virginia Apgar developed a scoring system to
evaluate the effects of obstetric practice on neonates.1
At 60
seconds after birth, 5 characteristics were evaluated—heart
rate, respiratory effort, muscle tone, reflex irritability and
color—and assigned numerical values of 0, 1, or 2. In the
1960s, an additional score obtained at 5 minutes of age was
added because it was found to correlate better with neonatal
survival.2
More recently, the usefulness of the Apgar system
has been questioned because of newer technologies such as
umbilical artery pH determination.3
However, Casey and col-
leagues have shown that the 5-minute Apgar score predicted
neonatal death more accurately than did the umbilical artery
pH value. As noted in an accompanying editorial, in the past
a 5-minute Apgar score of 3 or less was considered to reflect
the natural condition of an infant (presumably the natural
condition without resuscitation); now it is considered to rep-
resent a severely compromised infant who is unable to
respond to the resuscitative efforts of a skilled team.4
Neither
the 1- nor the 5-minute Apgar score was intended to predict,
or is predictive of, long-term neurological outcome. The 1-
minute Apgar score focuses attention on the newborn’s con-
dition and the 5-minute score is valid as a predictor of neona-
tal survival.
Editors’Note
MisuseoftheApgarscorewasaddressedina1996statement
by the AAP’s Committee on Fetus and Newborn in collabora-
tion with the American College of Obstetrics and Gynecology.
The statement emphasized that, while the Apgar score is use-
ful in assessing the condition of the infant at birth, this score
aloneshouldnotbeusedasevidencethatneurologicinjurywas
caused by hypoxia or from inappropriate intrapartum man-
agement.5
(Despitethislimitationandrelatedmisuse,theApgar
endures:Yes, Santa Claus, there is aVirginia!)
References
1. ApgarV. Curr Res Anaesth Anal. 1953;32:260-267.
2. Drage JS, et al. Obstet Gynecol. 1964;24:222-230.
3. Anonymous (editorial). Lancet. 1989;1:591-592.
4. Papile L. N Engl J Med. 2001;344:519-520.
5. Committee on Fetus and Newborn, AAP; Committee on Obstet-
ric Practice, ACOG. Pediatrics. 1996;98:141-142.
Assessing Adolescents
andYoung Adults
for Plastic Surgical
Intervention
Source: Simis KJ, Koot JM,Verhulst FC, et al. Assessing adoles-
cents and young adults for plastic surgical intervention: pre-
surgical appearance ratings and appearance-related burdens
as reported by adolescents and young adults,parents and sur-
geons. Brit J Plas Surg. 2000;53:593-600.
T
o understand how adolescents requesting plastic
surgery perceived their appearance when compared
totheperceptionsoftheirparentsandplasticsurgeons,
Simis et al surveyed 184 (131 girls, 53 boys) out of 240 eligible
patients (76.7%) aged 12-22 years scheduled to undergo elec-
tiveappearance-correctionsurgeryfrom1995-97.Theauthors
also interviewed 172 of the patients’ parents and 37 surgeons
from 16 hospitals in southwestern and northwestern Nether-
lands. The patients’ physical deformities were categorized
as:breast(n=62),ears(n=39),nose/lipsincludingclefts(n=44),
face including craniofacial deformities (n=25), and body
(n=14). Patients and parents completed questionnaires and
telephone interviews relating to appearance, psychosocial
burdens (ie, mood, self-confidence, romantic relationships,
making friends) and surgical expectations. Surgeons were
asked to rate the severity and visibility of the deformity and,
50 AAP Grand Rounds
PERINATOLOGY
PLASTIC SURGERY
Tell Us About It!We’d like your input and opinion.
Send letters to the editors to:
AAP Grand Rounds, Dept. of Pediatrics, College of Medicine,
University of Vermont, Burlington, VT 05405
or email your thoughts to grandrounds@aap.org.