Opinion
It’s Time to Reevaluate the Apgar Score
VIEWPOINT
Mario Rüdiger, MD When Virginia Apgar, MD, proposed her now-
Saxony Center for universal scoring system for newborns in 1953, her pri-
Feto-Neonatal Health, mary purpose was to get attention paid to the newborn
Department for
because, as she wrote, “Nine months observation of the
Neonatology and
Pediatric Intensive mother surely warrants one-minute observation of the
Care, University baby.”1 After the national Collaborative Perinatal Study
Hospital Carl Gustav showed that low Apgar scores occurred more frequently
Carus Dresden,
Technische Universität
inthosewhodiedintheneonatalperiodorhadhigherrates
Dresden, Dresden, of neurological morbidity at 1 year of life, the Apgar score
Germany. spread to where it is now assigned to newborns in almost
every country in the world. A PubMed search for Apgar
Henry J. Rozycki, MD score yields almost 12 000 publications.
Children’s Hospital of
Richmond, Division of However, almost 40 years ago, questions arose about
Neonatal Medicine, the (mis)use of the Apgar score, mainly based on studies
Virginia that found limitations when using the score to predict
Commonwealth
short-term or long-term morbidity and mortality.2 In these
University, Richmond.
studies, scores were often parsed into low (0-3), me-
dium (4-6), and high (7-10) groups, but to our knowl-
edge, these divisions have never been validated. Warn-
ings about equating low scores with asphyxia or telling
parents what was likely to happen in the future to their
newborn based on the Apgar scores have been sounded
for decades, including by the American Academy of Pe-
diatrics, which in 1986 stated, “the scores alone should
not be considered either of or consequent to substantial
asphyxia.”3 Nevertheless, recent publications still use the
score to predict outcome in groups of newborns.
While problems with poor prognostic ability are well
documented and referenced, other very important con-
cerns about the clinical use of the Apgar score have be-
come apparent over the last 20 years. First, there are a
number of studies that have demonstrated high levels
of interobserver variability. There are even geographic
or cultural differences in assigning the Apgar score. For
example, while 8.8% of newborns born in Latvia get a
5-minute score of 10, that’s the score assigned to 92.7%
of newborns born in France.4 Second, there is the issue
of prematurity. The original Apgar score did not specify
how to assess parameters such as reflex irritability and
tone in premature newborns. As a result, there is no con-
sensus on how to score a newborn born at 24 weeks’ ges-
tation, even if tone and reflex irritability are completely
normal for this stage of development.
Third, once people began to pay attention to the
newborn, they began to respond when the newborn had
bradycardia or apnea, but there is no consensus on how
Corresponding
Author: Henry J. to account for interventions when assigning the Apgar
Rozycki, MD, Children’s score. Apgar did not specify how to score newborns re-
Hospital of Richmond, ceiving an intervention, even though 7% of the new-
Division of Neonatal
Medicine, Virginia
borns in her first article were ventilated,1 resulting in large
Commonwealth variation in how these newborns are scored. Accept-
University, PO Box able oxygen saturation levels defined in the latest edi-
980646, Richmond,
tion of the Neonatal Resuscitation Program (NRP)5 could
VA 23298-0646
(henry.rozycki@ result in a newborn getting marked off for color but still
vcuhealth.org). have a normal oxygen level. Finally, and most signifi-
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cantly, with the advent of the NRP and its requirement
that “at least 1 qualified individual…whose only respon-
sibility is the management of the newly born baby”5 be
at every delivery, Apgar’s initial goal for her score, to fo-
cus attention on the newborn, has been achieved. The
Apgar score is not used in the NRP.
If a medical procedure or test had similar problems
with accuracy, reproducibility, universality, and even util-
ity, there would be calls for its retirement, and there have
been several such calls over the years. Yet as recently as
2015, the American Academy of Pediatrics and the
American College of Obstetrics and Gynecology
endorsed the continued use of the Apgar score.6 They
also recommended to report resuscitative interven-
tions along with the traditional scoring, what they
termed the Expanded Apgar score. It consists of 7 pos-
sible treatments and subtracts points for resuscitation
interventions performed at each point. Another modifi-
cation is the Specified Apgar score, in which the defini-
tions of the 5 parameters of the original score are speci-
fied to ignore the need for any interventions and just
assess the newborn and are renormalized to gesta-
tional age for the neurological responses rather than
comparing them to what a term newborn would look
like. The Combined Apgar score incorporates the Speci-
fied and the Expanded Apgar scores.7 These alterna-
tives, and others, have only been assessed in relatively
small prospective studies in selected populations, to
our knowledge.
Given the multiple concerns and limitations, we be-
lieve that the time has come to relook at the Apgar score
to determine if it is still useful, if it needs to be revised
or replaced by a different system, or if we should do away
with scoring newborns after delivery altogether. How-
ever, to do so, we must first define the purpose of a scor-
ing system. There are 3 potential goals for any quanti-
tative assessment of a newborn after delivery: (1) it can
be an easy way to describe the condition (and interven-
tions needed to achieve that condition) in a reproduc-
ible (and numerical) way and help in clinical communi-
cation; (2) it can measure the immediate clinical results
of delivery and resuscitation; and (3) it can quantify the
individual condition (and intervention) of a newborn at
different points and will thus make groups of new-
borns comparable, becoming a tool for classifying risk
of short-term and long-term complications, research, and
quality improvement.
Based on these scoring goals, useful end points for
a large prospective clinical trial can be defined. Thus, we
suggest to borrow from the experience of researchers
investigating plasma transfusion practices in the pedi-
atric intensive care unit, who needed to define clini-
cally significant bleeding before embarking on any large
prospective trials. A panel of international experts de-
veloped a set of clinical definitions or scenarios, and
(Reprinted) JAMA Pediatrics Published online February 24, 2020 E1
 Opinion Viewpoint

these were assessed by more than 500 practitioners using a web-
based survey platform. The expert panel then formulated bleeding
definitions that reflected a high level of agreement among the sur-
vey respondents. A second expert panel used a Delphi process un-
til there was agreement on all the elements.
To begin this process, a library of potential outcomes important
to measure in a clinical trial is needed. We invite readers to send their
suggestions for the purpose(s) of why a scoring system for all new-
borns should be performed and/or what outcomes should be mea-
sured in a clinical trial to determine the best scoring system, if any.

ARTICLE INFORMATION
Published Online: February 24, 2020.
doi:10.1001/jamapediatrics.2019.6016
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Apgar V. The newborn (Apgar) scoring system:
reflections and advice. Pediatr Clin North Am. 1966;
13(3):645-650. doi:10.1016/S0031-3955(16)31874-0
2. Nelson KB, Ellenberg JH. Apgar scores as
predictors of chronic neurologic disability. Pediatrics.
1981;68(1):36-44.
3. American Academy of Pediatrics Committee on
Fetus and Newborn. Use and abuse of the Apgar
score. Pediatrics. 1986;78(6):1148-1149.
4. Siddiqui A, Cuttini M, Wood R, et al;
Euro-Peristat Scientific Committee. Can the Apgar
score be used for international comparisons of
newborn health? Paediatr Perinat Epidemiol. 2017;
31(4):338-345. doi:10.1111/ppe.12368
5. Wyckoff MH, Aziz K, Escobedo MB, et al. Part 13:
neonatal resuscitation. 2015 American Heart
Association Guidelines Update for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care.
Circulation. 2015;132(18)(suppl 2):S543-S560. doi:
10.1161/CIR.0000000000000267
6. American Academy of Pediatrics Committee on
Fetus and Newborn; American College of
Obstetricians and Gynecologists Committee on
Obstetric Practice. The Apgar score. Pediatrics.
2015;136(4):819-822. doi:10.1542/peds.2015-2651
7. Rüdiger M, Braun N, Aranda J, et al; TEST-Apgar
Study-Group. Neonatal assessment in the delivery
room—Trial to Evaluate a Specified Type of Apgar
(TEST-Apgar). BMC Pediatr. 2015;15:18. doi:10.1186/
s12887-015-0334-7

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