The association between 5-min Apgar score and mortality disappears after 24 h at the borderline of viability

Early perinatal outcomes of babies born to adolescent mothers at two maternity hospitals in Mogadishu, Somalia

Background

Adolescent motherhood remains a major problem in developing countries. We set out to describe the perinatal outcomes of infants born to adolescent mothers and to determine factors associated with birth asphyxia among these infants in Mogadishu, Somalia.

Methods

This cross-sectional study involved adolescent mothers who presented in labor. Sociodemographic and medical data was collected and mother-infant pairs were followed up at 24hrs. Poor perinatal outcomes were: low birth weight, birth asphyxia, death or hospitalization after 24 hours. Data was entered into Epi data 3.1 and analysed using STATA version 12.0.

Results

Of the 270 adolescents, mean age was 17.7 years (±1.19), 89% were married, 94% were unemployed and 54% had not received formal education. Of the 270 babies born, 70 (25.9%) had poor perinatal outcomes which included; 35 (12.9%) died; of whom 30 (11.1%) were stillbirths. Thirty-two infants (13.3%) had birth asphyxia and 18 (6.7%) had low birth weight. Prolonged labor (p-value=<0.001) and preterm birth (p-value=0.023) were significantly associated with birth asphyxia while living in Mogadishu was protective (p- value=0.018).

Conclusions

About one in four adolescent mother's babies had poor perinatal outcomes. Prolonged labor and preterm delivery and were associated with birth asphyxia while residing closer to the facilities was protective.

Low Apgar score in term newborns and long-term infectious morbidity: a population-based cohort study with up to 18 years of follow-up

Since introduced, the Apgar score has remained the most widespread predictor for neonatal morbidity and mortality. We aimed to investigate the association between low 5-min Apgar score and long-term infectious pediatric morbidity. A population-based cohort analysis was performed comparing total and specific subtypes of infectious morbidity leading to hospitalization among term newborns with normal (≥ 7) and low (< 7) 5-min Apgar scores, born between 1999 and 2014 at a single tertiary regional hospital. Infectious morbidity included hospitalizations involving a pre-defined set of infection-related ICD-9 codes. A Kaplan-Meier survival curve was constructed to compare cumulative infectious morbidity incidence and a Cox proportional hazards model to adjust for confounders. The long-term analysis of 223,335 children (excluding perinatal death cases) yielded 585 (0.3%) infants with low 5-min Apgar scores. The rate of infection-related hospitalizations was 9.8% and 12.4% among newborns with normal and low 5-min Apgar scores, respectively (p = 0.06). Adjusting for maternal age, gestational age, hypertension, diabetes, cesarean delivery, and fertility treatments, the association proved to be statistically significant (adjusted HR = 1.28; 95% CI 1.01-1.61).Conclusion: Term infants with low 5-min Apgar scores may be at an increased risk for long-term pediatric infectious morbidity.What is Known:• Though not meant to be a prognostic tool for long-term morbidity, studies assessing the correlation between low Apgar score and long-term outcomes were and are being performed, reporting significant associations with many outcomes-such as cerebral palsy (CP), ophthalmic disorders, GI disorders, and several types of malignancies.• Yet, an association between low Apgar scores and future health remains a matter of controversy.What is New:• Our work shows that a low 5-min Apgar score is independently associated with long-term pediatric infection-related hospitalizations among term singleton newborns.

Determinants of Low Fifth Minute Apgar Score among Newborn Delivered in Jimma University Medical Center, Southwest Ethiopia

BACKGROUND

Apgar score is currently an accepted method for newborn infant assessment immediately after delivery. Low fifth minute Apgar score was strongly associated with the risk of neonatal and infant death. Even though much has been done, still, the levels of neonatal mortality in sub-Saharan African countries including Ethiopia were significant. Therefore, this study is aimed at identifying the risk factors so as providing strategies for decreasing the morbidity and mortality of newborns and identifying determinants of low fifth minute Apgar score among newborns delivered in Jimma University Medical Center, Southwest Ethiopia, 2018.

METHOD

Institution-based cross-sectional study was conducted involving 366 neonates delivered at Jimma University Medical Center. Data was collected by using interview questionnaire. Apgar score was assessed by standard tool at the 1st, 5th, and 10th minutes after birth and only 5th minute Apgar score was used as outcome variable. Consecutive sampling technique was used to select the participants. The collected data were analyzed using SPSS version 20.0. Chi-square test was done at bivariate level and P value was used to select candidate variables for multivariate analysis. Finally, a 95% confidence interval was used to assess significance.

RESULTS

A response rate of this study was 95%. The proportion of low 5th minute Apgar score in this study was 11.5%. Prolonged duration of labor (AOR = 15.18, 95% CI: 5.51-40.27), maternal history of khat use (AOR = 3.21, 95% CI: 1.26-8.85), and low birth weight (AOR = 1.65, 95% CI: 1.02-3.11) were predictors of low fifth minute Apgar score.

CONCLUSION

About one tenth of newborns were having low 5th minute Apgar score. The likelihood of low 5th minute Apgar score was found to increase with prolonged duration of labor, history of mother's khat use, and low birth weight.

Utility of the 5-Minute Apgar Score as a Research Endpoint

Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). We used 2 data sets to explore this issue: one contained planned community births from across the United States (n = 52,877; 2012-2016), and the other contained hospital births from California (n = 428,877; 2010). We treated 5-minute Apgars as clinical "tests," compared against 18 known outcomes; we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 3 different criteria to determine optimal cutpoints. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not; comparing median Apgars between groups might be an analytical alternative to dichotomizing. Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear.

Pregnant Inuit Women's Exposure to Metals and Association with Fetal Growth Outcomes: ACCEPT 2010⁻2015

Environmental contaminants such as heavy metals are transported to the Arctic regions via atmospheric and ocean currents and enter the Arctic food web. Exposure is an important risk factor for health and can lead to increased risk of a variety of diseases. This study investigated the association between pregnant women's levels of heavy and essential metals and the birth outcomes of the newborn child. This cross-sectional study is part of the ACCEPT birth cohort (Adaption to Climate Change, Environmental Pollution, and dietary Transition) and included 509 pregnant Inuit women ≥18 years of age. Data were collected in five Greenlandic regions during 2010⁻2015. Population characteristics and birth outcomes were obtained from medical records and midwives, respectively, and blood samples were analyzed for 13 metals. Statistical analysis included one-way ANOVA, Spearman's rho, and multiple linear and logistic regression analyses. The proportion of current smokers was 35.8%. The levels of cadmium, chromium, and nickel were higher compared to reported normal ranges. Significant regional differences were observed for several metals, smoking, and parity. Cadmium and copper were significantly inversely related to birth outcomes. Heavy metals in maternal blood can adversely influence fetal development and growth in a dose⁻response relationship. Diet and lifestyle factors are important sources of toxic heavy metals and deviant levels of essential metals. The high frequency of smokers in early pregnancy is of concern, and prenatal exposure to heavy metals and other environmental contaminants in the Greenlandic Inuit needs further research.

Apgar score and long-term respiratory morbidity of the offspring: a population-based cohort study with up to 18 years of follow-up

The objective of this study is to investigate whether a significant association exists between low 5-min Apgar scores (< 7) and respiratory morbidity of the offspring. A population-based cohort analysis was performed comparing subtypes of respiratory morbidity leading to hospitalizations among children (up to age 18 years) stratified by their 5 min Apgar scores. Data were collected from two databases of a regional tertiary center. All singleton deliveries occurring between 1991 and 2014 were included in the analysis. A Kaplan-Meier survival curve was constructed to compare cumulative respiratory-related hospitalization incidence and a Cox proportional hazards model to control for confounders. Deliveries (238,622) met the inclusion criteria. Low 5-min Apgar scores were recorded in 742 (0.3%) newborns. Incidence of respiratory hospitalizations was higher among the low 5 min Apgar score group (7.3 vs. 4.8% in the normal [≥ 7] 5 min Apgar score group; OR = 1.5, 95%CI 1.2-2.0, p = 0.003). Association remained significant in the Cox model (aHR = 1.4, 95%CI 1.1-1.9, p = 0.01). Incidence of respiratory-related hospitalizations in preterm born offspring was higher among the low vs. the normal 5 min Apgar score groups (13.4 vs. 7.2%, OR = 2.0, 95%CI 1.2-3.1 , p = 0.008). Association remained significant in the multivariable analysis (aHR = 1.6, 95%CI 1.1-2.5, p = 0.03). The survival curves demonstrated significantly higher cumulative respiratory morbidity in the low Agar score group for the entire cohort and for the preterm born subgroup.Conclusion: Newborns, of any gestational age, with low 5 min Apgar scores appear to be at an increased risk for pediatric respiratory morbidity. What is Known: • Apgar score is a method for assessment of the medical condition of a newborn, and of the need for medical intervention and/or resuscitation. Studies assesing the correlation between low Apgar score and short or long term outcomes report a sgnificant correlation with different outcomes including neurological development and more. As two of its five components (color and respiratory effort) are utilizing the respiratory status, low Apgar scoreis associated with a higher risk for immedisate respiratory morbidity. What is New: • Low Apgar score increases the chances for several long-term respiratory-related morbidities, independent of gestational age and other obstetrical circumstances.

Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands

BACKGROUND

It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands.

METHODS

We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed.

RESULTS

The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses.

CONCLUSIONS

In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.

Interrater reliability of the Saint-Anne Dargassies Scale in assessing the neurological patterns of healthy preterm newborns

Abstract Objectives: to assess the interrater reliability of the Saint-Anne Dargassies Scale in assessing neurological patterns of healthy preterm newborns. Methods: twenty preterm newborns met the inclusion criteria for participation in this prospective study. The neurologic examination was performed using the Saint-Anne Dargassies Scale, showing normal serial cranial ultrasound examination. In order to test the reliability, the study was structured as follows: group I (rater 1/physiotherapist; rater 2/neonatologist); group II (rater 3/physiotherapist; rater 4/child neurologist) and the gold standard (expert and professor in pediatric neurology). Results: high interrater agreement was observed between groups I - II compared with the gold standard in assessing postural pattern (p<0.01). Regarding the assessment ofprimitive reflexes, greater agreement was observed in the evaluation of palmar grasp reflex and Moro reflex (p< 0.01) for group I compared with the gold standard. An analysis of tone demonstrated heterogeneous agreement, without compromising the reliability of the scale. The probability of equality between measurements of head circumference in the two groups, compared with the gold standard, was observed. Conclusions: the Saint-Anne Dargassies Scale demonstrated high reliability and homogeneity with significant power of reproducibility and may be capable to identify preterm newborns suspected of having neurological deficits.

Proportion and factors associated with low fifth minute Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia

BACK GROUND

New born babies with low Apgar scores are at an increased risk of perinatal morbidity and mortality.

OBJECTIVE

To assess proportion and factors associated with low 5th minute Apgar Apgar score among singleton newborn babies in Gondar University referral hospital; North West Ethiopia.

METHODS

A cross-sectional study was conducted on singleton 261 live births from March - May, 2013. Data was collected from mother/newborn index using a structured and pre-tested questionnaire. It was then cleaned, coded and entered using EPI INFO version 3.4.3, then analyzed with IBM SPSS statistics versions 20.0. Logistic regression was used to identify significant variables with low 5th minute Apgar score.

RESULT

The proportion of low 5th minute Apgar score in this study was 13.8%. Factors that were significantly associated with low 5th minute Apgar score were: non-vertex fetal presentation, prolonged labor, presence of meconium stained liquor, induced/augmented labor and low birth weight.

CONCLUSION

Mainly obstetric factors contribute to low Apgar score. Improving labor management through implementing regular use of partograph, 1:1 midwife-client ratio and advanced electronic fetal monitoring technology is recommended.

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.

Borderline viability: controversies in caring for the extremely premature infant

Controversy surrounding the decision to resuscitate at the limits or borderline of viability has been at the center of neonatal ethical debate for decades. This debate has led to numerous reports from individual institutions, councils, and advisory committees that all have remarkable consistency in the development of gestational age-based guidelines. This article reviews legal or regulatory concerns that may contradict ethical discussion and guidelines, discriminatory and scientific basis concerns with consensus guidelines, and personal controversy about how to determine best interest. Guidelines are a reasonable place to start in helping determine parental authority and autonomy. The article also addresses controversies raised in counseling and costs.

Have the boundaries of the 'grey zone' of perinatal resuscitation changed for extremely preterm infants over 20 years?

AIM

To determine the boundaries of the grey zone of discretionary resuscitation over the past 20 years.

BACKGROUND

As the likelihood of survival improves over time, the BW- and GA-specific boundaries of discretionary nonresuscitation should fall.

HYPOTHESIS

Between 1988 and 2008 reductions in BW- and GA-specific mortality would drive a parallel reduction in BW and GA boundaries of discretionary resuscitation.

METHODS

We determined the likelihood of resuscitation and survival to NICU discharge for all infants born <700 g or <26 gestational weeks from 1988 to 2008. In addition, for 1988, 1993, 1998, 2003 and 2008, we determined the BW and GA for the 10 smallest infants who were resuscitated, and the 10 largest infants who were not resuscitated. We excluded any infant born with congenital anomaly.

RESULTS

Mortality fell from 80% in 1988 to 28% in 2008, and as expected, the percentage who were resuscitated rose from 63% in 1988-93 to 95% in 2004-2008. However, unexpectedly, over the 20-year study period, the smallest infants who were resuscitated despite extreme immaturity did not change (450-550 g and 23-24 weeks) and the largest infants not resuscitated did not change (600-700 g and 23-24 weeks.

CONCLUSION

Neither the BW nor GA boundaries of the grey zone of discretionary resuscitation have fallen over the past 20 years. Factors guiding resuscitation at the border of viability are complex and incompletely understood.

The prediction and cost of futility in the NICU

AIM

To quantify the cost and prediction of futile care in the Neonatal Intensive Care Unit (NICU).

METHODS

We observed 1813 infants on 100,000 NICU bed days between 1999 and 2008 at the University of Chicago. We determined costs and assessed predictions of futility for each day the infant required mechanical ventilation.

RESULTS

Only 6% of NICU expenses were spent on nonsurvivors, and in this sense, they were futile. If only money spent after predictions of death is considered, futile expenses fell to 4.5%. NICU care was preferentially directed to survivors for even the smallest infants, at the highest risk to die. Over 75% of ventilated NICU infants were correctly predicted to survive on every day of ventilation by every caretaker. However, predictions of 'die before discharge' were wrong more than one time in three. Attendings and neonatology fellows tended to be optimistic, while nurses and neonatal nurse practitioners tended to be pessimistic.

CONCLUSIONS

Criticisms of the expense of NICU care find little support in these data. Rather, NICU care is remarkably well targeted to patients who will survive, particularly when contrasted with care in adult ICUs. We continue to search for better prognostic tools for individual infants.