Elsevier

Resuscitation

Volume 143, October 2019, Pages 77-84
Resuscitation

Clinical paper
Neonates with a 10-min Apgar score of zero: Outcomes by gestational age

https://doi.org/10.1016/j.resuscitation.2019.07.036Get rights and content

Abstract

Background

The current resuscitation guidelines for neonates recommend considering stopping resuscitation efforts if the heart rate remains undetectable after 10 min of adequate resuscitation. However, this recommendation does not take into account the gestational age (GA) of the neonates. We determined the outcomes of neonates with a 10-min Apgar score of zero (Apgar10 = 0) with respect to their GA.

Methods

In a retrospective matched cohort study, we studied neonates admitted to the Canadian Neonatal Network NICUs between 2010 and 2016 with an Apgar10 = 0. The neonates were divided into 3 subgroups according to their GA: (1) ≥36 weeks’, (2) 320/7–356/7 weeks’, and (3) <32 weeks’. Each neonate with Apgar10 = 0 was matched 1:1 with neonates of same GA and sex but Apgar10 = 1–2 and Apgar10 = 3–5. Survival and brain injury were compared between matched groups.

Results

177 neonates had Apgar10 = 0. Survival to discharge was significantly different between GA groups [≥36 weeks’ 61% vs. 320/7–356/7 weeks’ 58% vs. <32 weeks’ 35%, p = 0.04]. Survival to discharge was similar to their matched cohort with Apgar10 = 1–2 for neonates born at ≥36 weeks’ (61% vs. 66%) and between 320/7 to 356/7 weeks’ (58% vs. 54%), but significantly different for neonates <32 weeks (35% vs. 61%, p = 0.04).

Conclusion

Neonates with Apgar10 = 0 had different outcomes depending on their GA. Less than half of neonates born at <32 weeks GA survived; however, a majority of neonates born at 320/7–356/7 weeks’ and ≥36 weeks’ GA survived at similar rates than their matched neonates with Apgar10 = 1–2.

Introduction

Approximately 5% of neonates require some form of resuscitation at birth.1 The neonate’s primary adaptation at birth and response to resuscitative efforts are typically quantified with the Apgar score.2 It is usually assessed at 1 and 5 min after birth; although subsequent scoring at 5-min intervals is suggested if the 5-min Apgar score is lower than 7.3

The International Liaison Committee on Resuscitation worksheet recommendations and the Neonatal Resuscitation Program guidelines currently recommend that it may be reasonable to consider stopping resuscitation efforts if the heart rate remains undetectable after 10 min of complete and adequate resuscitation efforts.1 These guidelines are based on evidence that the 10-min Apgar score is a predictor of mortality and morbidity in late-preterm and term infants.4, 5, 6, 7, 8, 9 However, most of this evidence is based on non-recent studies with small sample sizes that did not take into account some of the improvements in the neonatal care provision, such as the resuscitation of extremely preterm neonates or the use of hypothermia treatment for near-term and term neonates.

Thus, the objective of this study was (1) to determine the outcomes of neonates with a 10-min Apgar score of zero (Apgar10 = 0) born between 2010 and 2016 and admitted to the tertiary-level NICUs of the Canadian Neonatal Network (CNN); and (2) to examine whether their outcomes vary between different gestational ages (GA) or Apgar score groups at birth.

Section snippets

Study design

We used a retrospective matched-cohort study design using data from the CNN database. The CNN maintains a national perinatal-neonatal database that collects data for all infants admitted to 31 tertiary-level NICUs in Canada. Data were abstracted from infant medical records at each site according to standardized definitions and electronically transmitted to the CNN coordinating center as previously described.10, 11 As shown previously, the CNN database is remarkably consistent and reliable.12

Study cohort

Between 2010 and 2016, 102 674 neonates were admitted to the CNN tertiary-level NICUs (Fig. 1). 9618 infants were excluded for major congenital anomalies or missing 10-min Apgar scores. Among the remaining neonates, 177 had Apgar10 = 0, which represented an incidence rate of 0.19% (177/93 056; 95% CI 0.16–0.22). Most of the neonates with Apgar10 = 0 were born at ≥36 weeks’ GA (68%, 120/177); however, 15% (26/177) were born between 320/7 and 356/7 weeks’ GA and 17% (31/177) were born at <32

Discussion

Making the decision to stop resuscitating a neonate after 10 min of complete and adequate resuscitation efforts after birth remains a clinical and ethical challenge for health care providers. This decision is complicated by the unpredictable potential outcomes of death or survival with long-term disabilities. Further complicating decision-making also often includes the inability to adequately inform and counsel parents during the acute event (e.g., maternal general anesthesia). Our study in a

Funding source

Although no specific funding has been received for this study, organizational support for the Canadian Neonatal Network was provided by the Maternal-Infant Care Research Centre (MiCare) at Mount Sinai Hospital in Toronto, Ontario, Canada. MiCare is supported by a Canadian Institutes of Health Research (CIHR) Team Grant (CTP 87518), the Ontario Ministry of Health and in-kind support from Mount Sinai Hospital. Dr. Shah holds an Applied Research Chair in Reproductive and Child Health Services and

Financial disclosure

The authors have no financial relationships relevant to this article to disclose.

Potential conflicts of interest

The authors have no conflicts of interest relevant to this article to disclose.

Acknowledgements

The authors gratefully acknowledge all site investigators and abstractors of the Canadian Neonatal Network (CNN). We thank the staff at the Maternal-Infant Care (MiCare) Research Centre at Mount Sinai Hospital, Toronto, ON for organizational support of CNN. In addition, we thank Sarah Hutchinson, PhD, from MiCare for editorial assistance in the preparation of this manuscript. MiCare is supported by a team grant from the Canadian Institutes of Health Research (CTP 87518), the Ontario Ministry of

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  • Cited by (0)

    1

    Contributed equally.

    2

    A complete list of the CNN Investigators appears in the Appendix A.

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