Clinical paperNeonates with a 10-min Apgar score of zero: Outcomes by gestational age
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
References (28)
- et al.
Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome
J Pediatr
(1991) - et al.
Severe asphyxia and outcome of survivors
Resuscitation
(1984) - et al.
Outcome after successful resuscitation of babies born with apgar scores of 0 at both 1 and 5 minutes
Am J Obstet Gynecol
(2000) - et al.
Prediction of outcome in asphyxiated newborns treated with hypothermia: Is a MRI scoring system described before the cooling era still useful?
Eur J Paediatr Neurol
(2018) - et al.
Part 7: neonatal resuscitation: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations
Circulation
(2015) A proposal for a new method of evaluation of the newborn infant
Curr Res Anesth Analg
(1953)The Apgar score
Pediatrics
(2015)- et al.
Outcome of resuscitation following unexpected apparent stillbirth
Arch Dis Child Fetal Neonatal Ed
(1998) - et al.
The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort
Am J Obstet Gynecol
(2007) - et al.
Predicting death despite therapeutic hypothermia in infants with hypoxic-ischaemic encephalopathy
Arch Dis Child Fetal Neonatal Ed
(2010)
Birth asphyxia: incidence, clinical course and outcome in a Swedish population
Acta Paediatr
Variations in practice and outcomes in the Canadian NICU network: 1996-1997
Pediatrics
Internal audit of the Canadian Neonatal Network Data Collection System
Am J Perinatol
Cited by (0)
- 1
Contributed equally.
- 2
A complete list of the CNN Investigators appears in the Appendix A.