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Andrew B. Kairalla MD, Editor

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10-Minute Apgar Score of Zero 

Laptook AR, Shankaran S, Ambalavanan N, et al. Outcome of Term Infants Using Apgar Scores at 10 Minutes Following Hypoxic-Ischemic Encephalopathy.  PEDIATRICS (Dec 2009); 124:1619-1626.  [Full text] [PDF] 

OBJECTIVE: The objective of this study was to determine whether Apgar scores at 10 minutes are associated with death or disability in early childhood after perinatal hypoxic-ischemic encephalopathy.    
     
METHODS: This was a secondary analysis of infants who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hypothermia trial. Infants who were born at 36 weeks’ gestation and had clinical and/or biochemical abnormalities at birth and encephalopathy at <6 hours were studied. Logistic regression and classification and regression-tree analysis were used to determine associations between Apgar scores at 10 minutes and neurodevelopmental outcome, adjusting for covariates. Death or disability (moderate or severe) at 18 to 22 months of age was the measured outcome.

RESULTS: Twenty of 208 infants were excluded (missing data). More than 90% of the infants had Apgar scores of 0 to 2 at 1 minute, and Apgar scores at 5 and 10 minutes shifted to progressively higher values; at 10 minutes, 27% of infants had Apgar scores of 0 to 2. After adjustment, each point decrease in Apgar score at 10 minutes was associated with a 45% increase in the odds of death or disability. Death or disability occurred in 76%, 82%, and 80% of infants with 10-minute Apgar scores of 0, 1, and 2, respectively. Classification and regression-tree analysis indicated that Apgar scores at 10 minutes were discriminators of outcome. 

CONCLUSIONS: Apgar scores at 10 minutes provide useful prognostic data before other evaluations are available for infants with hypoxic-ischemic encephalopathy. Death or moderate/severe disability is common but not uniform with Apgar scores of <3; caution is needed before adopting a specific time interval to guide duration of resuscitation.

Comments.  We recently cared for an asphyxiated infant with a 10-minute Apgar  score of zero who was resuscitated and treated with whole body hypothermia.  He survived, and his neurodevelopmental outcome at 18 months of age looks pretty normal.  Since that experience, I have been questioning the wisdom of the current NRP recommendations to stop resuscitation after 10 minutes with no response.  After all, these recommendations were based on outcome data for asphyxiated infants who were not treated with hypothermia.  The present study looks at the population from the NICHD Whole-body hypothermia trial, and found that 24% of babies with zero Apgar score at 10 minutes had a good outcome (survival without moderate or severe disability). I guess we may have to rethink the “10-minute rule” for stopping neonatal resuscitation.  ABK

Additional Comments:

Date: 15 Dec 2009
Time: 16:34:40

I wonder if they counted for a full minute and obtained a heart rate of Zero!! Would be interesting to know if the neonate had the Objective Criteria for Asphyxia - pH less than 7.0 associated with evidence of MSOD. We recently had a term infant with Apgar Score of 1,1,1,4 - Arterial pH of 6.85 at 1/2 an hour of life, with evidence elevated Heart and Liver enzymes and elevated Cr - was in Sarnat Stage I-II - on discharge had a normal neurological exam. Normal head MRI at 5 days of age!! I expect the neonate have a 90% chance to have a normal Neurological Outcome - ref: NeoReviews Vol.3 No.6 June 2002. The NRP recommends stopping resuscitation based on a real Apgar score of Zero at 10 minutes( that means counting the heart rate for a full minute!!).

UserName: Ravi Agarwal
Institution: Fort Walton Beach Medical Center
telephone: 8504960855
email: neodoc1@yahoo.com

Editor's Response: 

In response to your questions about the case I mentioned:

1) In this infant, the first detectable heart rate was recorded at 17 minutes of life.  I doubt that they counted Heart Rate for a full minute during the resuscitation.  That would require pausing the chest compressions and the bag ventilation for a full minute each time  you listen for heart tones.  This might severely compromise your chances of a successful resuscitation.  NRP teaches to count heart rate for 6-seconds (then add a zero) during neonatal resuscitations.  You could make a good case for ELECTRONIC heart rate monitoring during neonatal resuscitations to circumvent this problem. 

2) The is no doubt that this infant had significant encephalopathy at birth.  His initial PH was 6.5, with a base deficit of -26.  He had no spontaneous movements or respirations during the first few hours of life, and his initial EEG showed seizure activity.  His liver and muscle enzymes were also markedly elevated.

3) We were all amazed that he not only survived, but he was doing so well at 18 month of age.  In fact, we presented a conference on Hypothermia for Neonatal Encephalopathy for our NICU staff, and brought this toddler back in as our "poster child" to show that this therapy really works. 

UserName: Andy Kairalla MD
Institution: Baptist Children's Hospital
telephone: 786-596-6669
email: andrewk@baptisthealth.net

Date: 16 Dec 2009
Time: 00:43:57

24% of babies with 0 APGAR scores did reasonably well at 18 months follow up. That means 76% of survivors had mod to severe disability. Is that good enough for a re-think of the '10 minute rule'??

UserName: Arun Nair
Institution: Waikato Hospital
email: naira@waikatodhb.govt.nz

Date: 17 Dec 2009
Time: 12:11:29

I agree it very difficult to stop resuscitation and count the heart rate for a full minute. Have had the prvilege of of being Regional NRP Instructor for the past 20 years. The Neonatal Resuscitation Program(hence it is no more called Neonatal Advanced Life Support) only gives evidence based guidelines - it is NOT a rule/law. The program Does NOT certify you in Neonatal Resucitation. The recommendation is to Stop Resuscitation after 10 minutes of Asystole. The six second count may be may show asytole if there is profound bradycardia.

UserName: Ravi Agarwal
Institution: Fort Walton Beach Medical Center
telephone: 8504960855
email: neodoc1@yahoo.com

Date: 12 Feb 2010
Time: 18:20:00

It should be left to the facilities of the center and country .For some centers there is no protocols .facilities for hypothermia .Also some countries have no adequate funds to care for moderate-severe disabilities

UserName: Safaa ELMeneza
Institution: FMG
telephone: 0103630411
email: safaa5@hotmail.com

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