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It’s time to remove skin color from the Apgar Score for newborns

In medicine, inertia can be a strangely powerful force, but Virginia Apgar never succumbed to it. She brought incredible energy to her work in anesthesia, neonatology, and dysmorphology (the study of birth defects) and questioned the status quo when she thought it might save lives. With gratitude for her tireless work, we have reevaluated the eponymous health assessment Apgar developed more than 70 years ago and concluded that one of its components — skin color — should be abandoned. It’s a step Apgar herself might have encouraged; she knew this part of her evaluation method was weaker than the others. We have a chance now to correct that bias.

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 How's Your Baby? Recalling The Apgar Score's Namesake

In the cafeteria one morning, a med student asked Dr. Apgar how a newborn might be evaluated. "That's easy, you'd do it like this," she said, dashing down heart rate, respiration, muscle tone, color and reflexes. Then she rushed off to try it, according to Selma Calmes, a retired anesthesiologist who has written about her. After testing the score on more than 1,000 newborns, Dr. Apgar presented it at a conference in 1952 and it caught on quickly.

 It Happened Here: The Apgar Score

Ask any parents, and they’ll likely say there’s nothing like holding their newborn baby for the first time. But before a mother or father can enjoy that cuddle, a critical event happens in the first minute of a baby’s life: The infant is given an Apgar score, a list of criteria that helps doctors and nurses assess health, including heart rate, muscle tone, physical appearance, and breathing. An easy way to remember the criteria is by its acronym (Appearance, Pulse, Grimace, Activity, Respiration). It is repeated five minutes post-birth.

 Why Does a Routine Test of Newborns Reward ‘Pink’ Skin?

The Apgar test grades infants in five areas, including skin tone. Babies of color score lower, and may be subjected to unnecessary treatment.

Articles of Interest

APGAR score

After World War II, infant mortality declined precipitously in the US, thanks to advances in medicine. In 1941, close to 5% of all infants died in the first month of life; by 1950 that mortality rate dropped below 3%. Virginia Apgar noticed that while overall outcomes were improving, the rates of neonatal mortality, meaning newborns dying within 28 days of birth, remained stubbornly high. All roads seemed to lead back to the first 24 hours of life, when infants were either being sent home with undiagnosed health conditions and dying shortly after, or, if they had trouble breathing, were often being labeled as stillborn and left to die. Legend has it that a student approached Apgar in the hospital cafeteria one day with a question: What signs of health or distress should they be looking for in newborns? Apgar grabbed a napkin and wrote down five metrics, creating the APGAR score on the spot.

Tests to assess newborns’ health not effective for BAME babies in UK

Minority ethnic newborns risk late diagnosis and poorer health as guidance was developed for white European babies in 1952

Apgar Score: Things You Might Not Know About This Routine Test

Interestingly, an Apgar score doesn’t assess baby’s overall wellbeing. Instead, it gives us a clue into how well babies are breathing on their own and how well their heart is pumping oxygenated blood. It also helps the medical team determine if babies needs any medical interventions to improve breathing.

Apgar scores are less predictive of infant mortality for Black babies than white ones, study finds

A standard screening test given to newborns minutes after birth is a less accurate predictor of infant mortality for Black babies than other children, a new study shows, but the authors said the Apgar test should still be used.

Apgar Scores: Examining the Long-term Significance

The Apgar scoring system was intended as an evaluative measure of a newborn's condition at birth and of the need for immediate attention. In the most recent past, individuals have unsuccessfully attempted to link Apgar scores with long-term developmental outcomes. This practice is not appropriate, as the Apgar score is currently defined. Expectant parents need to be aware of the limitations of the Apgar score and its appropriate uses.

Is it time to modify the Apgar score?

Of note, 1 of the 5 components, skin color, scores the color of the skin: a score of 2 is given if the skin is “completely pink,” a score of 1 is given if the skin is “acrocyanotic,” and a score of 0 is given if the skin is “pale.” It is the only clinical algorithm in obstetrics and neonatology that includes skin color (which is also a proxy for race) as part of its scoring.

The Apgar Score

The Apgar score provides an accepted and convenient method for reporting the status of the newborn infant immediately after birth and the response to resuscitation if needed. The Apgar score alone cannot be considered to be evidence of or a consequence of asphyxia, does not predict individual neonatal mortality or neurologic outcome, and should not be used for that purpose.

The Doctor Who Saved Countless Newborn Babies

You may not know who Virginia Apgar was, but chances are she touched your life the moment you emerged from your mother’s womb. Apgar is best known as the creator of a simple test that changed the course of neonatology—the care of newborn infants—forever. But because she was a woman, her groundbreaking career was born along with frustration, near-misses and discouragement.

Resources

StatPearls

The Apgar score is a standardized assessment of a neonate's status immediately after birth and the response to resuscitation efforts and remains the gold standard for evaluating neonates. Although the Apgar score was initially designed to assess the need for intervention to establish breathing at 1 minute, the Neonatal Resuscitation Program guidelines state that Apgar scores should not be used to determine the initial need for intervention, what interventions are indicated, or when to initiate them, as resuscitation must be commenced before the 1-minute Apgar score is assigned.