Apgar Score and Neurodevelopmental Outcomes at Age 5 Years in Infants Born Extremely Preterm
Authors: Ehrhardt Harald , Aubert Adrien M. , Ådén Ulrika , Draper Elizabeth S. , Gudmundsdottir Anna , Varendi Heili , Weber Tom , Zemlin Michael , Maier Rolf F. , Zeitlin Jennifer ,   EPICE-SHIPS Research Group, Lebeer Jo , van Reempts Patrick , Bruneel Els , Cloet Eva , Oostra Ann , Ortibus Els , Sarrechia Iemke , Boerch Klaus , Huusom Lene , Pedersen Pernille , Hasselager Asbjørn , Toome Liis , Männamaa Mairi , Ancel Pierre-Yves , Burguet Antoine , Jarreau Pierre , Pierrat Véronique , Truffert Patrick , Misselwitz Björn , Schmidt Stephan , Wohlers Lena , Cuttini Maria , Di Lallo Domenico , Ancora Gina , Baronciani Dante , Carnielli Virgilio , Croci Ileana , Faldella Giacomo , Ferrari Frederica , Franco Francesco , Gargano Giancarlo , van Heijst Arno , Koopman-Esseboom Corine , Gadzinowski Janusz , Mazela Jan , Montgomery Alan , Pikuła Tomasz , Barros Henrique , Costa Raquel , Graça Luís , do Céu Machado Maria , Rodrigues Carina , Rodrigues Teresa , Edstedt Bonamy Anna-Karin , Norman Mikael , Boyle Elaine , Fenton Alan , Johnson Samantha , Manktelow Bradley , Milligan David , Mader Silke , Thiele Nicole , Walz Johanna , Petrou Stavros , Bonet Mercedes , Bonnet Camille , El Raffei Rym , Piedvache Aurélie , Seppänen Anna-Veera 
Published: September 2023

Importance

The Apgar score is used worldwide as an assessment tool to estimate the vitality of newborns in their first minutes of life. Its applicability to estimate neurodevelopmental outcomes in infants born extremely preterm (EPT; &amp;lt;28 weeks’ gestation) is not well established.

Objective

To investigate the association between the Apgar score and neurodevelopmental outcomes in infants born EPT.

Design, Setting, and Participants

This cohort study was conducted using data from the Effective Perinatal Intensive Care in Europe-Screening to Improve Health in Very Preterm Infants in Europe (EPICE-SHIPS) study, a population-based cohort in 19 regions of 11 European countries in 2011 to 2012. Clinical assessments of cognition and motor function at age 5 years were performed in infants born EPT and analyzed in January to July 2023.

Exposures

Apgar score at 5 minutes of life categorized into 4 groups (0-3, 4-6, 7-8, and 9-10 points).

Main Outcomes and Measures

Cognitive and motor outcomes were assessed using the Wechsler Preschool and Primary Scale of Intelligence test of IQ derived from locally normed versions by country and the Movement Assessment Battery for Children–Second Edition. Parents additionally provided information on communication and problem-solving skills using the Ages and Stages Questionnaire, third edition (ASQ-3). All outcomes were measured as continuous variables.

Results

From the total cohort of 4395 infants born EPT, 2522 infants were live born, 1654 infants survived to age 5 years, and 996 infants (478 females [48.0%]) followed up had at least 1 of 3 outcome measures. After adjusting for sociodemographic variables, perinatal factors, and severe neonatal morbidities, there was no association of Apgar score with IQ, even for scores of 3 or less (β = −3.3; 95% CI, −10.5 to 3.8) compared with the score 9 to 10 category. Similarly, no association was found for ASQ-3 (β = −2.1; 95% CI, −24.6 to 20.4). Congruent results for Apgar scores of 3 or less were obtained for motor function scores for all children (β = −4.0; 95% CI, −20.1 to 12.1) and excluding children with a diagnosis of cerebral palsy (β = 0.8, 95% CI −11.7 to 13.3).

Conclusions and Relevance

This study found that low Apgar scores were not associated with longer-term outcomes in infants born EPT. This finding may be associated with high interobserver variability in Apgar scoring, reduced vitality signs and poorer responses to resuscitation after birth among infants born EPT, and the association of more deleterious exposures in the neonatal intensive care unit or of socioeconomic factors with greater changes in outcomes during the first 5 years of life.