The Apgar Score and Its Components in the Preterm Infant

Thomas Hegyi, Tracy Carbone, Mujahid Anwar, Barbara Ostfeld, Mark Hiatt, Anne
Koons, Jennifer Pinto-Martin and Nigel Paneth
Pediatrics 1998;101;77-81
DOI: 10.1542/peds.101.1.77

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located on the World Wide Web at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and
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Village, Illinois, 60007. Copyright © 1998 by the American Academy of Pediatrics. All rights
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 The Apgar Score and Its Components in the Preterm Infant
Thomas Hegyi, MD*; Tracy Carbone, MD*; Mujahid Anwar, MD*; Barbara Ostfeld, PhD*;
Mark Hiatt, MD*; Anne Koons, MD*; Jennifer Pinto-Martin, PhD‡; and Nigel Paneth, MD, MPH§
ABSTRACT. Objective. The Apgar score is well-char-
acterized in full-term infants but not in premature in-
fants. The objective of this study was to assess the Apgar
score in preterm infants with respect to the relationships
between the 1- and 5-minute scores, the correlation of the
Apgar score with pH and with other variables, and the
relationship among the individual Apgar components.
Methodology. We recorded Apgar scores at 1 and 5
minutes in a population-based cohort of preterm infants
(n 5 1105) with birth weight <2000 g, from three inten-
sive care nurseries in central New Jersey. Linear correla-
tion analysis was used to examine the relationship be-
tween 1- and 5-minute Apgar scores and between the
individual components of the Apgar score. Multiple re-
gression analysis was used to explore the relationship
between various perinatal characteristics and the Apgar
score, and between pH and Apgar score. Stepwise logis-
tic regression analysis was used to assess the determi-
nants of mortality.
Results. The 1-minute Apgar score median (25%,
75%) was 6(4,8) and correlated with the 5-minute score of
8(7,9) at r 5 .78. Slight but significant differences were
seen between male (n 5 557) and female (n 5 508) infants
in the 1-minute (6[4,8] and 7[4,8]) Apgar scores. One- and
5-minute scores of white infants (7[4,8] and 8[7,9]; n 5
713) were significantly higher than those of black infants
(5[3,7] and 8[6,9]; n 5 280). Birth weight and gestational
age were both linearly related to both Apgar scores. Low
Apgar score (<3 at 1 minute and <6 at 5 minutes) was
significantly associated with birth weight, gestational
age and mode of delivery. Low arterial blood pH (<7.01)
at birth was significantly related to low Apgar score. One
hundred fifty-nine infants died; these infants were sig-
nificantly smaller (983 6 382 vs 1462 6 369 g), less mature
(27 vs 31 weeks), had lower arterial blood pH (7.20 6 0.18
vs 7.31 6 0.11), had lower 1- (3[2,6] vs 7[4,8]) and 5-minute
Apgar scores (6[4,8] vs 8[7,9]), and a greater incidence of
low Apgar score (32% vs 6%) than did survivors.
Conclusions. Among the components of the Apgar
score, respiratory effort, muscle tone, and reflex activity
correlated well with one another; heart rate correlated
less well; and color the least. Our data confirms the
limited use of the Apgar score in preterm infants and
demonstrates the different responses of the Apgar score’s
From the *Division of Neonatology, Department of Pediatrics, UMDNJ-
Robert Wood Johnson Medical School, St Peter’s Medical Center, New
Brunswick, New Jersey; the ‡Department of Pediatrics and Clinical Epide-
miology Unit, University of Pennsylvania, Philadelphia, Pennsylvania; and
the §Program in Epidemiology and Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State University, East
Lansing, Michigan.
Received for publication Dec 12, 1996; accepted May 15, 1997.
Reprint requests to (T.H.) St Peter’s Medical Center, 254 Easton Ave, New
Brunswick, NJ 08903.
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 101 No. 1 January 1998
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components. Pediatrics 1998;101:77– 81; Apgar score, com-
ponents, prematurity, acidosis, mortality.
ABBREVIATION. UI, unit increase.
I
n the 40 years since the Apgar score was devel-
oped by Virginia Apgar1 to assess newborn in-
fants, it has promoted infant evaluation immedi-
ately after birth, trained students and physicians to
observe several clinical signs simultaneously in mak-
ing clinical decisions, and assisted in the establish-
ment of standard policies for resuscitation. The Ap-
gar score continues to be used as the best established
index of immediate postnatal health.
The description of the Apgar score and its corre-
lation with other measures such as pH is based
largely on data obtained from term newborns and
may not apply to premature infants. In the Central
New Jersey Neonatal Brain Hemorrhage Study, or-
ganized to screen a cohort of premature infants for
germinal matrix and intraventricular hemorrhage,
we systematically collected a large number of clinical
variables, including 1- and 5-minute Apgar scores.2
The data on the incidence, timing, and outcome of
intraventricular hemorrhage has been previously re-
ported.3,4 In this article we present the results of our
analysis of the Apgar score in preterm infants with
respect to the relationships between the 1- and
5-minute scores, the correlation of the Apgar score
with pH and with other variables, and the relation-
ship among the individual Apgar components.
METHODS
Study Population
Infants born in central New Jersey (Monmouth, Ocean, and
Middlesex counties) between August 1984 and June 1987, and
weighing 501 to 2000 g were eligible for inclusion. The 1105 study
infants were born or transferred to three study hospitals with
intensive care units constituted 83% of all infants in the region
born during the period of study who met the birth weight criteria.
Details of patient enrollment and collection of data have been
reported previously.2
Apgar Score Designation
Apgar scores were provided by care providers attending the
delivery of the premature infant including pediatric attendings
and housestaff, neonatal fellows, and obstetrical nursing staff.
Because delivery of these infants was attended by pediatric staff,
most of the Apgar scores were assigned by either a pediatric
attending, senior pediatric resident, or a neonatal fellow who were
well-trained in assigning the Apgar score. However, in a small
percentage of infants, due to unexpected delivery, Apgar score
was assigned by the obstetrical nursing staff who were oriented in
assessment of the infant and assigning the Apgar score. Apgar
77
scores were assessed at the designated time intervals after delivery 1-minute Apgar score showed significant positive
and recorded on standard labor and delivery forms. slopes for birth weight (b 5 0.391) and gestational
age (b 5 0.152). Similar prediction of birth weight (b
Statistical Analysis
5 0.346) and gestational age (b 5 0.207) was also
Apgar scores were expressed as median (25%–75%). Categori-
cal data were analyzed using the x2 test. Differences in median found for the 5-minute Apgar score. Stepwise regres-
values were analysed using Kruskal-Wallis analysis of variance by sion analysis showed that birth weight explained
ranks and median test. Multiple regression analysis was used to 25% of the variance in the 1-minute Apgar score and
explore the relationship between various perinatal characteristics this explained variance only increased to 27% with
and the Apgar score, and between pH and Apgar score. Stepwise the addition of gestational age. Similarly, for the
logistic regression analysis was used to assess the determinants of
mortality. Significant differences were judged by a P value ,.05. 5-minute Apgar score birth weight accounted for
25% of the explained variance, which increased to
RESULTS 28% with the addition of gestational age. Odds ratio
In the study population, mean birth weight was with low Apgar score for birth weight ,1.5 kg was
1393 6 406 g and mean gestational age 31.3 6 4.1 5.0 in comparison with birth weight of 1.5 to 2 kg,
weeks. Complete Apgar score data were available in and for birth weight ,1.0 kg was 9.0 in comparison
1067 (96.6%) infants. One-minute Apgar score was with birth weight of 1 to 2 kg.
6(4,8) and 5-minute score was 8(7,9). The two scores
correlated with each other at r 5 .78. Relationship of Blood pH and Apgar Score (Table 2)
Measurements of cord blood arterial pH were
Perinatal Characteristics and Apgar Score (Table 1) available in 869 infants. Blood pH correlated signif-
The relationship between 1- and 5-minute Apgar icantly with both 1- and 5-minute Apgar scores (r 5
score and the incidence of low Apgar score (,3 at 1 0.17 for the 1-minute and r 5 0.24 for the 5-minute
minute and ,6 at 5 minutes) with birth weight, Apgar score). Removing color from the Apgar score
gestational age, mode of delivery, sex, race, and ges- did not improve the correlation coefficient with
tation is shown in Table 1. Both 1- and 5-minute blood pH for either the 1- or 5-minute Apgar score.
Apgar scores and the incidence of low Apgar score Low blood pH (,7.01) was significantly associated
were significantly different among the birth weight with low Apgar score (,3 at 1 minute and ,6 at 5
groups. Significant differences for gestational age minutes). Complete information on all the variables
were seen between the two groups of infants ,31 included in Table 1 and cord blood pH was available
weeks’ gestation and the two groups .30 weeks’ on 701 infants. Multiple regression analysis for 1-
gestation. Infants born after vaginal delivery had minute Apgar score in this subset of 701 infants
lower 1-minute Apgar scores than those born by showed significant slopes for birth weight (b 5
caesarean section. Both 1- and 5-minute Apgar scores 0.357), gestational age (b 5 0.101), mode of delivery
were significantly higher in white than black infants, (b5 20.01), and pH (b 5 0.169). Stepwise linear
and the 1-minute score was higher in females. regression analysis showed that birth weight ac-
Multiple regression analysis of determinants of the counted for 18% of the variance in the 1-minute
Apgar score, with the addition of cord blood pH the
explained variance increased to 21% and with the
TABLE 1. Perinatal Characteristics and Apgar Score* addition of the other significant variables to 23%. For
1-min 5-min Low Apgar the 5-minute Apgar score significant slopes were
Apgar Apgar Score seen for birth weight (b 5 0.276), gestational age (b 5
Birth weight 0.206), and cord blood pH (b 5 0.233). Stepwise
,1001 g (n 5 218) 3 (2,5)† 6 (4,8)† 63 (29%)† linear regression analysis showed that birth weight
1001–1500 g (n 5 368) 6 (4,7) 8 (7,8) 21 (6%) again accounted for 18% of the variance in the 5-
.1500g (n 5 476) 7 (6,8) 9 (8,9) 16 (3%) minute Apgar score; the addition of pH increased it
Gestational age
,27 weeks (n 5 154) 3 (1,5)† 6 (4,8)† 45 (29%)† to 24% and gestational age to 26%.
27–30 weeks (n 5 329) 5 (4,7) 7 (6,8) 32 (10%)
31–34 weeks (n 5 410) 7 (5,8) 8 (8,9) 17 (4%) Relationship of Apgar Score to Mortality
.34 weeks (n 5 137) 8 (5,8) 9 (8,9) 3 (2%) One hundred fifty-nine infants died before day 28
Mode of delivery
Vaginal (n 5 432) 7 (4,8)† 8 (7,9) 50 (12%)†
of life and 946 infants survived. Nine infants died in
Cesarean section 6 (4,8) 8 (7,9) 38 (7%) the delivery room. Complete data on mortality, birth
(n 5 520) weight, gestational age, and 1- and 5-minute Apgar
Sex scores were available in 1009 infants of whom 134
Males (n 5 557) 6 (4,8)† 8 (7,9) 54 (10%) died. Stepwise logistic regression analysis showed
Females (n 5 508) 7 (4,8) 8 (7,9) 46 (9%)
Race birth weight accounted for 16% of the variance in
White (n 5 713) 7 (4,8)† 8 (7,9) 59 (9%)
Black (n 5 280) 5 (3,7) 8 (6,9) 31 (12%)
Others (n 5 63) 6 (3,8) 8 (6,9) 5 (8%) TABLE 2. Relationship Between Low Cord Blood pH and
Gestation Low Apgar Score
Singleton (n 5 786) 6 (4,8) 8 (7,9) 81 (11%) Low Apgar Score Low Apgar Score
Twin (n 5 245) 7 (4,8) 8 (7,9) 17 (7%) Present Absent
Triplet (n 5 26) 5 (5,7) 7 (7,8) 1 (4%)
Quadruplet (n 5 3) 9 (8,9) 9 (9,9) 0 Cord pH .7.00 59 (69%) 725 (98%)
Cord pH ,7.01 27 (31%) 17 (2%)
* Data expressed as median (25%–75%).
† Significantly different values P , .05. x2 significant at P , .05.

78 THE APGAR SCORE AND ITS COMPONENTS IN THE PRETERM INFANT

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mortality, which increased to 20% with the addition
of low Apgar score. Gestational age had little inde-
pendent effect on mortality. In a subset of 795 infants
with blood pH data available 117 died. In this subset
of infants stepwise logistic regression analysis showed
that the main determinant of mortality was again
birth weight accounting for 14% of the variance. This
explained variance in mortality increased to 19%
with the addition of low cord blood pH and to 21%
with the further addition of low Apgar score. Gesta-
tional age had no significant effect.
Apgar Score Component Analysis (Table 3)
Significant (P , .01) correlations were found
among components of the 1-minute Apgar score,
with the strongest correlations among the triad of
respiratory rate, tone, and reflex. Heart rate corre-
lated somewhat less well with the other components,
and color had the lowest correlation with the other
components. The Figure illustrates the increasing
contribution of each component to the 1-minute Ap-
gar score from 0 to 10. As the 1-minute Apgar score
increased, the absolute value of each component in-
creased. We constructed a model to compare the
contribution of each component by examining a hy-
pothetical rate of increase per each Apgar score be-
tween 1-minute Apgars of 0 and 10. The respiratory
rate, tone, and reflex components produced the larg-
est increases in the total score (unit increase [UI] 5
0.20), followed by heart rate (UI 5 .16), and then by
TABLE 3. Correlation Coefficients Between the Components
of the 1-Minute Apgar Score
Components of 1-Minute Score Correlation Coefficient*
Tone-reflex .72
Tone-respiratory rate .68
Respiratory rate-reflex .64
Respiratory rate-heart rate .60
Heart rate-tone .57
Heart rate-reflex .54
Color-reflex .39
Color-respiratory rate .35
Color-tone .34
Color-heart rate .31
* (Nonparametric Spearman R). All r values significant at P , .01.
Figure. Evolution of components with increasing 1-
minute Apgar score.
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color (UI 5 .14). As the Figure shows, these results
reflect the large contribution of heart rate at lower
Apgar scores and the smaller contribution at higher
scores. It also shows that tone contributes more at
higher Apgar scores compared with heart rate. Heart
rate leveled close to 1 at a 1-minute Apgar score of 1
but tone reached about the same value at a 1-minute
Apgar score of approximately 5. Table 4 shows the
mean level of each component at each 1-minute Ap-
gar score.
DISCUSSION
The Apgar score has been useful for nearly four
decades, focusing on five physiological signs (heart
rate, respiratory effort, reflex irritability, muscle tone,
and color) to denote the condition of an infant during
the first critical minutes of life. The score has been
used as a predictive index for neonatal mortality and
morbidity and for later neurologic or developmental
disability in term infants.5
The present investigation provides Apgar score
data on a large number of unselected preterm infants
weighing ,2000 g at birth, and examines the score
and its components. The observation that females
had significantly higher 1-minute scores is of statis-
tical rather than clinical interest. However, it is of
interest to speculate as to the etiology of this finding.
Greenough and colleagues6 measured catecholamine
levels in cord arterial blood from preterm infants and
found that females had significantly higher catechol-
amine levels after asphyxia and tended also to have
higher catecholamine levels without asphyxia. It is
possible that this difference in pressor response con-
tributes to the Apgar score differences noted.
Each component of the Apgar score, heart rate,
respiratory effort, tone, reflex irritability, and color,
carries the same weight in the assessment and there-
fore contributes equally to the total score. However,
each component has a different relationship to the
total score as well as to the remaining components of
the score. The most important of the signs is heart
rate, which indicates life or death; failure of the heart
rate to respond to resuscitation is an ominous prog-
nostic sign. We found respiratory effort, tone, and
reflex irritability to closely correlate and also to
ARTICLES 79
TABLE 4. Mean Component Values at Each 1-Minute Apgar
Apgar Heart Rate Respiratory Rate
0 0 0 0
1 1 0 0
2 1.0 6 0.4 0.5 6 0.5
3 1.2 6 0.4 0.5 6 0.5
4 1.3 6 0.5 0.9 6 0.4
5 1.4 6 0.5 1.0 6 0.3
6 1.6 6 0.5 1.1 6 0.4
7 1.80 6 0.4 1.5 6 0.5
8 1.9 6 0.4 1.7 6 0.5
9 2.0 6 .3 1.9 6 0.3
10 2.0 2.0
closely correlate with the total score. These compo-
nents seem to measure the neurological integrity of
the infant. Finally, color correlated most poorly
among the components and is likely a measure of
neither life or neurological integrity. Marx and co-
workers7 confirmed the lack of utility of color by
showing that the exclusion of the score for color
actually increased the correlation between the total
score and umbilical arterial pH. Our data do not
show improvement in correlation with blood pH by
excluding color from the Apgar score.
In our study, the incidence of low Apgar scores
was inversely related to birth weight, a finding con-
firming previous observations.8,9 In a retrospective
study of 641 live infants weighing ,2500 g, Laden-
hoff et al9 showed that the frequency of a low Apgar
score was significantly correlated with the birth
weight of the infant and was independent of the
mode of delivery and the presentation. Caitlin and
co-workers10 tested the hypothesis that Apgar scores
were related to the newborn infant’s level of matu-
rity and showed the 1- and 5-minute Apgar scores to
be directly related to gestational age. Respiratory
efforts, muscle tone, and reflex were the major de-
terminants of a decreasing Apgar score with declin-
ing gestational age. Lan and co-workers11 found that
at 1 minute of life, the relative risks of low birth
weight among infants with Apgar scores of 0 to 3 and
4 to 6 were 115.0 and 5.9 times higher than those of
normal infants, respectively. In the very low birth
weight category, the relative risks of the above score
were 252.5 and 51.1, in this order. Our subjects con-
sisted of infants with birth weights ,2000 g. Within
this weight group the odds ratio in infants with low
Apgar scores to have a birth weight ,1.5 kg was 5.0
and ,1.0 kg was 9.0, respectively.
A number of investigators have observed a poor
relationship between Apgar scores and pH measure-
ments.12,13 Perkins and Papile8 noted correlations be-
tween cord blood gases and Apgar scores to be poor,
with most preterm newborns showing normal gases
irrespective of Apgar scores. Similar findings were
noted by Goldenberg et al14 who compared 1- and
5-minute Apgar scores and umbilical cord arterial
pH values in preterm newborns. The more prema-
ture the infant, the more likely the Apgar score was
low in the presence of a pH $7.25. Conversely, the
closer to term, the more frequently an infant with a
pH of .7.25 had an Apgar score of $7. However,
Greenough and co-workers6 noted a good correlation
80 THE APGAR SCORE AND ITS COMPONENTS IN THE PRETERM INFANT
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Tone Reflex Color
0 0
0 0
0 6 0.2 0.1 6 0.3 0.4 6 0.5
0.4 6 0.4 0.4 6 0.4 0.5 6 0.5
0.6 6 0.5 0.8 6 0.4 0.4 6 0.5
0.9 6 0.3 0.9 6 0.4 0.7 6 0.5
1.1 6 0.3 0.12 6 0.5 0.8 6 0.4
1.3 6 0.5 1.4 6 0.5 0.9 6 0.4
1.6 6 0.5 1.7 6 0.5 0.8 6 0.5
1.9 6 0.3 2.0 6 0.3 1.0 6 0.2
2.0 2.0 2.0
in the presence of acidosis, a finding similar to ours.
Approximately 15% of our group died before day 28
of life. Several studies have examined the relation-
ship of neonatal death rate to the 1-minute Apgar
score. James and co-workers15 demonstrated, in
.27 000 infants, that death rate was inversely corre-
lated with this score. Myers et al16 noted enhanced
survival when the 1-minute Apgar score was at least
4. The importance of the 1-minute Apgar in predict-
ing survival was also observed by Behnke and co-
workers,17 although they also emphasized the contri-
bution of the 5-minute score, birth weight, and
gestational age. In our data the most important de-
terminant of mortality was birth weight, with addi-
tional small contributions by low cord blood arterial
pH and low Apgar score.
The Apgar score has been widely used to identify
infants who require resuscitation at birth, to predict
outcome, and to evaluate change in the condition of
the newly born over the first minutes of life. Our data
confirms the limited use of the Apgar score in pre-
term infants. However, it remains the best tool for
the identification of preterm infants in need of car-
diopulmonary resuscitation. Our data show that in
infants with birth weights ,2000 g, low Apgar score
correlates both with acidosis and mortality, but the
weak correlation emphasizes the limitations of the
score in predicting morbidity or immediate mortal-
ity, a conclusion similar to that of Schmidt et al.18
ACKNOWLEDGMENT
Supported by a grant (RO1-NS-20713) from the National Insti-
tute of Neurological Diseases and Stroke.
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41:843– 850

DEVELOPMENT OF LANGUAGE-SPECIFIC PHONEMES

A 6-month-old Japanese infant can still detect English “r” and “l” sounds. But
after another 6 months of exposure to the Japanese phoneme that lies between them
(and not to English phonemes), the child standardizes on the Japanese phoneme
and hears “l” and “r” as the same.

Calvin WH. Talking Heads. Review of Deacon TW. The Symbolic Species. New York, NY: WW Norton;
1997.

Submitted by Student

ARTICLES 81
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 The Apgar Score and Its Components in the Preterm Infant
Thomas Hegyi, Tracy Carbone, Mujahid Anwar, Barbara Ostfeld, Mark Hiatt, Anne
Koons, Jennifer Pinto-Martin and Nigel Paneth
Pediatrics 1998;101;77-81
DOI: 10.1542/peds.101.1.77
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