About the Apgar Score

The Apgar score, the very first test given to your newborn, occurs in the delivery or birthing room right after your baby's birth. The test was designed to quickly evaluate a newborn's physical condition and to determine any immediate need for extra medical or emergency care. Although the Apgar score was developed in 1952 by an anesthesiologist named Virginia Apgar, you may have also heard it referred to as an acronym for: Appearance, Pulse, Grimace,Activity, and Respiration. The Apgar test is usually given to a baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Sometimes, if there are concerns about the baby's condition or the score at 5 minutes is low, the test may be scored for a third time at 10 minutes after birth. Five factors are used to evaluate the baby's condition and each factor is scored on a scale of 0 to 2, with 2 being the best score: 1. 2. 3. 4. 5. appearance (skin coloration) pulse (heart rate) grimace response (medically known as "reflex irritability") activity and muscle tone respiration (breathing rate and effort)

Doctors, midwives, or nurses add these five factors together to calculate the Apgar score. Scores obtainable are between 10 and 0, with 10 being the highest possible score.

Apgar Scoring Apgar Sign Heart Rate (pulse) Breathing (rate and effort) Grimace(responsiveness or "reflex irritability") Activity (muscle tone) Appearance (skin coloration) 2 Normal (above 100 beats per minute) Normal rate and effort, good cry Pulls away, sneezes, coughs, or cries with stimulation Active, spontaneous movement Normal color all over (hands and feet are pink) 1 0 Below 100 beats per Absent minute (no pulse) Slow or irregular Absent (no breathing, weak cry breathing) Facial movement only Absent (no (grimace) with response to stimulation stimulation) Arms and legs flexed No movement, with little movement "floppy" tone Normal color (but Bluish-gray or pale hands and feet are all over bluish)

How is the Apgar score done?

The Apgar score is a number calculated by scoring the heart rate, respiratory effort, muscle tone, skin color, and reflex irritability (response to a catheter in the nostril). Each of these objective signs can receive 0, 1, or 2 points.

What does a high or low Apgar score mean?

A perfect Apgar score of 10 means an infant is in the best possible condition. An infant with an Apgar score of 0-3 needs immediate resuscitation. It is important to note that diligent care of the newborn is an immediate response to the current status of the infant. It is inappropriate to wait until Apgar scores are obtained to begin or continue to address the needs of the neonate.

When is the Apgar scoring done?

The Apgar score is done routinely 60 seconds after the birth of the infant and then is repeated five minutes after birth. In the event of a difficult resuscitation, the Apgar score may be done again at 10, 15, and 20 minutes.

What does a persistently low Apgar score mean?

The persistence of low (0-3) Apgar scores at 20 minutes of age is predictive of high rates of morbidity (disease) and mortality (death).

Why was the Apgar score developed?

The score is named for the preeminent American anesthesiologist Dr. Virginia Apgar (19091974), who invented the scoring method in 1952. Having assisted at thousands of deliveries, Dr. Apgar wished to focus attention on the baby. Babies were traditionally dispatched directly to the nursery, often without much formal scrutiny after delivery. Apgar wanted the baby to be assessed in an organized meaningful manner by the delivery-room personnel. Dr. Apgar was the first woman to be appointed a full professor at Columbia University's College of Physicians and Surgeons.

About Newborn Screening

Newborn screening is the practice of testing every newborn for certain harmful or potentially fatal disorders that aren't otherwise apparent at birth.

Many of these are metabolic disorders (often called "inborn errors of metabolism") that interfere with the body's use of nutrients to maintain healthy tissues and produce energy. Other disorders that screening can detect include problems with hormones or the blood. In general, metabolic and other inherited disorders can hinder an infant's normal physical and mental development in a variety of ways. And parents can pass along the gene for a certain disorder without even knowing that they're carriers. With a simple blood test, doctors often can tell whether newborns have certain conditions that could eventually cause problems. Even though these conditions are considered rare and most babies are given a clean bill of health, early diagnosis and proper treatment can make the difference between lifelong impairment and healthy development.

How States and Hospitals Decide Which Tests to Offer

Traditionally, state decisions about what to screen for have been based on weighing the costs against the benefits. "Cost" considerations include: the risk of false positive results (and the worry they cause) the availability of treatments known to help the condition financial costs

And states often face conflicting priorities when determining their budgets. For instance, a state may face a choice between expanding newborn screening and ensuring that all expectant mothers get sufficient prenatal care. Of course, this is little comfort to parents whose children have a disorder that could have been found through a screening test but wasn't. These questions have not yet all been decided, even though most states have acknowledged the recommendations and have expanded screening. So what can you do? Your best strategy is to stay informed. Discuss this issue with both your obstetrician or health care provider and your future baby's doctor before you give birth. Know what tests are routinely done in your state and in the hospital where you'll deliver (some hospitals go beyond what's required by state law). If your state isn't offering screening for the expanded panel of disorders, you may want to ask your doctors about supplemental screening, though you'll probably have to pay for additional tests yourself.

If you're concerned about whether your infant was screened for certain conditions, ask your child's doctor for information about which tests were done and whether further tests are recommended.

Screening Tests
Newborn screening varies by state and is subject to change, especially given advancements in technology. However, the disorders listed here are the ones typically included in newborn screening programs. PKU When this disorder is detected early, feeding an infant a special formula low in phenylalanine can prevent mental retardation. A low-phenylalanine diet will need to be followed throughout childhood and adolescence and perhaps into adult life. This diet cuts out all high-protein foods, so people with PKU often need to take a special artificial formula as a nutritional substitute. Incidence: 1 in 10,000 to 25,000. Congenital Hypothyroidism This is the disorder most commonly identified by routine screening. Affected babies don't have enough thyroid hormone and so develop retarded growth and brain development. (The thyroid, a gland at the front of the neck, releases chemical substances that control metabolism and growth.) If the disorder is detected early, a baby can be treated with oral doses of thyroid hormone to permit normal development. Incidence: 1 in 4,000. Galactosemia Babies with galactosemia lack the enzyme that converts galactose (one of two sugars found in lactose) into glucose, a sugar the body is able to use. As a result, milk (including breast milk) and other dairy products must be eliminated from the diet. Otherwise, galactose can build up in the system and damage the body's cells and organs, leading to blindness, severe mental retardation, growth deficiency, and even death. Incidence: 1 in 60,000 to 80,000. Several less severe forms of galactosemia that may be detected by newborn screening may not require any intervention.

Sickle Cell Disease Sickle cell disease is an inherited blood disease in which red blood cells mutate into abnormal "sickle" shapes and can cause episodes of pain, damage to vital organs such as the lungs and kidneys, and even death. Young children with sickle cell disease are especially prone to certain dangerous bacterial infections, such as pneumonia (inflammation of the lungs) and meningitis(inflammation of the brain and spinal cord). Studies suggest that newborn screening can alert doctors to begin antibiotic treatment before infections occur and to monitor symptoms of possible worsening more closely. The screening test can also detect other disorders affecting hemoglobin (the oxygen-carrying substance in the blood). Incidence: about 1 in every 500 African-American births and 1 in every 1,000 to 1,400 Hispanic-American births; also occurs with some frequency among people of Mediterranean, Middle Eastern, and South Asian descent. Biotinidase Deficiency Babies with this condition don't have enough biotinidase, an enzyme that recycles biotin (a B vitamin) in the body. The deficiency may cause seizures, poor muscle control, immune system impairment, hearing loss, mental retardation, coma, and even death. If the deficiency is detected in time, however, problems can be prevented by giving the baby extra biotin. Incidence: 1 in 72,000 to 126,000. Congenital Adrenal Hyperplasia This is actually a group of disorders involving a deficiency of certain hormones produced by the adrenal gland. It can affect the development of the genitals and may cause death due to loss of salt from the kidneys. Lifelong treatment through supplementation of the missing hormones manages the condition. Incidence: 1 in 12,000. Maple Syrup Urine Disease (MSUD) Babies with MSUD are missing an enzyme needed to process three amino acids that are essential for the body's normal growth. When not processed properly, these can build up in the body, causing urine to smell like maple syrup or sweet, burnt sugar. These babies usually have little appetite and are extremely irritable. If not detected and treated early, MSUD can cause mental retardation, physical disability, and even death. A carefully controlled diet that cuts out certain high-protein foods

containing those amino acids can prevent this. Like people with PKU, those with MSUD are often given a formula that supplies the necessary nutrients missed in the special diet they must follow. Incidence: 1 in 250,000. Tyrosinemia Babies with this amino acid metabolism disorder have trouble processing the amino acid tyrosine. If it accumulates in the body, it can cause mild retardation, language skill difficulties, liver problems, and even death from liver failure. Treatment requires a special diet and sometimes a liver transplant. Early diagnosis and treatment seem to offset longterm problems, although more information is needed. Incidence: not yet determined. Some babies have a mild self-limited form of tyrosinemia. Cystic Fibrosis Cystic fibrosis (CF) is a genetic disorder that particularly affects the lungs and digestive system and makes kids who have it more vulnerable to repeated lung infections. There is no known cure treatment involves trying to prevent serious lung infections (sometimes with antibiotics) and providing adequate nutrition. Early detection may help doctors reduce the problems associated with CF, but the real impact of newborn screening has yet to be determined. Incidence: 1 in 2,000 Caucasian babies; less common in African-Americans, Hispanics, and Asians. MCAD deficiency (medium chain acyl CoA dehydrogenase deficiency) Children with this fatty acid metabolism disorder are prone to repeated episodes of low blood sugar (hypoglycemia), which can cause seizures and interfere with normal growth and development. Treatment makes sure kids don't fast (skip meals) and supplies extra nutrition (usually by intravenous nutrients) when they're ill. Early detection and treatment can help affected children live normal lives. Toxoplasmosis Toxoplasmosis is a parasitic infection that can be transmitted through the mother's placenta to an unborn child. The disease-causing organism, which is found in uncooked or undercooked meat, can invade the brain, eye, and muscle, possibly resulting in blindness and mental retardation. The benefit of early detection and treatment is uncertain. Incidence: 1 in 1,000. But only one or two states screen for toxoplasmosis. These aren't the only disorders that can be detected through newborn screening. Other conditions that are candidates for newborn screening include:

Duchenne muscular dystrophy, a childhood form of muscular dystrophy that can be HIV neuroblastoma , a type of cancer that can be detected with aurine test

detected through a blood test

Hearing Screening
Most but not all states require newborns' hearing to be screened before they're discharged from the hospital. If your baby isn't examined then, be sure that he or she does get screened within the first 3 weeks of life. Kids develop critical speaking and language skills in their first few years. A hearing loss that's caught early can be treated to help prevent interference with that development.

Should I Request Additional Tests?

If you answer "yes" to any of these questions, talk to your doctor and perhaps a genetic counselor about additional tests: Do you have a family history of an inherited disorder? Have you previously given birth to a child who's affected by a disorder? Did an infant in your family die because of a suspected metabolic disorder? Do you have another reason to believe that your child may be at risk for a certain

condition?

How Newborn Screening Is Performed

In the first 2 or 3 days of life, your baby's heel will be pricked to obtain a small blood sample for testing. Most states have a state or regional laboratory perform the analyses, although some use a private lab. It's generally recommended that the sample be taken after the first 24 hours of life. Some tests, such as the one for PKU, may not be as sensitive if they're done too soon after birth. However, because mothers and newborns are often discharged within a day, some babies may be tested within the first 24 hours. If this happens, the AAP recommends that a repeat sample be taken no more than 1 to 2 weeks later. It's especially important that the PKU

screening test be run again for accurate results. Some states routinely do two tests on all infants.

Getting the Results

Different labs have different procedures for notifying families and pediatricians of the results. Some may send the results to the hospital where your child was born and not directly to your child's doctor, which may mean a delay in getting the results to you. And although some states have a system that allows doctors to access the results via phone or computer, others may not. Ask your doctor how you'll get the results and when you should expect them. If a test result comes back abnormal, try not to panic. This doesnot necessarily mean that your child has the disorder in question. A screening test is not the same as diagnostic test. The initial screening provides only preliminary information that must be followed up with more specific diagnostic testing. If testing confirms that your child does have a disorder, your child's doctor may refer you to a specialist for further evaluation and treatment. Keep in mind that dietary restrictions and supplements, along with proper medical supervision, can often prevent most of the serious physical and mental problems that were associated with metabolic disorders in the past. You also may wonder whether the disorder can be passed on to any future children. You'll want to discuss this with your doctor and perhaps a genetic counselor. Also, if you have other children who weren't screened for the disorder, consider having testing done. Again, speak with your doctor.

Know Your Options

Because state programs are subject to change, you'll want to find up-to-date information about your state's (and individual hospital's) program. Talk to your doctor or contact your state's department of health for more information.

In Search of Cuts, Health Officials Question NICU Overuse

An unlikely battlefield in Texas budget war is a hushed pink-and-blue hospital nursery, where 1- and 2-pound babies bleat like lambs under heating lamps and neonatal nurses use tiny rulers to measure limbs that are no bigger than fingers.
Enlarge This Image

Caleb Bryant Miller/The Texas Tribune

Adrienne Ball, of Austin, with her baby Mila, who was born three months early in Seton Medical Center Austin's neonatal intensive care unit.

Caleb Bryant Miller/The Texas Tribune

Natasha Rosen with Matthew, who was born three months premature, in Seton Medical Center Austin's neonatal I.C.U.

State health officials, searching for solutions to Texas multibillion-dollar budget shortfall, have set their sights on these neonatal intensive care units, or NICUs, which they fear are being overbuilt and overused by hospitalseager to profit from the high-cost care and by doctors who are too quick to offer pregnant mothers elective inductions and Caesarean sections before their babies are full term. The Texas Health and Human Services Commission, under the gun to find savings in the states huge Medicaidprogram, suggested last month that it could save $36.5

million over the next biennium by better managing which babies end up in NICUs, curbing so-called convenience C-sections and refusing to finance elective inductions before the 39th week of pregnancy. When we look at the data, it indicates that, yes, there is overutilization of NICUs. More babies are being put in NICUs than need to be in NICUs, said Thomas M. Suehs, the commissioner of health and human services, adding that two of his own grandchildren were put in Texas hospital NICUs in the last two years, even though they were healthy and the deliveries were uncomplicated. Lawmakers are not ready to assert that Texas has an NICU overutilization problem, though their comments suggest it. We are seeing some trends that are a bit troubling, said State Representative Lois Kolkhorst, Republican of Brenham, who has filed legislation to create a commission to study NICU use. SenatorJane Nelson, Republican of Flower Mound, added, We dont want to reduce services, but we need to combat inefficient, unnecessary use. Nor will most hospitals admit to a NICU problem. Combine Texas high birth rate, lowhealth insurance coverage and limited prenatal care with the growth of in vitro fertilization, multiple-baby births and so-called geriatric past the age of 35 pregnancies, hospital administrators say, and you have a full NICU. The services exist because they fill a need, said Amanda Engler, spokeswoman for the Texas Hospital Association. That need was felt acutely by Natasha and Mark Rosen in January when their son, Matthew, was born at 1 pound 14 ounces at the Seton Medical Center in Austin, after Mrs. Rosen had complications with her placenta and began contracting three months before her delivery date. In their case, there was no judgment call: Matthew needed a NICU. He only had a 35 percent chance of survival, Mrs. Rosen said, as she held Matthew against her chest still tethered to plastic tubes and no bigger than a kitten during his daily break from the incubator. We were so lucky to be here. The data suggest that NICU beds may not be proliferating because of natural demand alone. Births in Texas are up nearly 18 percent since 1998, according to

state health statistics. Meanwhile, the number of NICU beds in Texas hospitals has surged roughly 84 percent, to 2,510 in 2009 from 1,365 in 1998. Some state health officials suggest there is a profit motive at play for hospitals. The average routine delivery costs Medicaid $2,500, according to state records; the average NICU stay costs $45,000. Elective procedures like induction of labor before 39 weeks of gestation or Caesarean-section delivery at the mothers request contribute to complications that send babies to the NICU, these health officials say. In 1998, C-sections accounted for 23.8 percent of Medicaid births, state data show; more than a decade later, they made up 35 percent. In 2009, 137 Medicaid-covered newborns suffered complications resulting from elective inductions, according to state health officials, at a cost of $1.6 million to the Texas Medicaid program, the joint state-federal health program that covers more than half of Texas births. Dr. Charles T. Hankins, a longtime neonatologist at Texas Childrens Hospital in Houston and an associate professor of pediatrics at the Baylor College of Medicine, suggested there is a far more nuanced motive than pure profit. Hospitals hit hard by low reimbursement rates and high malpractice costs for routine obstetric care are simply looking for ways to make up the difference. A lot of facilities realize that if they had a Level 3 nursery, they could help offset their costs, he said. Dr. Hankins thinks the NICU boom is often driven less by hospitals than by obstetricians who do their residency training in facilities with NICUs and cannot imagine not having one available. The doctors want their patients to be happy, and the hospital administrators want to keep the doctors happy, he said. The problem is that diagnosing the need for neonatal care can be subjective, Dr. Hankins said. If a hospital wants to increase its NICU census, providers can admit more infants or lengthen their stays and parents generally trust those assessments. He said there is also no state oversight of either admission or discharge best practices. Hospitals are willing to work together to accomplish the optimal care for these babies, Dr. Hankins said, but added that they need proper guidance to do so.

Some state lawmakers are under the impression that Texas Medicaid program is already offering such guidance. The growth in NICU beds much of it along the Texas-Mexico border, which has the youngest population in the state, and in suburban hospitals outside Houston, Dallas and San Antonio comes despite years of improvements in prenatal care for mothers on Medicaid. One of the tenets of Medicaid has long been better prenatal care, and less babies needing NICUs, said Senator Robert Deuell, Republican of Greenville, a family practice doctor who, in a recent Senate hearing, suggested that the cost savings health officials are looking for might not be ample in the delivery room. But Dr. Frank Mazza, vice president and chief patient safety officer for the Seton Family of Hospitals, said state health officials are on the right path in considering birth inefficiencies. When Seton made the almost unheard-of move in 2005 of prohibiting elective inductions before 39 weeks part of a systemwide effort to improve perinatal safety the number of babies admitted to the NICU fell dramatically. The hospitals revenue from them also dropped by 96 percent, to $186,000 per year from roughly $4.5 million per year. We should have in Texas the safest health care and the most cost-effective health care, Dr. Mazza said. By keeping babies out of the NICU, you accomplish both. Still, even Dr. Mazza acknowledged that if his own wife were having a baby today, he would choose a hospital with all the bells and whistles. Of course Id want her in a hospital with a NICU, he said, with the latest and greatest technology.

Congenital Abnormalities

Spina Bifida In this condition, there is a raw swelling over a portion of the spine at birth. This results in paralysis of the legs (either partial or complete), inability to control bladder functioning and inability to feel anything below the spina bifida. In some cases, there is a build up and retention of water in the brain, which is known as hydrocephalus. This swelling can be closed by an operation by specialists.

Umbilical hernias In this condition, parts of the digestive system are lying outside the stomach cavity. This is because the area around the navel is not very strong. Normally, cases of umbilical hernias around the navel heal on their own; if they dont, surgery is required.

Sickle cell disease

This is a hereditary condition that is most commonly found among people of West African or African Caribbean descent. The hemoglobin in the red blood corpuscles disintegrates at a quicker rate than normal. Hemoglobin is important, as it carries oxygen to the different parts of the body. Reduction in hemoglobin causes anemia and blocks blood vessels in the hands, legs and stomach. An attack can last for a few days and can be treated with painkillers. This is also known as Sickle Cell disease.

Cystic Fibrosis This is another hereditary illness, in which the tissues in the body produce unusually thick mucus. The commonly affected organs are the lungs, the intestines and pancreas. If the lungs are affected, the air ducts are blocked and hence, vulnerable to infection. Children with this condition have an inability to digest food completely and have bad smelling bowel movements and constipation. They are well below the normal weight for their age. This illness has no cure, but if detected in the initial stages, lung damage can be reduced. These children are susceptible to chest infections and have to be treated with antibiotics. Chest physiotherapy is required regularly to remove thick phlegm.

Coeliac disease In this condition, the child's intestine reacts strongly to gluten, a protein found in wheat. These children have a severe case of diarrhea, where the stools are fatty, pale and don't flush away. The child does not put on weight as required. The illness can be detected by a blood test. After being detected, the child will have to completely give up gluten containing food. Once this is done, stools return to normal and the child will put on weight.

Clubfoot In this condition, the foot curves inwards or outwards. All babies are checked for this at birth, more so, if they were born in the breech position, as it occurs more frequently with these babies. Often, they can be manipulated into the proper position, with little or no treatment. Surgery may be required in severe cases. This condition is also known as Talipes.

Cleft palate In this condition, the cleft lip and the cleft palate are fused, thus the baby cannot be breast-fed. Various support groups will help you deal with the situation and corrective plastic surgery is possible. Congenital dislocation of the hip All babies are screened for this condition at birth and when they are eight weeks old. If this condition goes undetected, walking can become a problem later in life. If diagnosed with this problem, the baby will have to wear a special splint for sometime. Most recover without having to be operated on, but some do need an operation. This condition is prevalent more among girls and breech babies. Cerebral palsy In this condition, the parts of the brain that control body movements are damaged. This can happen before birth, during birth, or in the first two years after birth. In some cases, damage may not be noticed at birth, but as the child grows, it becomes evident. It is difficult to pinpoint as to what causes this damage. There are a few tests that can be conducted when the baby is eight weeks old to screen him for cerebral palsy.