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Predicting death or disability of newborns >34 weeks based on APGAR and/or breathing

Question Type:
Prognostic
Full Question:
In newborn infants >34weeks gestation that receive positive pressure ventilation at birth  (P), does Apgar scores at 1, 5 and/or 10 minutes =3,or spontaneous breathing by 10 minutes  (I), compared with Apgar scores at 1, 5 and/or 10 minutes <3 , or no spontaneous breathing by 10 minutes  (C), change  (O)?
Consensus on Science:
Apgar Score at 20 Minutes For all the outcomes, we could not find studies that reported on individual Apgar scores (1, 2, or 3) beyond 10 minutes. One very-low-quality study (downgraded for indirectness) reported on Apgar scores at 20 minutes but included patients with an Apgar score of 0. (Nelson 1981, 36) This study reported that in babies weighing greater than 2500 g with an Apgar score of 0 to 3 at 20 minutes, the mortality was 59% and 57% of survivors developed cerebral palsy. Apgar Score at 10 Minutes For the critical outcome of death, we identified low-quality evidence (downgraded for imprecision) from 2 randomized studies involving babies who participated in induced-hypothermia studies.(Laptook 2009, 1619; Natarajan 2013, F473) One study(Laptook 2009, 1619) reported mortality of 64%, 47%, and 39% for Apgar score of 1, 2, and 3, respectively, with an OR of 1.42 (95% CI, 1.19–1.69) at 18 to 22 months. The other study (Natarajan 2013, F473) reported outcomes from the same study, but at 6 to 7 years. Babies with Apgar scores of 1, 2, and 3 had mortality rates of 67%, 43%, and 27%, respectively, if they were managed with induced hypothermia and 63%, 57%, and 62% if they were not cooled. For the critical outcome of moderate/severe disability, we identified low-quality evidence (downgraded for imprecision) from 2 randomized studies involving babies who participated in induced hypothermia studies,(Laptook 2009, 1619),(Natarajan 2013, F473) one (Laptook 2009, 1619) reporting the outcome in 50%, 63%, and 38% for Apgar scores of 1, 2, and 3, respectively, with an OR of 1.30 (95% CI, 1.06–1.58) at 18 to 22 months. The other study (Natarajan 2013, F473) reported at 6 to 7 years of life that 100%, 75%, and 9% of babies with Apgar score of 1, 2, and 3, respectively, had moderate/severe disability if managed with induced hypothermia and 67%, 67%, and 71% if not managed with hypothermia. No Spontaneous Respiration For the critical outcome of death, we identified very-low-quality evidence (downgraded for imprecision) from 2 observational studies(Scott 1976, 712; Koppe 1984, 193) that time to spontaneous respiration for more than 30 minutes was associated with 52% to 77% mortality. For the critical outcome of cerebral palsy or abnormal neurologic findings, we identified very-low-quality evidence (downgraded for imprecision) (Steiner 1975, 696; Scott 1976, 712; Koppe 1984, 193) that time to respiration of more than 30 minutes was associated with 35% of cerebral palsy and 67% to 100% abnormal neurologic findings. For the critical outcome of death and/or moderate-to-severe disability, we identified very-low-quality evidence (downgraded for imprecision) from 2 observational studies(Ekert 1997, 613; Shah 2006, 729) that time to spontaneous respiration of 10 to 19 minutes and more than 20 minutes was associated with this outcome in 56% and 88% of patients, respectively,(Ekert 1997, 613) and time to spontaneous breathing at 30 minutes or more was a predictor of this outcome (OR, 2.33; 95% CI, 1.27–4.27).
Treatment Recommendation:
Absence of spontaneous breathing or an Apgar score of 1 to 3 at 20 minutes of age in babies of greater than 34 weeks of gestation but with a detectable heart rate are strong predictors of mortality or significant morbidity. In settings where resources are limited, we suggest that it may be reasonable to stop assisted ventilation in babies with no spontaneous breathing despite presence of heart rate or Apgar score of 1 to 3 at 20 minutes or more (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this statement, in infants of greater than 34 weeks with an Apgar score of 0, 1, 2, or 3 for 20 minutes or more, the likelihood of dying or having severe or moderate developmental disabilities at 18 to 24 months is very high. Importantly, all of the studies were conducted in a resource setting where therapeutic hypothermia was likely to be available'(see NRP 734). Perhaps there is a publication bias when those babies who did not respond at 20 minutes are not included in the numbers. The question was raised, if the prognosis is the same, why would we recommend something different for resource-limited settings? A response was that in resource-limited regions, there will likely not be the regional systems and postresuscitation neonatal intensive care facilities and subspecialty personnel that were available in the recent studies reviewed in the Consensus on Science. If such facilities are available, this treatment recommendation may be less applicable.

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