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Apgar score of 0 or 1 for ≥ 10 minutes

Question Type:
Prognostic
Full Question:
In infants ≥36 weeks GA with an Apgar score of 0 or 1 for ≥ 10 minutes
 (P), does in spite of ongoing resuscitation
 (I), compared with  (C), change death, death or neurocognitive impairment at 18-22 months, survival to NICU admission (O)?
Consensus on Science:
For the critical outcome of death up to 22 months, very-low-quality evidence (downgraded for risk of bias, inconsistency, and imprecision) from 6 studies encompassing 8 case series showed that 75 of 129 infants (58%) with an estimated gestational age of 36 weeks or greater and an Apgar score of 0 at 10 minutes of life died before 22 months of age. (Casalaz 1998, F112; Patel 2004, 136; Harrington 2007, 463; Laptook 2009, 1619; Sarkar 2010, F423; Kasdorf 2015, F102) Results from 3 of these studies performed after 2009 that included nested observational series of cases from 3 randomized clinical trials of therapeutic hypothermia and a series of infants who received therapeutic hypothermia outside a randomized trial (low-quality evidence, downgraded for risk of bias) found that 46 of 90 infants (51%) with an Apgar score of 0 at 10 minutes died before 22 months of age. (Laptook 2009, 1619; Sarkar 2010, F423; Kasdorf 2015, F102)For the critical outcome of death or moderate/severe neurodevelopmental impairment at 22 months of age or older, 6 studies (very-low-quality evidence, downgraded for risk of bias, inconsistency, indirectness, and imprecision) showed this outcome in 106 of 129 infants (85%) with a gestational age of 36 weeks or greater and an Apgar score of 0 at 10 minutes of life. (Casalaz 1998, F112; Patel 2004, 136; Harrington 2007, 463; Laptook 2009, 1619; Sarkar 2010, F423; Kasdorf 2015, F102) Results from 3 of these studies performed after 2009 (very-low-quality evidence, downgraded for risk of bias, inconsistency, indirectness, and imprecision) that included nested observational series in randomized clinical trials of therapeutic hypothermia and series of infants who received therapeutic hypothermia showed that this adverse outcome occurred in 68 of 90 infants (76%) with an Apgar score of 0 at 10 minutes. Among the 44 survivors of these studies, 22 (50%) survived without major/moderate disabilities. Among the 56 cooled infants in these studies, 15 (27%) survived without major/moderate disabilities (Laptook 2009, 1619; Sarkar 2010, F423; Kasdorf 2015, F102) (very-low-quality evidence, downgraded for risk of bias). No studies differentiated between severe and moderate disability.None of the studies described the resuscitation procedures that were provided.
Treatment Recommendation:
An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late-preterm and term infants. We suggest that, in babies with an Apgar score of 0 after 10 minutes of resuscitation, if the heart rate remains undetectable, it may be reasonable to stop resuscitation; however, the decision to continue or discontinue resuscitative efforts should be individualized. Variables to be considered may include whether the resuscitation was considered to be optimal, availability of advanced neonatal care, such as therapeutic hypothermia, specific circumstances before delivery (eg, known timing of the insult), and wishes expressed by the family (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsIn making this statement in infants of 35 weeks or greater with an Apgar score of 0 for 10 minutes or longer, the likelihood of dying or having severe or moderate developmental disabilities at 18 to 24 months is very high. Studies that included 69 infants with an Apgar score of 0 at 10 minutes after birth who were successfully resuscitated and randomly assigned to hypothermia or normothermia, and case series of 21 additional infants who were managed with therapeutic hypothermia, suggest improvement in outcome compared with previously reported cohorts. Among these 90 infants, 45 (50%) died and 22 (24%) survived without major or moderate disability at 18 to 24 months. However, the number of infants with no heart rate at 10 minutes who died in the delivery room is unknown. This topic resulted in a long and spirited debate. A question was raised as to how can we say that we should consider stopping with a 24% survival possibility without major handicap? Is 10 minutes sufficient time to make this decision? It was suggested not to use the word adequate, because the resuscitation was not assessed. What would the adults do with 20% chance of survival? However, it was pointed out that it is not a 20% chance, because not all babies got to cooling. Someone advocated using the term discontinue instead of withdraw. The term adequate caused a lot of debate. What do we mean by it? Can it be clearer? Concern was expressed that providers will likely not use science to guide the decisions for this situation and will likely use own judgment. Parents tend to choose continuation even when the data are presented to them. The decision to continue or discontinue should be based on consultation with the family. The optimal way to restore circulation can be in the qualifier. An Apgar score of 0 at 10 minutes is a strong predictor of disability at all gestations.
CoSTR Attachments:
ApgarZeroWS-CoSTR-Final-13jan15_n.docx    
Assessment of Bias_n.xlsx    
Ruth-Apgar0at10minutes-GRADE GRID-30Nov14_n.docx    

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