Written by Kimiko Dunbar
Spoon Feed
Infants with an Apgar score of less than 5 at one minute of life are more likely to need advanced resuscitation. Of the 5 components of the Apgar score, heart rate, reflexes (i.e. grimace/reflex irritability) and chest movement are most relevant.
When should you call the NICU?
The Apgar was first introduced by Virginia Apgar in the 1950s and is now used internationally as a gauge of the newborn condition. The Apgar score was updated to the “Specified Apgar” in order to take into account resuscitation efforts. Still, the Apgar score has been insufficiently validated as a predictor of infant needs. Can the need for advanced resuscitation (intubation or compressions) be predicted by the 1-minute Apgar, so experienced providers can be called immediately?
This secondary analysis of two prospective trials assessed whether specified Apgar score components predict neonatal resuscitation and which component is most relevant. Among 2,093 high-risk newborns, heart rate, reflexes, and chest movement at 1 minute most strongly predicted resuscitative needs at 5 minutes (R² = 0.31). These items also predicted rare interventions like intubation and epinephrine (AUC 0.78–0.89). Limitations include exclusion of moderate preterm infants and use of specified, nonstandard Apgar scoring.
How does this change my practice?
As someone who resuscitates newborns, I’m not typically assigning Apgars during initial resuscitation. This study found that infants with a score less than 5 at 1 minute are more likely to require advanced resuscitation. Among the 5 components, skin color and tone are of less relevance. Authors suggest that HR, chest rise, and reflexes at 1 minute can be sufficient to assess need for advanced resuscitation. I’d argue we’re already doing this (in a way), by following NRP and assessing an infant’s HR and respiratory effort to determine the need for PPV. That said, I’ll be more cognizant of an infant’s condition at 1 minute of life, with strong consideration of calling for advanced support (i.e. NICU) if the infant continues to show signs of depression.
Source
Assessing the postnatal condition: the predictive value of single items of the Apgar score. BMC Pediatr. 2025 Mar 19;25(1):214. doi: 10.1186/s12887-025-05565-0. PMID: 40102790
