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Evaluation of interobserver agreement of apgar scoring in preterm infants
Monuj T Bashambu1, Halana Whitehead, Anna Maria Hibbs
1Department of Pediatrics, Division of Neonatology, Rainbow Babies and Children's Hospital, 11100 Euclid Ave, RBC Suite 3100, Cleveland, OH 44106, USA. monuj.bashambu@case.edu
Insights
Apgar scoring shows high agreement for full-term infants but significant variability for preterm infants. This highlights the need for a more reliable delivery room assessment tool for premature babies.
Area of Science:
- Neonatal medicine
- Pediatric assessment
Background:
- Apgar scoring is a standard measure for infant clinical status and response to resuscitation.
- Recent studies indicate variability in Apgar scoring for preterm infants.
- Hypothesized improved agreement with increased gestational age and reduced respiratory support.
Purpose of the Study:
- To investigate agreement in Apgar scoring across different gestational ages and respiratory support levels.
- To identify components of Apgar scoring with the least agreement, specifically grimace and muscle tone.
Main Methods:
- Survey of 335 neonatologists using film clips of infants at various gestational ages (24, 28 weeks, and full-term).
- Participants provided Apgar scores at 1, 5, and 10 minutes after birth.
- Agreement was assessed using kappa (κ) coefficients for each Apgar component.
Main Results:
- Near-perfect agreement for Apgar components in full-term infants (κ > 0.89).
- Significant disagreement for respiratory effort, muscle tone, and grimace in preterm infants (κ range: 0.07-0.75).
- Agreement only improved in preterm infants if they were apneic and limp.
Conclusions:
- Current Apgar scoring demonstrates substantial variability among professionals when assessing preterm infants.
- A more precise and consistent delivery room assessment tool is necessary for accurate evaluation of preterm infants' clinical status.
Background And Objectives:
Apgar scoring is accepted by medical professionals both as a measure of the infant's clinical status and the infant's response to resuscitation. Recent studies, however, have suggested significant variability when used for scoring preterm infants. We hypothesized that agreement in Apgar scoring would improve with increasing gestational age and at low levels of respiratory support. We also hypothesized that grimace and muscle tone would demonstrate the least agreement.
Methods:
Neonatologists from the Perinatal Section of the American Academy of Pediatrics were presented with 4 film clip cases via a secure online survey: (1) full-term infant in room air; (2) 28 weeks' gestation infant with continuous positive airway pressure; (3) 28 weeks' gestation infant intubated; and (4) 24 weeks' gestation infant intubated. Participants were shown 30-second clips at 1, 5, and 10 minutes of life and were asked to provide Apgar scores. κ coefficients were used to compare agreement for each component.
Results:
A total of 335 neonatologists participated in the survey. κ coefficients in the full-term infant for respiratory effort (0.94, 0.91), grimace (0.91, 0.90), and muscle tone (0.91, 0.89) demonstrated almost perfect agreement at 1 and 5 minutes. For preterm infants, respiratory effort (range: 0.07-0.40), muscle tone (range: 0.10-0.75), and grimace (range: 0.11-0.71) all demonstrated disagreement at 1, 5, and 10 minutes of life unless the infants were apneic and limp.
Conclusions:
An improved delivery room score that decreases variability among medical care professionals is needed to accurately reflect the clinical status of preterm infants.
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