Chapter 11: The Infant
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Infant Scoring Systems

As soon as the delivery is complete, there are numerous assessments to be made in order to determine the infant's health status. These include checking the respiratory and cardiac status, and weight. The Apgar scoring system (see Figure 1), named after Dr. Virginia Apgar, was developed as an objective way to evaluate the general status of the newborn at one minute and five minutes after birth. APGAR is also an acronym for what the practitioner will assess: The practitioner evaluates newborn Appearance, Pulse, Grimace, Activity, Respiratory rate and effort.

The five areas examined are respiratory effort, heart rate, muscle tone, reflex irritability, and color (see Figure 1). Each area is given a score of 0, 1, or 2 depending on the response noted. A score of "0" indicates maximum distress/dysfunction for that parameter. A score of "2" means the opposite. The first score is assessed at 1 minute after delivery, with a second evaluation performed at 5 minutes. Since the Apgar is an objective assessment of the infant's status, a 5-minute score that is higher than the 1-minute score indicates the effectiveness of the resuscitation.

After assigning numerical scores for the categories, scores are totaled, with normal infants scoring 7 to 10, moderately depressed infants scoring 4 to 6, and severely depressed infants scoring less than 4. Realistically, in the clinical setting the latter infants are not scored immediately because they are obviously in severe distress, and resuscitation measures are instituted before there is time to total scores.

The Apgar evaluations can be done every 5 minutes as needed, up to 20 minutes or when the resuscitation ends. The 5-minute Apgar score is predictive of future impairment, with a low score being associated with a likelihood of long-term damage. For example, an Apgar score of two or less at one minute is associated with a high mortality rate. An Apgar score of 8-10 is considered normal.

Figure 1. The Apgar scoring system.
Scoring Component How Component is Tested Score 0 Score 1 Score 2
  • Heart rate
Ausculation or count pulses at junction of umbilical cord & abdomen Absent Slow below 100 Over 100
  • Respiratory Effort
Observation Apnea Slow, Irregular Good, yelling
  • Muscle tone
Observation: resistance to straightening of extremities Limp Somewhat flexible Well flexed
  • Reflex Effort
Flick soles of feet/insert catheter in nostril No Response Grimace withdraws Vigorous cry
  • Color
Observation Blue or pale hands & feet blue Body pink; Completely pink

As you can see, the Apgar is an excellent method for assessing the effectiveness of resuscitation, however it should not be used as the sole basis for making resuscitative decisions. One limitation of the Apgar system is that it was designed to assess normal full term infants, not preemies, so it is less valuable in their assessment. For evaluating premature neonates, umbilical cord pH or the Silverman-Anderson scoring system may be more valuable than Apgar.

In order to assess the degree of respiratory distress in neonates, practitioners often use the Silverman-Anderson scoring system. Like the Apgar system it evaluates five parameters and assigns a numerical score for each parameter. However, unlike the Apgar score, the lower the total score the better the baby in the Silverman-Anderson system. The best score possible in each category is a "0" the worst is a "2". Parameters assessed are: retractions of the upper chest, lower chest, and xiphoid, nasal flaring, and expiratory grunt.

Table 3. Silverman-Anderson Scoring System

Score 0 1 2
  • Upper Chest Retractions
synchronized lag on inspiration see-saw movement
  • Lower Chest Retractions
none just visible marked
  • Xiphoid Retractions
none just visible marked
  • Nasal Flaring
none minimal marked
  • Expiratory Grunting
none stethoscope only naked eye and ear

As you can see from Table 3, neonates with no retractions, flaring or grunting with synchronized respiratory movements are scored with "0s". Infants with visible retractions of the lower chest and xiphoid, with the upper chest lagging compared to the lower on inspiration, receives a "1". Minimal nasal flaring and an expiratory grunt heard only with a stethoscope also receive a "1". Marked retractions with a "see-saw" movement of the upper and lower chests deserves a "2". Marked nasal flaring and audible expiratory grunting also deserve a "2". Normal babies have a cumulative score close to "0". Severely depressed babies score close to "10".

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