Category — 2.2 Children with Biological Risk Conditions: Low Apgar Scores

The Apgar test, the first test ever given to babies, is usually given to newborns one and five minutes after birth (Fig. 1). It aims to measure how well a newborn is doing in the following areas:

Figure 1. A few minutes after birth

• Skin color/complexion (a maximum of 2 points);
• Pulse rate (a maximum of 2 points);
• Reflex (a maximum of 2 points);
• Muscle tone (a maximum of 2 points);
• Breathing (a maximum of 2 points).

The highest score a child can get is 10/10. A score of 3 or below is considered critically low. Babies with low scores may be taken to the neonatal intensive care unit for more testing. A score of 7 or more is considered good. In rare cases, when the baby continues to struggle in the above-mentioned areas, the Apgar test may be done again at 10 minutes after birth.

It is important to note that a low Apgar may or may not be followed by delayed development. However, a range of other assessments are now used in the newborn and early infancy period. Some reference should be made to these tests because some of them are more comprehensive and have greater predictive powers for children with significant delay, for example, the Brazelton Neonatal Assessment Scale.  Low scores on some of these tests mean that some children should be followed very closely and carefully assessed as they grow older.

Many children who are born premature or small for gestational age, or who were born with low birth weight, have low Apgar scores.

To learn more about the Apgar score, please visit the zero to six section of this course.

Some children with low Apgar scores develop just fine. Others are slow to reach most developmental milestones. Of those who were slow to reach these milestones, some eventually catch up with their typically developing peers, while others do not. Those who do not may end up with the following characteristics:

• Delays in cognitive development: some of these children continue to perform less well than their peers in all areas related to cognitive development. They may be slower to respond to others, may process information slowly and seem to struggle with abstract and/or complex terms and directions;
• Delays in the development of academic skills: some of these children will need help in all academic areas, including reading, writing and math;
• Delays in the development of language and communication skills: some of these children may be late to meet language and communication milestones. They may struggle with their language skills, even after they reach school age. Some may have a vocabulary that is smaller than that of their typically developing peers, and others may struggle with grammar;
• Delays in the achievement of motor milestones: many of these children are late to sit up, walk and run. When they reach school age, they may appear a bit awkward, and may struggle with activities that involve the use of their large muscles (for example, using the slides and swings on the playground). Others may experience fine motor difficulties, which would be expressed in difficulties with writing;
• Delays in the development of social/emotional skills: some of these children will struggle in social situations, and may not know how to respond to others. This may be caused by their slightly immature cognitive and language skills.

Some children with low Apgar scores may have trouble with their kidneys, bones and sometimes with their heart. This is because the low Apgar score may be the result of an infection or other medical complication; for example, they breathe in meconium, that is, their own waste. These children will need the help of highly specialized medical professionals.

Because of the difficulties described above, some children with low Apgar scores could benefit from the following services:

• Special education assistance: in school, some of these children may require the help of the school’s special educator. These children are not usually placed on an Individual Education Plan (IEP) unless they are diagnosed with one of the conditions listed above. But that does not mean they do not need help. They may need a lot of help with academic skills, paying attention, and following directions. They can often get this help from the school’s special educator;
• Speech and language pathologist (SLP): some of these children may continue to need the help of an SLP, well into their school years. That is because some them continue to perform less well than their peers, in all aspects of language, especially when it comes to expressive and receptive language skills. An SLP will help these children improve their receptive and expressive language skills, as well as increase the size of their vocabulary;
• Behavioral interventionist (BI): some of these children may need help managing their behavior. Some may engage in extreme behaviors, such as severe temper tantrums, and may need help in order to learn how to manage these extremes in behavior;
• Occupational therapy (OT): some of these children may struggle with sensory integration difficulties. Those who do may need the help of an OT who would help them with these difficulties. OTs can also help children who are born premature improve their fine motor skills;
• Vision specialist: some of these children will have vision problems and their vision may need to be monitored by an ophthalmologist. Those who do not have vision problems may still need regular visits with an ophthalmologist. This is usually just a precaution, but some general practitioners and/or pediatricians will recommend it;
• Hearing specialist (Fig. 2): some of these children will have hearing problems and their hearing may need to be monitored by an audiologist. Those who do not have hearing problems may still need regular visits with an audiologist, even if their hearing is fine. This is usually just a precaution, but some general practitioners and/or pediatricians will recommend  it;
• Orthopedist: some of these children will need the services of an orthopedist or orthopedic surgeon because of problems with their bones;
• Cardiologist: some of these children may have heart problems and may need to be monitored closely by a pediatric cardiologist.

Figure 2. Hearing specialist

Although some children with low Apgar scores continue to experience difficulties well into their middle childhood years, many others do not. Many do catch up with their peers, fully and go on to lead very fulfilling, healthy and happy lives.

see References

http://kidshealth.org/parent/pregnancy_center/q_a/apgar.html

http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm

http://pediatrics.aappublications.org/content/117/4/1444.full