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

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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