European Journal of Cardiovascular Medicine

Neonatal Resuscitation Program (NRP) was launched in 1987 and since then major changes have taken place in newborn resuscitation protocols.¹ The American Academy of Pediatrics endorse using the Apgar score to assess the transition of each newborn infant to extra uterine life. Despite developed over a half-century ago by Virginia Apgar, the Apgar score still remains the method of choice for immediate assessment of the efficacy of newborn resuscitation.² The intended purpose of using Apgar scoring has been to assess the newborn infant at delivery and has been used as a predictor for outcomes.³

However, there is no accepted standard for reporting an Apgar score in infants undergoing resuscitation after birth because many of the elements contributing to the score are altered by resuscitation.⁴ The concept of an assisted score that accounts for resuscitative interventions has been suggested, but there is death of literature over the status of predictive reliability.⁵ There are certain documented shortcomings of using Apgar score including the subjectivity of elements such as tone, color, and reflex irritability, which can lead to significant interobserver variability, also the effect of prematurity of newborn on the Apgar score is not conclusive.^6-10

Therefore, in order to address these concerns regarding the impact of resuscitation on the Apgar score and how resuscitation can be accounted for in the Apgar scoring assessment, the Neonatal Resuscitation and Adaptation Score (NRAS) was developed. In contrast to using Apgar scoring, NRAS can be assessed during the resuscitation and takes into account the infant’s response. It also maintains the familiar 10-point scoring system.¹⁰

The objectives of the current study were to retrospectively use NRAS in parallel to the Apgar score to examine the predictive ability of NRAS score for mortality and selected short term morbidities and also how Apgar score and NRAS correlate.

A year-long retrospective and descriptive study was carried out in the MVJ Medical College and Research Hospital, Hoskote, Karnataka, India. The study setting included rural tertiary care teaching hospital with an average of 2000 births/year, with 12 bedded NICU. The study took place between November 2017 and November 2018. Inclusion criteria constituted all new-born babies with birth asphyxia according to WHO definition.

Heart rate of the study subjects was assessed by auscultation. Respiratory support was initiated with 21% or 30% FiO₂ for term or preterm infant respectively, if needed.

Apgar score and Neonatal Resuscitation and Adaptation Score (NRAS) were recorded in parallel at the time of delivery by neonatal resuscitation team members. NRAS and APGAR score were recorded on paper, most of the time at the time of the delivery or usually within 1 hour.

Short term outcomes included: a) respiratory support at 48 hours in the form of oxygen requirement, invasive or noninvasive ventilation, b) requirement of pressure support and c) seizures.

Statistical Analysis

NRAS and Apgar score were compared by simple and multiple linear regressions. Scores were analyzed by Wilcoxon rank-sum test and proportions by χ2 or fishers exact test. A p value of <0.05 was considered significant.

A total of 2012 deliveries were conducted during the study period in the hospital and there were 110 new-borns who were assessed for NRAS over the study period of November 2017 to November 2018, representing 5.5% of the total new born babies included.

All the 110 of the subjects had complete data, and are included in the results. Subject demographic information is listed in Table 1.

Table 1. Subject Demographics

Of note, 8.2% were <34 weeks of gestational age and 42.7% were between 34 and 37 weeks of gestational age and 49.1% were >37 weeks of gestational age.

There were 16.4% new-borns who weighed <2000 g whereas 15.5% new-borns and 68.2% new-borns who weighed 2000 g to 2500 g and 2500 g to 4000 g, respectively.

All subjects had Apgar scores at both 1 and 5 min. The distribution of the score divided into low (0-3), middle (4-6), high (7-10) and Table 2, Figure 1 and Figure 2 shows the distribution of scores. There was a strong correlation between the two scoring systems.

Table 2. Distribution of scores

Figure 1. Linear regression of Apgar – NRAS scores at 1 min r= 0.6, r² =3.3

Figure 2. Linear regression of Apgar – NRAS scores at 5 min r= 0.8, r² =0.6

Mortality:

Mortality data are reported in Table 3. In the current study, there were 13 deaths in the study population.

Table 3. Mortality data 

Figure 3, 4, 5 and Figure 6 details the positive predictive value (PPV) and negative predictive value (NPV) of APGAR or NRAS for predicting the mortality. For all outcomes at both 1 and 5 min, NRAS had a higher PPV, while NPV was comparable between groups.

Figure 3. PPV and NPV of APGAR or NRAS for low level (0-3) for predicting the mortality at 1 min

Figure 4. PPV and NPV of APGAR or NRAS for low level (0-6) for predicting the mortality at 1 min

Figure 5. PPV and NPV of APGAR or NRAS for low level (0-3) for predicting the mortality at 5 min

Figure 6. PPV and NPV of APGAR or NRAS for low level (0-6) for predicting the mortality at 5 min

The above figures (figure 3, 4, 5 and 4) represents the ability of low scores (0-3) or low moderate score (0-6) to identify babies who are at risk of dying. Also, it is to be noted that the study did not record any results for NPV and SP for low moderate (0-6) Apgar score at 1 min as there were no babies with high Apgar (7-10) score at 1 min. We can observe that the NRAS score having better predictive ability than Apgar score at both 1 min and 5 min for risk of mortality. Also, as per the published literature evidences NRAS have significant values that would help in an early evaluation of asphyxia, as it is one of the main causes of mortality in newborns.^11-14

Respiratory support:

One of the Neonatal Resuscitation and Adaptation score (NRAS) uses objective parameter including newborn’s respiratory status through supplemental oxygen and the respiratory support.

In the current study, the need for respiratory support were recorded for study subjects at 1 min and 5 min for both APGAR score and NRAS score. It was recorded that in the cases falling within the low category (0-3) and middle category (4-6) for both APGAR score and NRAS score there was statistically significant correlation (<0.001) and (0.001) at 1 min and 5 min, respectively. This is in agreement with a study conducted by Witcher ET al.¹⁵ as it showed that NRAS < 7 had higher positive predictive values compared with a similar Apgar score for the need for respiratory support at 48 h of life. A 1-min NRAS score of <7 was present in 47.9% infants receiving respiratory support at 48 h, compared 38.2% with 1-min Apgar scores < 7.

Table 4. Short term outcome over respiratory support at 48 hours

Figure 7. Respiratory support at 48 hrs (1 min)

Figure 8. Respiratory support at 48 hrs (5 min)

Pressor support:

In the current study, the need for pressor support were recorded for study subjects at 1 min and 5 min for both APGAR score and NRAS score. It was recorded that in the cases falling within the low category (0-3) and middle category (4-6) for both APGAR score and NRAS score there was statistically significant correlation (<0.001) and (0.001) at 1 min and 5 min, respectively.

This is in agreement with a study conducted by Kebede (2022)¹⁶ as it showed that NRAS < 7 had higher better outcome compared with a similar Apgar score for the need for pressor support.

Table 5. The need for pressor support

Figure 9. Pressor support (1 min)

Figure 10. Pressor support (5 min)

Seizures:

In the current study, seizures were recorded for study subjects at 1 min and 5 min for both APGAR score and NRAS score. It was recorded that in the low category (0-3) and middle category (4-6) for both APGAR score and NRAS score there was statistically significant correlation (<0.001) and (0.008) at 1 min and 5 min, respectively.

The American College of Obstetricians and Gynecologists and American Academy of Pediatrics suggest an evidence of neurologic involvement including seizures, altered tone, coma.¹⁷ The APGAR score, though widely used for birth asphyxia diagnosis can either overestimate or underestimate seizures due to its subjective nature.¹⁸ Seizures due to birth asphyxia is a major contributor to neonatal morbidity and mortality. Globally, it contributes to a quarter of all neonatal deaths.¹⁹ According to Zhong (2019)²⁰ the failure to optimally diagnose birth asphyxia directly interferes with the timeline of managing these neonates, thereby increasing the risk of neonatal mortality and development of asphyxia-related morbidity.

Table 6. Record of seizures

Figure 11. Record of seizures (1 min)

Figure 12. Record of seizures (5 min)

Based on the current investigation, it is clear that the NRAS score have a better predictive ability than Apgar score at both 1 min and 5 min for risk of mortality. This new test provides an easy-to-apply and understandable tool for determining the transition state in newborns. However, a multicenter study at the national level is necessary to confirm and strengthen the evidence found in this research work, with amplification in the clinical variables of the study, with the aim of improving the specific application of NRAS.

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