Effectmerkers van kind en moeder per gebied overzicht van resultaten

Appendix 19. Effectmerkers kind en moeder - overzicht gebiedsverschillen.doc

Effectmerkers van kind en moeder per gebied – overzicht van resultaten In onderstaande tabellen worden de gebiedsverschillen samengevat. Tabel 1: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor effectmerkers bij het kind per studiegebied. Deze tabel geeft een samenvatting van de resultaten in ‘Appendix H1. Effectmerkers kind per gebied - gecorrigeerd voor confounders’. Tabel 2: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor allergie-gerelateerde effectmerkers bij de moeder per studiegebied. Tabel 3: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor effectmerkers van fertiliteit bij de moeder per studiegebied. Deze tabellen geven een samenvatting van de resultaten in ‘Appendix H2. Effectmerkers moeder per gebied - gecorrigeerd voor confounders’.

Op basis van deze resultaten wordt de overzichtstabel in het samenvattende rapport voor moeders en intermediairen aangemaakt.

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Tabel 1: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor effectmerkers bij het kind per studiegebied.

Lengte (cm)

Gewicht (kg)

Hoofdomtrek (cm) Zwangerschapsduur (weken) (1) Vroeggeboorte (%) (1) Apgar

Apgarscore 10 (%) TSH navelstreng (mIU/L)

Antwerpse agglomera -tie

Gentse agglomera -tie

Fruitstreek

Landelijk

50,3

50,1

50,3

50,2

(50,0-50,5)

(49,9-50,4)

(50,0-50,5)

3,38

3,42

(3,33-3,44)

Havens

Regio Olen

Albert kanaal zone

Menen+

50,2

50,3

49,8

50,2

(50,0-50,5)

(49,9-50,5)

(50,0-50,7)

(49,4-50,3)

(49,4-51,0)

3,32

3,37

3,37

3,44

3,34

3,51

(3,37-3,48)

(3,27-3,37)

(3,32-3,43)

(3,31-3,44)

(3,37-3,51)

(3,24-3,44)

(3,34-3,67)

34,5

34,5

34,4

34,4

34,5

34,4

34,2

34,1

(34,4-34,7)

(34,3-34,7)

(34,2-34,5)

(34,3-34,6)

(34,2-34,7)

(34,1-34,6)

(33,9-34,6)

(33,6-34,7)

39,4 #

39,4

38,9 $

39,1

39,1

39,4

39,1

38,9

(39,2-39,6)

(39,2-39,6)

(38,7-39,2)

(38,8-39,3)

(38,9-39,4)

(39,1-39,6)

(38,7-39,6)

(38,2-39,5)

2,3

2,6

9,3

4,1

2,2

2,5

0,0

10,9

(0,0-65,6)

(0,0-67,7)

(0,1-88,4)

(0,1-76,4)

(0,0-65,3)

(0,0-68,0)

(0,0-100)

(0,1-91,9)

9,7 $

9,9 #

9,8

9,7 $

9,9

9,9

9,9

9,9

(9,7-9,8)

(9,8-9,9)

(9,7-9,9)

(9,6-9,8)

(9,8-9,9)

(9,8-10,0)

(9,7-10,0)

(9,7-10,1)

78,0 $

90,7 #

81,0

80,8

89,2

90,2

89,4

95,8

(8,3-99,3)

(19,6-99,7)

(9,8-99,4)

(9,7-99,4)

(17,1-99,7)

(18,6-99,7)

(16,7-99,7)

(26,1-99,9)

8,6

7,8

7,2

8,4

8,2

7,6

6,6

7,4

(7,8-9,5)

(6,9-8,7)

(6,4-8,1)

(7,6-9,3)

(7,2-9,2)

(6,5-8,7)

(5,0-8,2)

(4,9-9,9)

Anova

Referentie * 50,2

p=0,71

(50,1-50,3) 3,39

p=0,07

(3,36-3,42) 34,5

p=0,63

(34,4-34,5) 39,2

p=0,04

(39,1-39,3) 1,9

p=0,06

(0,0-100) p=0,002 (2) P<0,001 (2)

9,8 (9,8-9,8) 85,4 (13,1-99,6) 8,1

p=0,18

(7,7-8,5)

* Referentie = populatiegewogen referentie-waarde voor totale studiegroep. # significant hoger dan referentiewaarde; § significant lager dan referentiewaarde. (1) enkel bij spontane bevallingen (2) zie nota blz. 7

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Gebiedsverschillen (zie ook analyse-plan): - In een eerste stap werd nagekeken of er een significant verschil is tussen de gebieden (Anova, met correctie voor confounders (zie lijst)) - Bij een niet-significante Anova (p≤0.05) werd geen post-hoc analyse gedaan. Bij een significante Anova (p<0.05) werd ieder individueel gebied vergeleken met de referentiewaarde. De waarden die significant hoger liggen dan de referentiewaarde zijn aangeduid met het symbool # ; de waarden die significant lager liggen dan de referentiewaarde zijn aangeduid met het symbool §. Lijst met confounders (verstorende factoren): - Voor lengte bij geboorte: zwangerschapsduur, pariteit, geslacht baby, leeftijd moeder, lengte moeder, lengte vader, roken tijdens zwangerschap. - Voor gewicht bij geboorte: zwangerschapsduur, pariteit, meerlingzwangerschap, geslacht baby, leeftijd moeder, gewicht moeder, roken tijdens zwangerschap. - Voor hoofdomtrek bij geboorte: zwangerschapsduur, pariteit, meerlingzwangerschap, geslacht baby, leeftijd moeder, roken tijdens zwangerschap. - Voor zwangerschapsduur en vroeggeboorte: meerlingzwangerschap, complicaties tijdens zwangerschap, leeftijd moeder, roken tijdens zwangerschap, pariteit - Voor aggar-score: ‘Small for gestational age’, meerlingzwangerschap, aard bevalling (selectie: enkel a-terme baby’s) - Voor TSH navelstrengbloed: duur zwangerschap, ‘Small for gestational age’, aard bevalling

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Tabel 2: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor allergie-gerelateerde effectmerkers bij de moeder per studiegebied.

Huidig astma (%) Astma – diagnose door dokter (%) Ooit astma (%)

Hooikoorts (%)

Huidallergie (%)

Voedselallergie (%)

Dierenallergie (%) Luchtweginfecties (%)



Fruitstreek

Landelijk

13,0

10,1

7,2

7,9

(8,9-18,6)

(6,5-15,6)

(4,3-11,8)

6,4

7,7 #

(3,8-10,7)

Havens

Regio Olen

Albert kanaal zone

Menen+

10,8

3,8

6,7

7,7

(4,8-12,8)

(6,6-17,0)

(1,6-8,8)

(0,2-16,5)

(0,2-27,1)

6,5

0,9 $

4,6

1,9

3,0

3,2

(4,6-12,5)

(3,8-11,0)

(0,2-3,4)

(2,2-9,1)

(0,6-6,0)

(0,7-11,4)

(0,4-20,8)

20,3 #

21,0

13,0

10,1 $

18,8

8,6 $

15,4

8,3

(15,0-26,8)

(15,6-27,8)

(8,9-18,5)

(6,5-15,4)

(13,1-26,1)

(4,8-15,0)

(8,2-27,2)

(0,2-28,8)

38,0

37,7

32,6

23,3

37,0

34,1

29,8

30,5

(31,4-45,0)

(30,9-45,0)

(26,3-39,6)

(17,8-29,8)

(29,6-45,0)

(26,3-42,9)

(19,6-42,5)

(15,3-51,7)

14,2

10,6

8,0

9,2

10,5

10,3

8,2

8,0

(9,4-19,0)

(6,2-15,1)

(4,2-11,8)

(5,1-13,3)

(5,6-15,5)

(4,9-15,7)

(1,1-15,3)

(0,0-19,4)

6,9

8,1

4,5

6,1

8,6

5,6

8,3

0,0

(3,4-10,5)

(4,1-12,0)

(1,6-7,4)

(2,7-9,5)

(4,1-13,0)

(1,5-9,7)

(1,1-15,5)

(0,0-0,0)

13,5

16,0

7,5

5,4 $

13,4

8,7

12,9

16,0

(8,8-18,1)

(10,7-21,2)

(3,8-11,2)

(2,3-8,6)

(8,0-18,8)

(3,7-13,6)

(4,3-21,5)

(0,6-31,4)

21,9

22,8

25,5

14,1

24,4

24,2

26,4

21,4

(16,7-28,2)

(17,3-29,4)

(19,9-32,1)

(9,9-19,7)

(18,2-31,9)

(17,5-32,4)

(16,8-38,9)

(9,1-42,3)

Anova

p=0,18

p=0,048

p=0,01

p=0,06

p=0,65

p=0,42

p=0,01

p=0,20

Referentie * 9,6 (7,8-11,8) 4,3 (3,1-6,0) 16,2 (13,8-18,9) 34,2 (31,1-37,5) 11,3 (9,2-13,5) 7,0 (5,3-8,7) 12,0 (9,8-14,2) 21,7 (19,1-24,6)

* Referentie = populatiegewogen referentie-waarde voor totale studiegroep. # significant hoger dan referentiewaarde; § significant lager dan referentiewaarde.

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Gebiedsverschillen (zie ook analyse-plan): - In een eerste stap werd nagekeken of er een significant verschil is tussen de gebieden (Anova, met correctie voor confounders (zie lijst)) - Bij een niet-significante Anova (p≤0.05) werd geen post-hoc analyse gedaan. Bij een significante Anova (p<0.05) werd ieder individueel gebied vergeleken met de referentiewaarde. De waarden die significant hoger liggen dan de referentiewaarde zijn aangeduid met het symbool # ; de waarden die significant lager liggen dan de referentiewaarde zijn aangeduid met het symbool §. Lijst met confounders (verstorende factoren): - Voor astma: familiaal voorkomen van astma, roken voor de zwangerschap. - Voor hooikoorts: roken voor de zwangerschap. - Voor luchtweginfecties: roken voor de zwangerschap. - Voor huidallergie, voedselallergie en dierenallergie: geen.

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Tabel 3: Gemiddelde (95% betrouwbaarheidsinterval) waarden voor effectmerkers van fertiliteit bij de moeder per studiegebied.

Tijd tot zwangerschap (weken) (1) Ooitzwangerschapsstimulatie (%) Ooit miskraam (%)



Fruitstreek

Landelijk

8,0

9,7

9,6

10,2

4,7-11,4)

(6,2-13,3)

(6,4-12,9)

7,1

7,2

(4,3-11,5)

Havens

Regio Olen

Albert kanaal zone

Menen+

11,6

11,3

9,7

16,5

(6,9-13,4)

(8,0-15,2)

(7,3-15,3

(8,1-11,3)

(5,8-27,3)

6,8

9,8

8,3

11,8

4,5

8,5

(4,3-11,6)

(4,0-11,1)

(6,4-14,8)

(4,9-13,7)

(7,2-18,6)

(1,4-13,3)

(2,1-28,8)

15,9

20,9

16,2

9,6

16,8

17,7

11,8

20,5

(10,9-22,4)

(15,1-28,2)

(11,3-22,7)

(5,9-15,3)

(11,2-24,4)

(11,3-26,6)

(5,3-24,2)

(6,7-48,2)

Anova

Referentie * 8,0

p=0,62

(4,7-11,4) 7,6

p=0,63

(6,0-9,7) 15,9

p=0,29

(13,2-18,9)

* Referentie = populatiegewogen referentie-waarde voor totale studiegroep. (1) enkel indien zwangerschap van eerste kindje Gebiedsverschillen (zie ook analyse-plan): - In een eerste stap werd nagekeken of er een significant verschil is tussen de gebieden (Anova, met correctie voor confounders (zie lijst)) - Bij een niet-significante Anova (p≤0.05) werd geen post-hoc analyse gedaan. Bij een significante Anova (p<0.05) werd ieder individueel gebied vergeleken met de referentiewaarde. De waarden die significant hoger liggen dan de referentiewaarde zijn aangeduid met het symbool # ; de waarden die significant lager liggen dan de referentiewaarde zijn aangeduid met het symbool §. Lijst met confounders (verstorende factoren): - Voor tijd tot zwangerschap: leeftijd moeder, roken voor de zwangerschap. - Voor zwangerschapsstimulatie: leeftijd moeder, roken voor de zwangerschap. - Voor miskramen: leeftijd moeder, roken voor de zwangerschap, pariteit.

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Op basis van bovenstaande tabellen, werd volgend overzichtsschema gegenereerd:

Schematische samenvatting van afwijkingen van het gemiddelde per gebied in vergelijking met het berekende referentiegemiddelde. In kleuren is aangegeven of de gebiedswaarde boven (rood), onder (groen) of niet verschillend van (wit), het referentiegemiddelde lag. Antwerpse agglomeratie

Gentse agglomeratie

Fruit streek

Landelijk

Havens

Regio Olen

Albertkanaal zone

Menen+

Astma - diagnose door dokter (%)

Ooit astma (%)

Dierallergie (%)

Zwangerschaps duur (weken)

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Nota bij apgar score In deze studie werden significante gebiedsverschillen gevonden voor de apgar score op 10 minuten. Toch worden deze verschillen niet als prioritair vermeld in het eindrapport. Enerzijds is de validiteit van de meting niet optimaal. Anderzijds is het de vraag of de apgar score een relevante merker is voor neurologische ontwikkeling zoals hij oorspronkelijk was bedoeld. 1. Validiteit van de meting Over validiteit wordt geschreven: het is een subjectieve test, opgebouwd uit rigide categorieën met slechts 3 keuzes per categorie. De inter-rater reliability is pover; ook voor de categorieën die gemakkelijk te beoordelen lijken vb. acrocyanose en reflexen (in 1/3 fout gecodeerd). Zie referenties in bijlage: - Enrico Lopriore, G Frederiek van Burk, Frans J Walther, Arnout Jan de Beaufort. Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study. BMJ 2004;329: 143-4. - Bharti B, Bharti S. A review of the Apgar score indicated that contextualization was required within the contemporary perinatal and neonatal care framework in different settings. J Clin Epidemiol. 2005;58(2):121-9. 2. Relevantie van apgar score als neurologische parameter De apgar score was geselecteerd als effect merker omdat sommige polluenten zoals PCBs en dioxines mogelijk een effect hebben op de neurologische ontwikkeling tijdens de zwangerschap. Er zijn inderdaad publicaties waarbij de apgar score wordt gelinkt met long term outcome op neurologisch vlak en ook op pulmonair vlak (longrijping). De neurologische gevolgen lijken echter vooral terug gaan op cerebrale schade tijdens de geboorte (asphyxie en intracraniële bloedingen). Dat deze complicaties na de geboorte de apgar verstoren is logisch, dat ze op langere termijn gevolgen kunnen hebben ook. De link met blootstelling is daar echter niet evident, deze werd ook in onze blootstelling-effect relaties niet gevonden. Zie referenties in bijlage: - Finster M, Wood M. The Apgar score has survived the test of time. Anesthesiology. 2005;102(4):855-7. - Schmidt B, Kirpalani H, Rosenbaum P, Cadman D. Strengths and limitations of the Apgar score: a critical appraisal. J Clin Epidemiol. 1988;41(9):843-50. - MacCobb S, Greene S, Nugent K, O'Mahony P. Measurement and prediction of motor proficiency in children using bayley infant scales and the Bruininks-Oseretsky test. Phys Occup Ther Pediatr. 2005;25(1-2):59-79. - Sepou A, Yanza MC, Nguembi E, Vohito J, Mbary-Daba RA, Siopathis RM. Value of fetal pulmonary maturity determination with the Clements test in high risk pregnancies Dakar Med. 2002;47(1):22-6. - Sato M, Aotani H, Hattori R, Funato M. Behavioral outcome including attention deficit hyperactivity disorder/hyperactivity disorder and minor neurological signs in perinatal high-risk newborns at 4-6 years of age with relation to risk factors. Pediatr Int. 2004 Jun;46(3):346-52.

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Manganaro R, Mami C, Gemelli M. The validity of the Apgar scores in the assessment of asphyxia at birth. Eur J Obstet Gynecol Reprod Biol. 1994 Apr;54(2):99-102. Casiro OG, Moddemann DM, Stanwick RS, Panikkar-Thiessen VK, Cowan H, Cheang MS. Language development of very low birth weight infants and fullterm controls at 12 months of age. Early Hum Dev. 1990 Oct;24(1):65-77. Jaeger M, Grussner SE, Omwandho CO, Klein K, Tinneberg HR, Klingmuller V. Cranial sonography for newborn screening: a 10-year retrospective study in 11,887 newborns. Rofo. 2004 Jun;176(6):852-8. Topp M, Langhoff-Roos J, Uldall P.Preterm birth and cerebral palsy. Predictive value of pregnancy complications, mode of delivery, and Apgar scores. Acta Obstet Gynecol Scand. 1997 Oct;76(9):843-8. Seidman DS, Paz I, Laor A, Gale R, Stevenson DK, Danon YL. Apgar scores and cognitive performance at 17 years of age. Obstet Gynecol. 1991 Jun;77(6):875-8. Blackman JA. The value of Apgar scores in predicting developmental outcome at age five. J Perinatol. 1988 Summer;8(3):206-10.

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BMJ. 2004 Jul 17;329(7458):143-4. Epub 2004 Jun 18.

Correct use of the Apgar score for resuscitated and intubated newborn babies: questionnaire study Enrico Lopriore, consultant,1 G Frederiek van Burk, senior house officer,1 Frans J Walther, professor,1 Arnout Jan de Beaufort, consultant2 1

Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, Netherlands 2 Department of Paediatrics, Division of Neonatology, Juliana Children's Hospital, The Hague, Netherlands

The Apgar score has played a crucial role in the delivery room assessment of newborn babies since 1953,1 2 but this system has its limitations and is prone to inter-observer variation.3 4 Moreover, scoring definitions in textbooks vary slightly and no specific guidelines are available for scoring intubated babies. We studied variations between observers and focused on the scoring of respiratory effort in resuscitated and intubated newborn babies. Participants, methods, and results We developed a questionnaire with three case presentations of newborns in which the Apgar score had to be determined. Case 1—A full term newborn baby is breathing irregularly at five minutes after birth. Oxygen and mask and bag ventilation are applied. The infant's heart rate is 120 beats/min. The infant cries in response to stimulation, has some flexion of extremities, and is pink with blue extremities. Case 2—A full term newborn baby is born after a breech extraction. The infant is immediately intubated and ventilated because of apnoea. At five minutes, the heart rate is 120 beats/min, the infant is completely flaccid on the ventilator, does not respond to stimulation, and is pink. Case 3—A preterm boy, born at 25 weeks of gestation, is intubated and ventilated immediately after birth. At five minutes the child is active on the ventilator with a heart rate of 120 beats/min and is pink with blue extremities. His muscle tone is normal for gestational age and response to stimulation is good. A total of 166 paediatric professionals from nine general hospitals and three university hospitals in the Netherlands participated in the study (table). Scores for respiratory effort in case 2 and 3 varied most (standard deviation 0.90 and 0.84). We also found many different scores for colour and reflex irritability in case 1 and 3. In case 1, the total Apgar score assigned was 6 (16%), 7 (55%), 8 (21 %), or 9 (7%). In case 2, the total Apgar score was 2 (1%), 3 (1%), 4 (68%), 5 (1%), or 6 (24%). In case 3, the total Apgar score was 7 (16%), 8 (23%), 9 (38%), or 10 (16%). (The bracketed values are the percentage of participants assigning that score.) Comment The assessment of the Apgar score varied greatly among participants, particularly when scoring respiratory effort in intubated newborn babies. The original definition for scoring respiratory effort states that an apnoeic infant should score 0, and an infant who “breathed and cried lustily” should score 2.1 2 All other types of respiratory effort, such as irregular shallow

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ventilation, should score 1.1 2 We propose therefore that an infant who is apnoeic and requires intubation and ventilation should receive the minimum value of 0 for respiratory effort, not withstanding the fact that normoxia may be achieved through adequate artificial ventilation. If an infant requires artificial ventilation at birth due to irregular or shallow ventilation, he or she should score 1. To assess whether an artificially ventilated infant is apnoeic or not, ventilation should be stopped briefly, when possible, to check for the presence of spontaneous respiratory movements. Scores for colour and reflex irritability also varied widely. Although acrocyanosis (cases 1 and 3) should score 1, and a cry in response to a brisk tangential slap of the soles of the feet (case 1) should score 2, actual scores were incorrect in a third of cases. For the Apgar score to survive another 50 years, uniformity in scoring is paramount. Paediatric professionals should follow Apgar's original definitions more strictly, and consensus on scoring intubated newborn babies should be reached.

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J Clin Epidemiol. 2005 Feb;58(2):121-9.

A review of the Apgar score indicated that contextualization was required within the contemporary perinatal and neonatal care framework in different settings. Bharti B, Bharti S. Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India. [email protected] OBJECTIVE: To triangulate the Apgar score by using a crossdisciplinary approach and highlighting the differences that exist between actual everyday practice and accepted standards of scoring in contrasting populations of the world. STUDY DESIGN AND SETTING: Clinimetrics review of Apgar scoring. RESULTS: The Apgar scoring has weighting problems, rigid categorization, redundancy and subjectivity in its variables. Poor inter-rater reliability and equivocal validity mark its use in the present milieu. The ceiling and floor effects further hamper the evaluative responsiveness of scoring. Moreover, despite some recent evidence in its favor, the Apgar score has poor calibration when used as an isolated criterion to predict mortality and long-term morbidity, particularly in preterms. Also, the vigor of resuscitation (nature and duration), in essence, is beyond the realm of the Apgar score in contemporary resuscitation guidelines. In developed nations, with rapidly decreasing age of viability, and alternative modes of childbearing, threats to Apgar are more ominous today than before. On the other hand, in developing countries, feasibility problems due to unattended home deliveries and barriers to effective scoring in the overburdened and understaffed hospitals cast doubts about its accuracy as a measure of neonatal well-being. CONCLUSION: Use of the Apgar score definitely needs to be contextualized within the contemporary perinatal and neonatal care framework in different settings.

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Anesthesiology. 2005 Apr;102(4):855-7.

Related Articles, Links

The Apgar score has survived the test of time. Finster M, Wood M. Department of Anesthesiology, College of Physicians and Surgeons, ColumbiaPresbyterian Medical Center, 630 West 168th Street, New York, NY 10032, USA. [email protected] In 1953, Virginia Apgar, M.D. published her proposal for a new method of evaluation of the newborn infant. The avowed purpose of this paper was to establish a simple and clear classification of newborn infants which can be used to compare the results of obstetric practices, types of maternal pain relief and the results of resuscitation. Having considered several objective signs pertaining to the condition of the infant at birth she selected five that could be evaluated and taught to the delivery room personnel without difficulty. These signs were heart rate, respiratory effort, reflex irritability, muscle tone and color. Sixty seconds after the complete birth of the baby a rating of zero, one or two was given to each sign, depending on whether it was absent or present.Virginia Apgar reviewed anesthesia records of 1025 infants born alive at Columbia Presbyterian Medical Center during the period of this report. All had been rated by her method. Infants in poor condition scored 0-2, infants in fair condition scored 3-7, while scores 8-10 were achieved by infants in good condition. The most favorable score 1 min after birth was obtained by infants delivered vaginally with the occiput the presenting part (average 8.4). Newborns delivered by version and breech extraction had the lowest score (average 6.3). Infants delivered by cesarean section were more vigorous (average score 8.0) when spinal was the method of anesthesia versus an average score of 5.0 when general anesthesia was used. Correlating the 60 s score with neonatal mortality, Virginia found that mature infants receiving 0, 1 or 2 scores had a neonatal death rate of 14%; those scoring 3, 4, 5, 6 or 7 had a death rate of 1.1%; and those in the 8-10 score group had a death rate of 0.13%. She concluded that the prognosis of an infant is excellent if he receives one of the upper three scores, and poor if one of the lowest three scores. PMID: 15791116 [PubMed - in process]

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J Clin Epidemiol. 1988;41(9):843-50.


Strengths and limitations of the Apgar score: a critical appraisal. Schmidt B, Kirpalani H, Rosenbaum P, Cadman D. Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada. The Apgar score is widely used for several purposes: to discriminate between infants who require resuscitation at birth and those who do not; to predict outcome; and to evaluate change in the condition of the newly born over the first minutes of life. Using published evidence of its clinical reliability and validity, this article explores whether the Apgar score serves all three measurement purposes equally well. Methodologic guidelines for assessing health indices are applied to examine the structure of the Apgar score as well as its function where performance data are lacking or inadequate. Despite the advent of modern technology, the Apgar score remains the best tool for the identification of newly born infants in need for cardiopulmonary resuscitation. For predicting later death or handicap, the Apgar score is insensitive but fairly specific. The ability of the Apgar score to measure change over time has not been studied systematically; however, available data suggest that serial Apgar ratings in infants with early low scores detect clinically important recovery of lack thereof. PMID: 3183690 [PubMed - indexed for MEDLINE]

14


Phys Occup Ther Pediatr. 2005;25(1-2):59-79.


Measurement and prediction of motor proficiency in children using bayley infant scales and the Bruininks-Oseretsky test. MacCobb S, Greene S, Nugent K, O'Mahony P. School of Occupational Therapy, University of Dublin, Trinity College, Dublin, Ireland. A sample of 76 Irish girls and boys of about 9 years of age, for whom neonatal (birthweight, Apgar and Neonatal Behavioural Assessment Scale) and infancy measures (Bayley Infant Scales at 18 months) were available, were administered the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). The main focus of this paper is on a longitudinal analysis of the relationships between the neonatal and infancy measures and the BOTMP administered at about 9 years. However, since the literature expresses some doubts about the basis of the division of the BOTMP subtests into fine motor and gross motor groups and about the meaningfulness of the overall battery score, an initial statistical analysis was undertaken to examine these construct validity issues with this sample of children. This analysis indicated that the division of subtests into fine motor and gross motor skills groups, as formulated by the BOTMP, is not supported. The longitudinal analysis, therefore, focused mainly on subtest scores and provided some evidence of a degree of continuity in measured motor proficiency between birth, 18 months and the prepubertal period. Continuity was more evident for female children. PMID: 15760824 [PubMed - in process]

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Dakar Med. 2002;47(1):22-6.


[Value of fetal pulmonary maturity determination with the Clements test in high risk pregnancies] [Article in French] Sepou A, Yanza MC, Nguembi E, Vohito J, Mbary-Daba RA, Siopathis RM. Service de Gynecologie-Obstetrique, Hopial Communautaire de Bangui, Service de Pediatrie, Complexe Pediatrique de Bangui. To extract a foetus which presents chronic suffering in high risk pregnancy, the determination of pulmonary maturity leads to take the decision. Among the complementary analysis to determine the pulmonary maturity, we used of Clements test (CT) which realization is easy and the results rapid. The objectives of this paper were to evaluate the pulmonary maturity with CT, to establish correlation between CT and breathing distress syndrome at birth and to determine the validity of CT about new born vitals parameters. During a two years prospection in "Hopital Communautaire" maternity and "Complexe Pediatrique", we have recruited 390 laboring women with high risk pregnancy who attained six months. We have leaved out the search cases of prematureness membrane rupture or tinted amniotic fluid. The fluid amniotic to be analyzed was taken with syringe and was subjected to different techniques allowing to conclude pulmonary maturity or not. Statistical tests has permitted to establish correlation between CT and new born vitals parameters. The means of laboring women age was 25 years old. In 59.3%, the women have between 1 and 3 children. The caesarians decided in 21.4% of cases were related to generally restricted pelvis with bi-scared uterus. The prematurity confinement had concerned 37.4% of new born. The CT result was positive in 61% of cases. The Apgar score under 7 had been more observed among children who had positive CT. The respiratory distress was significantly more frequent among children born by caesarian. The stillbirths rates of was more exalted with cases of negative CT. The results of this search have permitted to identify new born correlative parameters with pulmonary maturity. This one might be determined by CT, in high risk new born, the vulgarization of this test would improve their management. PMID: 15776586 [PubMed - indexed for MEDLINE]

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Pediatr Int. 2004 Jun;46(3):346-52.


Behavioral outcome including attention deficit hyperactivity disorder/hyperactivity disorder and minor neurological signs in perinatal high-risk newborns at 4-6 years of age with relation to risk factors. Sato M, Aotani H, Hattori R, Funato M. Department of Pedology, Kyoto Women's University, Kyoto, Japan. [email protected] BACKGROUND: Diagnostic problems with the criteria of attention deficit hyperactivity disorder (ADHD) in the Diagnostic Statistical Manual, 4th edn, have been identified. The aim of this study was to clarify whether the minor neurological signs test (MNT) the authors had previously reported was a predictor for the criteria of ADHD or hyperactivity disorder (HD) in perinatal risk children at 4-6 years of age and what kind of risk factors related to MNT. METHODS: A total of 136 children discharged from neonatal intensive care units were examined at the age of 4-6 years by a developmental neuropediatrician using both MNT and diagnostic criteria of DSM-IV ADHD/ICD-10 (International Classification of Diseases, 10th edn) HD. SPSS base and professional were used for statistical analysis. RESULTS: On comparison of diagnostic criteria between ADHD (11.0%) and HD (27.5%), the incidence in the same subjects showed significant difference. MNT scores showed significant correlation with criteria of ADHD (P < 0.01) and HD (P < 0.05). Diagnostic validity of MNT for predicting ADHD was demonstrated with 78% sensitivity and 79% specificity. High positive rates on MNT did not show a significant difference between the very low birthweight (VLBW) and non-low birthweight (NLBW) groups. Behavioral outcome with relation to risk factors were analyzed using multiple regression analysis. Apgar 5 in the NLBW group and toxemia of pregnancy and small for gestational age (SGA) in VLBW group were highly correlated with behavioral outcome. CONCLUSIONS: Minor neurological signs test score was a significant predictor for criteria of ADHD and HD. High incidences of positive MNT were suspected in not only VLBW children but also NLBW children and Apgar 5 in NLBW children and toxemia of pregnancy and SGA in VLBW children influenced behavioral outcome. PMID: 15151555 [PubMed - indexed for MEDLINE]

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Eur J Obstet Gynecol Reprod Biol. 1994 Apr;54(2):99-102.


The validity of the Apgar scores in the assessment of asphyxia at birth. Manganaro R, Mami C, Gemelli M. Service of Neonatology, University of Messina, Italy. A prospective study was performed in 613 consecutively live born infants to investigate the validity of 1- and 5-min Apgar scores as an index for asphyxial assessment at birth. The independent and combined relationship between Apgar scores, metabolic acidemia, pulse oximeter (SaPO2) measurements and neonatal outcome were determined. In the term infants 1-min Apgar score was more influenced by the mode of delivery and by gestational age than by asphyxia. Instead, 5-min Apgar score had a high concordance with metabolic acidemia. Infants with low Apgar scores, metabolic acidemia and arterial desaturation have the highest incidence of neonatal intensive care unit admission and poor neonatal outcome. The study suggests that the 5-min Apgar score is useful for immediate clinical assessment and care of the neonate. PMID: 8070606 [PubMed - indexed for MEDLINE]

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Early Hum Dev. 1990 Oct;24(1):65-77.


Language development of very low birth weight infants and fullterm controls at 12 months of age. Casiro OG, Moddemann DM, Stanwick RS, Panikkar-Thiessen VK, Cowan H, Cheang MS. Department of Pediatrics, University of Manitoba, Canada. Twenty-eight very low birth weight (VLBW) and 32 full term infants were prospectively assessed at one year of age for hearing, language development and neurological status. The prevalence of conductive hearing deficits was the same in both groups. Language scores in VLBW infants were significantly lower than in fullterm controls and 39% had significant language delays. VLBW infants exhibited a shorter attention span and were less likely to understand simple questions, to recognize objects or body parts when named, to initiate speech-gesture games, to follow simple commands and to imitate or use words consistently. Language quotients were directly associated with gestational age and five minute Apgar scores and inversely associated with severity of intraventricular hemorrhage, bronchopulmonary dysplasia and length of hospital stay. VLBW small for gestational age infants exhibited more advanced language skills than VLBW appropriate for gestational age infants. Language delays were more prevalent among, but not limited to, infants with mild to moderate neurological abnormalities. The influence of prematurity and VLBW on language development is complex and multifactorial and research is continuing to determine the predictive validity and long term significance of the early language delays described in this study. PMID: 2265600 [PubMed - indexed for MEDLINE]

19


Rofo. 2004 Jun;176(6):852-8.


[Cranial sonography for newborn screening: a 10-year retrospective study in 11,887 newborns] [Article in German] Jaeger M, Grussner SE, Omwandho CO, Klein K, Tinneberg HR, Klingmuller V. Department of Gynecology and Obstetrics, University of Giessen, Germany. We retrospectively analyzed the results of a sonographic cranial screening study, performed between 1985 and 1994 to determine the incidence of intracranial hemorrhage and cerebral anomalies based on obstetrical risk factors. In the Department of Obstetrics and Gynecology of the University Giessen, Giessen, Germany, 94.6 % (n = 11,887) of all children born during the study period were included and underwent sonographic cranial screening within the first 10 days after birth. Cerebral abnormalities were found in 653 (= 5.5 %) cases, and peri/intraventricular hemorrhages (PIVH, grade I-IV) in 303 cases. Periventricular leucomalacia, porencephaly, subarachnoidal hemorrhage and hydrocephaly were rare (< or = 0.2 %). The Apgar index proved to be a good prognostic factor, particularly at 1 and 5 minutes after birth (p < 0.0001). In contrast, correlation between PIVH and cardiotocography, arterial cord blood gases, and pH was poor. We did not observe a higher incidence of PIVH in newborns with growth retardation, preeclampsia and premature ruptures of membranes or prolonged labor. With decreasing gestational age, the frequency of PIVH increased progressively from 0.4 % at 39 weeks to 53.2 % at 27 weeks (p < 0.001). We also found a higher risk of intracranial hemorrhage in preterm newborns with amniotic infections (38.1 %, p < 0.001). In mature babies, we did not find a difference between the incidence of PIVH and delivery-modes; however, we noted a higher risk of PIVH Grade IV in preterm newborns with breech presentation for vaginal delivery versus caesarean section (38.5 % versus 7.4 %, p = 0.005). The incidence of PIVH over this 10 year time period did not increase despite an increasing number of preterm newborns over time. In conclusion, this study, which represents one of the largest patient cohorts studied for PIVH, indicates that neonatal sonographic cranial screening is an important tool to define quality control in obstetrics. PMID: 15173979 [PubMed - indexed for MEDLINE]

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Acta Obstet Gynecol Scand. 1997 Oct;76(9):843-8.


Preterm birth and cerebral palsy. Predictive value of pregnancy complications, mode of delivery, and Apgar scores. Topp M, Langhoff-Roos J, Uldall P. Department of Obstetrics and Gynecology, University of Copenhagen, Hvidovre Hospital, Denmark. BACKGROUND: Preterm infants are at 8 times higher risk than term infants for pre- and perinatal brain damage, resulting in cerebral palsy. In this paper we have analysed the influence of prenatal and birth-related risk factors on cerebral palsy in preterm infants. METHODS: In a register-based study, 175 preterm singleton infants with cerebral palsy, born in 1982-86, were compared with 687 controls matched by gestational age and year of birth. RESULTS: Statistically significant higher rates in cases were found in parity > or = 3 (22% vs. 16%, p < 0.05), Cesarean section (67% vs. 56%, p < 0.01), and low Apgar scores at 1 minute (45% vs. 36%, p < 0.05). By multivariate analyses, two variables remained statistically significant: parity > or = 3 (adjusted OR = 1.53 (95% CI 1.00-2.34), p < 0.05) and Cesarean section (adjusted OR = 1.57 (95% CI 1.07-2.32), p < 0.05). CONCLUSIONS: Pregnancy complications preceding preterm birth did not imply a higher risk of cerebral palsy. Delivery by Cesarean section was a prognostic factor for developing cerebral palsy, and the predictive value of Apgar scores was highly limited. Publication Types: •

Review

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Obstet Gynecol. 1991 Jun;77(6):875-8.


Apgar scores and cognitive performance at 17 years of age. Seidman DS, Paz I, Laor A, Gale R, Stevenson DK, Danon YL. Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel. The association between low Apgar scores (7 or less) at 1 and 5 minutes and cognitive performance in late adolescence was assessed. A 17-year follow-up of 1942 subjects was performed. The intelligence test scores at 17 years of age were matched with 1- and 5-minutes Apgar scores. A multiple linear regression analysis was used to control for the possible confounding effect of perinatal factors (birth weight, gestational age, serum bilirubin levels, birth order) and demographic characteristics (ethnic origin, paternal education, social class). The sensitivity and positive predictive value of a low 1-minute Apgar score were 8 and 8% and of a low 5-minute Apgar score 1.5 and 5%, respectively. Low Apgar scores are poorly correlated with long-term intellectual outcome. PMID: 2030860 [PubMed - indexed for MEDLINE]

22


J Perinatol. 1988 Summer;8(3):206-10.


The value of Apgar scores in predicting developmental outcome at age five. Blackman JA. Department of Pediatrics, University of Iowa, Iowa City 52242. Although Apgar scores as indicators of physiologic depression in newborns appeared to have limited value in predicting developmental outcome, they remain attractive indicators of risk status because they are obtained routinely in this country. Unfortunately, most follow-up studies of the relationship between Apgar scores and outcome have been generally of short duration. Thus the long-term predictive value of Apgar scores is not completely known. In this study 111 otherwise normal fullterm infants with 5 minute Apgar scores of less than 7 were enrolled prospectively in a follow-up program. Approximately 13% died (2) or had significant developmental disabilities (12) identified by 30 months of age. Sixty-seven percent of the children with these poor outcomes had a history of neonatal seizures. The remainder received an extensive developmental evaluation at age 5. The mean performance on psychoeducational tests of children without a history of neonatal seizures did not differ from that of a comparison group, whereas the mean of children who experienced neonatal seizures was significantly lower. Thus, low Apgar scores warrant developmental surveillance during the early years of life but, if unaccompanied by neonatal seizures, do not appear to predict more subtle developmental dysfunction evident at school entry age. However, seizures remain an ominous sign for significant early and late developmental sequelae. PMID: 3225662 [PubMed - indexed for MEDLINE]

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