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Does “Pink All Over” Accurately Describe an Apgar Color Score of 2 in Newborns of Color?
Abstract
Virginia Apgar's original scoring system reserved a score of 2 for color only "…when the entire child was pink." However, Dr Apgar also said that color was "the most unsatisfactory sign" and "…the inherited pigmentation of the skin of colored children" interfered with this sign. We aimed to evaluate current knowledge of Apgar scores and perceptions of color among medical professionals.
A survey was distributed to medical professionals within obstetrics and pediatrics at two major medical centers; it assessed knowledge and purpose of Apgar scores and perceptions of skin color as it relates to Apgar scores.
The survey was completed by 61 participants: 37.7% (23) nurses; 41.0% (25) attendings, residents, or fellows; and 21.3% (13) others. A total of 32.8% answered questions about the purpose of Apgar scores incorrectly, and 29.5% answered questions about the most important components of the Apgar score incorrectly. When asked if a newborn's ethnicity was considered when assigning Apgar score, 34.4% said "yes" and when asked if "pink" accurately described the skin color of vigorous African American newborns, 57.4% said "no."
Our study shows that a large proportion of medical providers who routinely assign Apgar scores are not sufficiently knowledgeable about the significance of the individual components. There is confusion about the color component, especially for neonates of color who are not usually expected to be "pink all over" and are, therefore, likely to get a lower score. Consideration should be given to reassess whether "pink all over" is an appropriate descriptor of color for all newborns.
... The Apgar score involves five components, one of which is "appearance", involving skin colour [9,10]. There are concerns about the applicability of the appearance component to ethnic minority neonates [10], as it includes assessing whether the neonate is 'pink all over' [11]. ...
... HCPs rely upon the fact that if an infant is breathing, they should be the colour 'pink' [41]. However, other literature has questioned the relevance of the terminology 'pink all over' [11,35], with this of further controversy in our interviews. ...
Objectives
To explore neonatal assessments that include an element of evaluating skin colour in neonates of black, Asian and minority ethnicities, focusing on the Apgar score, presence of cyanosis and presence of jaundice.
Design
We employed focused ethnography involving diverse healthcare professionals (HCPs) and parents or caregivers with Black, Asian, or ethnic minority children born in the last five years. Zoom interviews were performed following a semi-structured interview guide. Ethnographic data analysis was conducted using NVivo software.
Results
There was a lack of consistency in how HCPs applied the Apgar scores, which also varied from textbook guidelines. The use of pink as a skin colour descriptor for ethnic minority neonates created a divide among both parents and HCPs. HCPs relied more heavily on other elements of the Apgar score or infant breathing and crying at birth to gauge infant wellness. When identifying cyanosis, HCPs depend on specific body locations for accurate assessment of oxygenation, but the limitations of visual assessment are acknowledged. For jaundice, most HCPs recognised the difficulty in identifying the colour yellow in infants with darker skin tones. HCPs focussed on yellowing of the sclera and gums and other well-being assessments to detect jaundice. Some interviewed parents noticed jaundice in their infants before HCPs but felt they were not listened to when raising concerns. HCPs acknowledged the need for additional training to effectively assess the health of ethnic minority infants.
Conclusion
This study highlights disparities in neonatal health assessment from the perspectives of healthcare professionals and parents from diverse backgrounds. Varied practices in determining the Apgar score and recognising cyanosis and jaundice signal the need for standardised protocols, appropriate educational materials, and targeted training. Addressing these challenges is vital for equitable care, emphasising comprehensive training and bias mitigation efforts in maternal and neonatal healthcare.
... 3 Concerns have particularly been raised over neonatal assessments that require assessment of skin color, which is subject to observer and potential racial bias. 4,5 The Apgar score is a routine perinatal practice which includes skin color assessment. The Apgar score assesses five components: the neonate's heart rate, respiratory effort, reflex irritability, muscle tone, and appearance. ...
Background
Apgar score and cyanosis assessment may disadvantage darker-skinned babies. This review explored cyanosis and Apgar score assessments in Black, Asian, or minority ethnic neonates compared to White neonates.
Material and methods
Four databases were searched. Studies of any methodology were included. A narrative synthesis was undertaken.
Results
Ten studies were included. Three studies involving over 39 million neonates showed Apgar score ≤3 was predictive of neonatal mortality across all ethnicities. Black babies with Apgar score ≤3 had lower mortality rates before 28 days, however, variations in scoring practices were also observed. Three further studies ( n = 39,290,014) associated low Apgar scores with poorer mental development up to 22 months, especially in mixed ethnicity and Black infants. One study reported inadequate training in assessing ethnic minority neonates. Cyanosis was the focus of three included studies ( n = 455) revealing poor visual assessment of cyanosis across ethnicities. With pulse oximetry occult hypoxemia occurred slightly more frequently in Black neonates. Tongue color indicated oxygen requirement at birth, regardless of ethnicity.
Conclusions
Apgar scores correlate well with neonatal mortality in all ethnicities, however scoring variations exist. Cyanosis assessment is challenging, with tongue and lips the best places to observe in the absence of pulse oximetry.
Impact
Assessment of the color component of the Apgar score and of cyanosis visually are not accurate in babies with darker skin. Small racial differences may exist for pulse oximetry in neonates, but it is more reliable than visual assessment.
... https://doi.org/10.1371/journal.pmed.1004040.g002 efficacious across a range of skin tones, as demonstrated by a recent study stating that a majority of physicians do not agree that "pink all over" is an accurate description of vigorous African-American infants [8,31]. It is possible that refinement of the scoring system to capture circulatory status more reliably could improve its performance in identifying infants at high risk of mortality. ...
Background
Apgar scores measure newborn health and are strongly associated with infant outcomes, but their performance has largely been determined in primarily white populations. Given the majority of the global population is not white, we aim to assess whether the association between low Apgar score and mortality in infants varies across racial groups.
Methods and findings
Population-based cohort study using 2016 to 2017 United States National Vital Statistics System data. The study included singleton infants born between 37⁺⁰ and 44⁺⁶ weeks to mothers over 15 years, without congenital abnormalities. We looked at 3 different mortality outcomes: (1) early neonatal mortality; (2) overall neonatal mortality; and (3) infant mortality. We used logistic regression to assess the association between Apgar score (categorized as low, intermediate, and normal) and each mortality outcome, and adjusted for gestational age, sex, maternal BMI, education, age, previous number of live births, and smoking status, and stratified these models by maternal race group (as self-reported on birth certificates). The cohort consisted of 6,809,653 infants (52.8% non-Hispanic white, 23.7% Hispanic, 13.8% non-Hispanic black, 6.6% non-Hispanic Asian, and 3.1% non-Hispanic other). A total of 6,728,829 (98.8%) infants had normal scores, 63,467 (0.9%) had intermediate scores, and 17,357 (0.3%) had low Apgar scores. Compared to infants with normal scores, low-scoring infants had increased odds of infant mortality. There was strong evidence that this association varied by race (p < 0.001) with adjusted odds ratios (AORs) of 54.4 (95% confidence interval [CI] 49.9 to 59.4) in non-Hispanic white, 70.02 (95% CI 60.8 to 80.7) in Hispanic, 23.3 (95% CI 20.3 to 26.8) in non-Hispanic black, 100.4 (95% CI 74.5 to 135.4) in non-Hispanic Asian, and 26.8 (95% CI 19.8 to 36.3) in non-Hispanic other infants. The main limitation was missing data for some variables, due to using routinely collected data.
Conclusions
The association between Apgar scores and mortality varies across racial groups. Low Apgar scores are associated with mortality across racial groups captured by United States (US) records, but are worse at discriminating infants at risk of mortality for black and non-Hispanic non-Asian infants than for white infants. Apgar scores are useful clinical indicators and epidemiological tools; caution is required regarding racial differences in their applicability.
... 4 Interference with the parameter. Skin color is mainly affected by oxygenation, but also skin thickness, pigmentation, 15 perfusion, blood hemoglobin concentration, and environmental factors such as light color and intensity. 16 Oxygenation is affected by mode of delivery 13,17,18 and sex. ...
Assessment of an infant’s condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed.
This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn’s postnatal condition.
A revised neonatal scoring system should account for infant maturity and the interventions administered.
Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.
... This lack of diversity in teaching is apparent in textbooks and in pre-clinical lecture presentations [45][46][47]. This is particularly stark in scoring systems such as APGAR (appearance, pulse, grimace, activity, respiration) where the category of appearance is scored by range in colour from pink to blue [48]. These dermatological differences are more visible in babies with white skin, with no official guide on how to recognise signs in BAME children with darker skin tones. ...
Major racial disparities continue to exist in our healthcare education, from the underrepresentation of ethnic minorities when teaching about clinical signs to health management in primary and secondary care. A multi-centre group of students discuss what needs to change in medical education to cultivate physicians who are better prepared to care for patients of all backgrounds. We argue that the accurate portrayal of race in medical education is a vital step towards educating medical students to consider alternative explanations to biology when considering health inequities.
... When examining the different Apgar score components, reduced values (0-1) of heart rate, and of respiratory effort, were independently associated with increased relative risks of neonatal mortality [2,6]. As for the color component, several studies have shown different findings and some studies have even questioned the ability of medical providers who routinely assign Apgar scores to asses this component correctly especially for neonates of color who are not usually expected to be Bpink all over^and are, therefore, likely to get a lower score. ...
The objective of this study is to investigate whether a significant association exists between low 5-min Apgar scores (< 7) and respiratory morbidity of the offspring. A population-based cohort analysis was performed comparing subtypes of respiratory morbidity leading to hospitalizations among children (up to age 18 years) stratified by their 5 min Apgar scores. Data were collected from two databases of a regional tertiary center. All singleton deliveries occurring between 1991 and 2014 were included in the analysis. A Kaplan-Meier survival curve was constructed to compare cumulative respiratory-related hospitalization incidence and a Cox proportional hazards model to control for confounders. Deliveries (238,622) met the inclusion criteria. Low 5-min Apgar scores were recorded in 742 (0.3%) newborns. Incidence of respiratory hospitalizations was higher among the low 5 min Apgar score group (7.3 vs. 4.8% in the normal [≥ 7] 5 min Apgar score group; OR = 1.5, 95%CI 1.2–2.0, p = 0.003). Association remained significant in the Cox model (aHR = 1.4, 95%CI 1.1–1.9, p = 0.01). Incidence of respiratory-related hospitalizations in preterm born offspring was higher among the low vs. the normal 5 min Apgar score groups (13.4 vs. 7.2%, OR = 2.0, 95%CI 1.2–3.1 , p = 0.008). Association remained significant in the multivariable analysis (aHR = 1.6, 95%CI 1.1–2.5, p = 0.03). The survival curves demonstrated significantly higher cumulative respiratory morbidity in the low Agar score group for the entire cohort and for the preterm born subgroup.Conclusion: Newborns, of any gestational age, with low 5 min Apgar scores appear to be at an increased risk for pediatric respiratory morbidity.
What is Known:
• Apgar score is a method for assessment of the medical condition of a newborn, and of the need for medical intervention and/or resuscitation. Studies assesing the correlation between low Apgar score and short or long term outcomes report a sgnificant correlation with different outcomes including neurological development and more. As two of its five components (color and respiratory effort) are utilizing the respiratory status, low Apgar scoreis associated with a higher risk for immedisate respiratory morbidity.
What is New:
• Low Apgar score increases the chances for several long-term respiratory-related morbidities, independent of gestational age and other obstetrical circumstances.
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