Apgar score and long-term respiratory morbidity of the offspring: a population-based cohort study with up to 18 years of follow-up

  • Elisha ErnestEmail author
  • Tamar Wainstock
  • Eyal Sheiner
  • Idit Segal
  • Daniella Landau
  • Asnat Walfisch
Original Article


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.


Newborn Child Respiration Pneumonia Asthma 


Authors’ contributions

Elisha Ernst has participated in all the phases of this study including planning, literature search, data interpretation and has written the first draft of the manuscript.

Tamar Wainstock PhD is an equal first author contributor. Dr. Wainstock is a specialist in performing all aspects of the statistical analysis needed for this study. She has participated in all phases of this study and has performed most of the analyses presented in this paper and has taken a significant part in the manuscript preparation and drafting.

Eyal Sheiner MD PhD has initiated the study and supervised actively throughout its conduct. Specifically, he was involved in the data interpretation, statistical analysis, and has revised the manuscript.

Daniella Landau MD has participated in all phases of this study including literature search and research planning, data collection, and review and took part in the data interpretation and manuscript preparation.

Asnat Walfisch MD has initiated and participated in all phases of this study including study planning, literature search, data collection and review, and interpretation of the results and has supervised and extensively revised the manuscript.

Compliance with ethical statements

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

431_2018_3311_MOESM1_ESM.docx (31 kb)
ESM 1 (DOCX 31 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Joyce and Irving Goldman Medical School, Faculty of Health SciencesBen-Gurion University of the NegevBeer-ShevaIsrael
  2. 2.Department of Public Health, Faculty of Health SciencesBen-Gurion University of the NegevBeer-ShevaIsrael
  3. 3.Department of Obstetrics and Gynecology, Soroka University Medical CenterBen-Gurion University of the NegevBeer-ShevaIsrael
  4. 4.Ministry of HealthJerusalemIsrael
  5. 5.Department of Neonatology, Soroka University Medical CenterBen-Gurion University of the NegevBeer-ShevaIsrael

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