Systematic review of Apgar scores & cyanosis in Black, Asian, and ethnic minority infants

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.