Journal of Perinatology https://doi.org/10.1038/s41372-018-0189-5 ARTICLE Neonatal Resuscitation and Adaptation Score vs Apgar: newborn assessment and predictive ability Teresa J. Witcher 1 ● Shadi Jurdi 1 ● Vidhya Kumar 2 ● Aditi Gupta 3 ● Russell R. Moores Jr. 1 ● Joseph Khoury 1 ● Henry J. Rozycki 1 Received: 12 March 2018 / Revised: 25 May 2018 / Accepted: 5 June 2018 © Springer Nature America, Inc. 2018 Abstract Objective To test the non-inferiority of an alternative to the Apgar score. Study design The Neonatal Resuscitation and Adaptation Score (NRAS) was recorded in parallel to the Apgar score by a resuscitation team at deliveries. Correlation between the systems was assessed, as well as the predictive ability of NRAS and Apgar scores for mortality or short-term morbidities. Results A total of 340 infants were in the study group. The two scores correlated strongly (r = 0.87 and 0.83 at 1 and 5 min, respectively). Those needing ventilation at 48 h of life had a 5-min NRAS < 7 in 23/26 vs Apgar < 7 (23/36, p = 0.001). A low (0–3) 1-min NRAS score was more predictive of death, 53% vs 17%, p = 0.0065. Conclusions NRAS correlates with Apgar status assessment, and identifies newborns who die or may require further care better than the Apgar score. Introduction Assigning a score to each newborn infant using the system for assessing the transition to extrauterine life, which Vir- ginia Apgar developed over a half-century ago [1], con- tinues to be endorsed by the American Academy of Pediatrics [2]. Over this same period, however, major changes have taken place in newborn resuscitation, espe- cially since the introduction of the Neonatal Resuscitation Program (NRP) in 1987, a program now in its seventh edition [3]. Yet the immediate assessment of the efficacy of resuscitation still remains the Apgar score [2], despite the increasing disconnection between resuscitation practice and the scoring system. For example, if resuscitative efforts are required, they should be initiated prior to the 1-min scoring time. The NRP does not use the Apgar assessment of status at 1 and 5 min at all. New oxygen saturation targets as low as 60% at 1 min and 80% at 5 min could lead to a lower score for color. More significantly, how does one account for the effect of resuscitative procedures on the score? “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. The concept of an assisted score that accounts for resuscitative interventions has been suggested, but the predictive reliability has not been studied.” [2]. Other lim- itations of the Apgar score that have been documented over the years include the subjectivity of elements such as tone, color, and reflex irritability, which can lead to significant interobserver variability [4] and the effect of prematurity on the score [5, 6]. While its intention was, and remains, to assess the newborn infant at delivery, from the beginning, the score has been studied and used as a predictor for outcomes, including in Dr. Apgar’s initial report [1], where infants with a low 1-min score had a much higher mortality rate compared to those with moderate to high scores. Sub- sequent large studies also looked at the Apgar score in relation to mortality [7], as well as morbidity [8]. The Neonatal Resuscitation and Adaptation Score (NRAS) was developed to address the concerns regarding * Henry J. Rozycki henry.rozycki@vcuhealth.org 1 Division of Neonatal Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA, USA 2 School of Medicine, Virginia Commonwealth University, Richmond, VA, USA 3 Department of Pediatrics, Virginia Commonwealth University, Richmond, VA, USA 1234567890();,: 1234567890();,: