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Comment & Response
September 14, 2020

Apgar Score—It Is Time to Avoid Pain

Author Affiliations
  • 1Department of Pediatrics, University Hospital of Siena, Siena, Italy
JAMA Pediatr. Published online September 14, 2020. doi:10.1001/jamapediatrics.2020.2551

To the Editor In a Viewpoint, Rüdiger and Rozycki1 invite us to reconsider the use of the Apgar score, with all its flaws. In particular, they invite readers to send their proposal for a new tool to be used at birth, aimed to assess more reliably the possible outcomes for an infant. I hope this future new tool would provide respect for an infant with regard to one point: pain. The original papers by Virginia Apgar did specify how to assess the parameters of her score, in particular “reflex irritability,” and that was not reassuring. She wrote that “The usual testing method was suctioning the oropharynx and nares with a soft rubber catheter which called forth a response of facial grimaces, sneezing or coughing.”2 As anyone can understand, this is inapplicable today: airway aspiration is discouraged in most infants by the current guidelines3 because, among other drawbacks, it provokes unnecessary pain. Thus, while most studies that use the Apgar score fail to assess how they score this specific item, some, considering the aforementioned objections about suctioning, have nonetheless proposed other types of painful stimulations.4 I underline that unnecessary pain should always be proscribed, in particular infants’ pain; even single and apparently innocent episodes of procedural pain can lead to ominous consequences.5 I have analyzed neonatal literature and published several articles on how frequent the use of unnecessary pain was in infants in research trials and I propose that provoking pain should not be included in the development of a new prognostic tool to be used at birth, at least for healthy infants. In the case of infants who need supportive or resuscitative maneuvers, the level of reactivity to pain might be calculated, although it may be difficult to determine a single potentially painful maneuver (eg, suctioning or intubation) that would be routinely performed in each of these infants. Nonetheless, I argue that no pain should be provoked purposely either for research purposes or for prognostic assessment.