Outcomes of Neonates with a 10-min Apgar Score of Zero: A Systematic Review and Meta-Analysis

Neonatology. 2022;119(6):669-685. doi: 10.1159/000525926. Epub 2022 Aug 31.


Introduction: The Apgar score is a standardized method of assessing the primary adaptation and clinical status of a neonate after birth. Our objective was to systematically review and meta-analyze the survival and the survival without moderate-to-severe neurodevelopmental impairment (NDI) of neonates with a 10-min Apgar score of zero.

Methods: Six electronic databases were searched for reports published until November 2021 of neonates with a 10-min Apgar score of zero. Risk of bias was assessed using the Newcastle-Ottawa scale for cohort studies and the Joanna Briggs Institute Critical Appraisal Checklist for case series/reports. Meta-analyses of the proportion of outcomes were conducted using a random-effects model for studies published after year 2000 and reporting >5 neonates. Meta-regression using the median year of the study period and subgroup analyses by treatment with therapeutic hypothermia and by gestational age were conducted.

Results: Twenty-eight studies of 820 neonates with moderate risk of bias were included. Survival was 40% (95% confidence interval 30-50%, 16 studies, 646 neonates, I2 = 83%), and it increased by 2.3% per year (95% CI 1.3-3.2%, p < 0.001). Survival without moderate-to-severe NDI was 19% (95% confidence interval 11-27%, 13 studies, 211 neonates, I2 = 62%). Survival was higher for neonates who received therapeutic hypothermia and for those with a gestational age ≥32 weeks compared to <32 weeks.

Conclusion: Approximately 2 in 5 neonates with a 10-min Apgar score of zero survived, and 1 in 5 survive without moderate-to-severe NDI survived. Survival has improved over the years, especially since the era of therapeutic hypothermia.

Keywords: Apgar; Hypoxic-ischemic encephalopathy; Neonate; Perinatal asphyxia; Therapeutic hypothermia.

Publication types

  • Systematic Review
  • Meta-Analysis

MeSH terms

  • Humans
  • Infant
  • Infant, Newborn