Why Does a Routine Test of Newborns Reward ‘Pink’ Skin?
Shortly after they’re born, infants are assigned an Apgar score, a measure of how well they’re adapting to life outside the womb. It’s the first time a child is graded: on a scale from 0 to 10, with up to two points awarded for each of five metrics.
One of them is skin color, an indication of how much oxygen the baby is getting. A newborn gets two points only if he or she is pink all over. Pale or blue fingers and toes earn one point; a baby who is white, gray or blueish all over gets none.
Some doctors regard the tool as a quick, simple way to assess a newborn’s need for urgent care. But an accumulating body of research has found that Black infants and other babies of color don’t score as well on the Apgar as white infants.
Now a growing number of experts are calling for changes, worried that relying on the widely used scale could make some newborns seem sicker than they are and expose them to unnecessary medical treatment.
Not only is color perception subjective, critics say, but skin tone is a discomfiting and discriminatory measure to include in a medical screening tool.
“Skin color as a determination of someone’s well-being needs to go out of the window,” said Dr. Amos Grünebaum, a professor of obstetrics and gynecology at the Zucker School of Medicine at Hofstra University. “It should not be a part of a health evaluation.”
In addition to skin tone, the Apgar test scores infants on heart rate, breathing, muscle tone and reflexes. A perfect score is a 10.
Dr. Grünebaum led a study that analyzed the Apgar scores of more than nine million American babies born between 2016 and 2019. Overall, he found, only 2.6 percent of newborns got a perfect score.
But the odds for a Black baby to do so were less than half those of a white infant: 3.3 percent of white babies scored a perfect 10, compared with 1.4 percent of Black newborns, the study found.
Only 1.2 percent of Chinese-American infants got a 10, and less than 1 percent of Indian-American newborns got a 10. The paper was published last year in the Journal of Perinatal Medicine.
Criticism of the universally used Apgar score comes as racial disparities and concern over systemic bias in medicine are drawing new attention. Experts are re-examining many aspects of health care, including the ways in which race is used in clinical algorithms that determine treatment.
Steps have been taken in recent years to remove race and ethnicity from numerous health assessments. Many health systems, for example, have moved away from using a common measure of kidney function that adjusted results by race, adopting a race-neutral measure instead.
Late last year, the American Heart Association dropped race from formulas used to calculate a patient’s risk for developing cardiovascular disease.
But experts are tweaking these algorithms with trepidation, concerned that careless changes could cause harm. If skin color is taken out of the Apgar score, for example, it won’t be easy to find another measure to replace it — and it’s not clear that losing the metric altogether would suffice.
The goal must be to ensure that people of color have fair access to the full array of medical treatments and resources available, said Dr. David Jones, a Harvard professor who has been a leading proponent of removing race from clinical algorithms.
But critics of the Apgar score’s reliance on skin color fear that it is resulting in extra medical treatment being heaped on babies of color who are healthy, potentially sending them to intensive care unnecessarily.
The decision separates neonates from their mothers, disrupts bonding and breastfeeding, exposes babies to the risk of infections, and can be traumatizing for parents. “Neonatal intensive care units save lives, but babies don’t belong there unless they need to be there,” Dr. Grünebaum said.
Other research also has found that Apgar scores are a less accurate indicator of health status for Black babies than for white babies. One study tied the disparities specifically to the skin color component of the grading system.
It was the first clinical method that drew attention to the unique medical needs of newborns and recognized them as patients. It has since been adopted worldwide to provide a rapid assessment of the infant’s transition to life outside the womb.
Yet the scores have been validated only in predominantly white populations, and most of the world is not white.
In a paper published in July 1953, Dr. Apgar said a score of two for skin color “was given only when the entire child was pink.” She had reservations about the metric, however, saying that it was “by far the most unsatisfactory” of the five that make up the composite score.
“Foreign material so often covering the skin of the infant at birth interfered with interpreting this sign, as did the inherited pigmentation of the skin of colored children, and an occasional congenital defect,” she wrote.
The test is done one minute after birth and repeated again five minutes after birth. If the newborn is still not scoring well, the Apgar is repeated at five-minute intervals.
A score anywhere from seven to 10 is considered normal, while a score of three or less is considered low and means the baby is at higher than average risk of dying before age 1.
But the association between scores and infant well-being varies widely by race and ethnicity, according to a study Dr. Emma Gillette, of the Arnhold Institute for Global Health at Icahn School of Medicine in New York City.
Low scores at five minutes were far more inaccurate predictors of poor outcomes for Black babies than for other babies, she and her colleagues found.
Asian infants with low Apgar scores were 100 times more likely to die than Asian babies with normal scores. Low-scoring white babies were 54 times more likely to die than white babies with normal scores.
But Black babies with low scores were only 23 times more likely to die than those with normal scores. “That was kind of shocking, because overall Black babies are almost twice as likely to die,” Dr. Gillette said.
Nevertheless, the scores are a useful tool during the first few minutes of life and a “powerful predictor of mortality across the first year of life,” she added.
Only one study has incorporated the kind of data needed for researchers to examine whether the skin color component was the culprit dragging down Black babies’ Apgar scores. Dr. Sara E. Edwards initiated the study because she thought some Black infants were sent to the neonatal intensive care unit unnecessarily at her medical center, University of Illinois Hospital and Health Science System.
“I felt like I was seeing babies who didn’t seem like they needed to go to the NICU go to the NICU,” said Dr. Edwards, who is now a maternal-fetal medicine fellow at the Icahn School of Medicine at Mount Sinai in New York. “They seemed clinically well and vigorous, but they ended up with lower Apgar scores.”
She and her colleagues analyzed data on babies at the Chicago hospital, which included the individual component scores. The study also compared Apgar scores with results from lab tests that analyzed umbilical cord blood gases, which are an objective measure of the newborn’s metabolic condition and oxygen levels.
What the researchers found surprised them. Although Black newborns had lower Apgar scores at one and five minutes than non-Black babies and were admitted to the NICU at higher rates than non-Black babies, they did not have more abnormal cord gas values.
“There was no difference in the umbilical cord gases, but there was a difference in the Apgar scores — that’s the essential take-home message,” said Dr. Quetzal Class, who is a senior author of the study, which was published last year in the American Journal of Obstetrics and Gynecology.
The study also found that the skin color portion of the test was driving the racial discrepancies in the first Apgar tests, those given to babies one minute after birth.
“The reason that’s important is because the quick score given subjectively by the provider contributes to whether that neonate is sent to the NICU or not,” Dr. Class said.
She added: “There are a ton of other factors that may be considered, but the fast thing is, do you have an Apgar of 3 or Apgar 4? Then you’re going to go to the NICU.”
Experts in neonatal resuscitation acknowledge both the subjectivity and imprecision of aspects of the Apgar test, and say it is not supposed to be used in isolation to guide clinical decisions.
“We do not emphasize the Apgar score at all,” said Dr. Vishal S. Kapadia, co-chair of the American Academy of Pediatrics’ neonatal resuscitation program steering committee.
A 2015 policy statement by the A.A.P. and the American College of Obstetricians and Gynecologists clearly acknowledges the Apgar score’s limitations, Dr. Kapadia noted.
“What we stress is a quick assessment of breathing and heart rate to guide resuscitation decisions, not color,” Dr. Kapadia said. “We know Apgar scores can be subjective and imperfect.”
Dr. Eric Eichenwald, chief of neonatology at the Children’s Hospital of Philadelphia, noted that since the test’s development, many other tools had been added to delivery rooms to help assess newborns.
If skin color is scrapped as an indicator of oxygenation, however, a substitute may be hard to find. Umbilical cord gas analyses take time to run through a lab and can’t provide immediate results.
Pulse oximetry — a noninvasive method that uses a cliplike device attached on a finger to measure oxygen saturation in the blood — has also been found to be less accurate for Black patients.
The devices work by shining light through the skin and detecting the color of the blood, which varies depending on the amount of oxygen. Scientists suspect that inaccurate readings may occur because of the way light is absorbed by darker skin pigment.
Dr. Grünebaum believes the skin color component should be dropped from the Apgar, and an eight-point scale should be adopted. But, he said, change will be difficult to implement because the test is so widely used all over the world. “People don’t even think about the Apgar score anymore — it’s done automatically,” he said.