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7/31/2019 About the Apgar Score
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About the Apgar Score
The Apgar score, the very first test given to your newborn, occurs in the delivery or birthingroom right after your baby's birth. The test was designed to quickly evaluate a newborn's
physical condition and to determine any immediate need for extra medical or emergencycare.
Although the Apgar score was developed in 1952 by an anesthesiologist named VirginiaApgar, you may have also heard it referred to as an acronym
for: Appearance, Pulse, Grimace,Activity, and Respiration.
The Apgar test is usually given to a baby twice: once at 1 minute after birth, and again at 5
minutes after birth. Sometimes, if there are concerns about the baby's condition or thescore at 5 minutes is low, the test may be scored for a third time at 10 minutes after birth.
Five factors are used to evaluate the baby's condition and each factor is scored on a scale of0 to 2, with 2 being the best score:
1. appearance (skin coloration)2. pulse (heart rate)
3. grimace response (medically known as "reflex irritability")
4. activity and muscle tone5. respiration (breathing rate and effort)
Doctors, midwives, or nurses add these five factors together to calculate the Apgar score.
Scores obtainable are between 10 and 0, with 10 being the highest possible score.
Apgar Scoring
Apgar Sign 2 1 0
Heart Rate
(pulse)
Normal (above 100
beats per minute)
Below 100 beats per
minute
Absent
(no pulse)
Breathing
(rate and effort)
Normal rate and effort,
good cry
Slow or irregular
breathing, weak cry
Absent (no
breathing)
Grimace(responsiveness or"reflex irritability")
Pulls away, sneezes,
coughs, or cries withstimulation
Facial movement only
(grimace) withstimulation
Absent (no
response tostimulation)
Activity
(muscle tone)
Active, spontaneous
movement
Arms and legs flexed
with little movement
No movement,
"floppy" tone
Appearance
(skin coloration)
Normal color all over
(hands and feet arepink)
Normal color (but
hands and feet arebluish)
Bluish-gray or pale
all over
How is the Apgar score done?
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The Apgar score is a number calculated by scoring the heart rate, respiratory effort, muscle
tone, skin color, and reflex irritability (response to a catheterin the nostril). Each of these
objective signs can receive 0, 1, or 2 points.
What does a high or low Apgar score mean?
A perfect Apgar score of 10 means an infant is in the best possible condition. An infant with
an Apgar score of 0-3 needs immediate resuscitation. It is important to note that diligent
care of the newborn is an immediate response to the current status of the infant. It is
inappropriate to wait until Apgar scores are obtained to begin or continue to address the
needs of the neonate.
When is the Apgar scoring done?
The Apgar score is done routinely 60 seconds after the birth of the infant and then is
repeated five minutes after birth.
In the event of a difficult resuscitation, the Apgar score may be done again at 10, 15, and 20
minutes.
What does a persistently low Apgar score mean?
The persistence of low (0-3) Apgar scores at 20 minutes of age is predictive of high rates
ofmorbidity (disease) andmortality (death).
Why was the Apgar score developed?
The score is named for the preeminent Americananesthesiologist Dr. Virginia Apgar (1909-
1974), who invented the scoring method in 1952. Having assisted at thousands of
deliveries, Dr. Apgar wished to focus attention on the baby. Babies were traditionally
dispatched directly to the nursery, often without much formal scrutiny after delivery. Apgar
wanted the baby to be assessed in an organized meaningful manner by the delivery-room
personnel. Dr. Apgar was the first woman to be appointed a full professor at Columbia
University's College of Physicians and Surgeons.
About Newborn Screening
Newborn screening is the practice of testing every newborn for certain harmful or potentially
fatal disorders that aren't otherwise apparent at birth.
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Many of these are metabolic disorders (often called "inborn errors of metabolism") that
interfere with the body's use of nutrients to maintain healthy tissues and produce energy.
Other disorders that screening can detect include problems with hormones or the blood.
In general, metabolic and other inherited disorders can hinder an infant's normal physical
and mental development in a variety of ways. And parents can pass along the gene for acertain disorder without even knowing that they're carriers.
With a simple blood test, doctors often can tell whether newborns have certain conditions
that could eventually cause problems. Even though these conditions are considered rare and
most babies are given a clean bill of health, early diagnosis and proper treatment can make
the difference between lifelong impairment and healthy development.
How States and Hospitals Decide Which Tests to Offer
Traditionally, state decisions about what to screen for have been based on weighing the
costs against the benefits. "Cost" considerations include:
the risk of false positive results (and the worry they cause)
the availability of treatments known to help the condition
financial costs
And states often face conflicting priorities when determining their budgets. For instance, a
state may face a choice between expanding newborn screening and ensuring that all
expectant mothers get sufficient prenatal care. Of course, this is little comfort to parents
whose children have a disorder that could have been found through a screening test but
wasn't.
These questions have not yet all been decided, even though most states have acknowledged
the recommendations and have expanded screening.
So what can you do? Your best strategy is to stay informed. Discuss this issue with both
your obstetrician or health care provider and your future baby's doctor before you give
birth. Know what tests are routinely done in your state and in the hospital where you'll
deliver (some hospitals go beyond what's required by state law).
If your state isn't offering screening for the expanded panel of disorders, you may want to
ask your doctors about supplemental screening, though you'll probably have to pay for
additional tests yourself.
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If you're concerned about whether your infant was screened for certain conditions, ask your
child's doctor for information about which tests were done and whether further tests are
recommended.
Screening Tests
Newborn screening varies by state and is subject to change, especially given advancements
in technology. However, the disorders listed here are the ones typically included in newborn
screening programs.
PKU
When this disorder is detected early, feeding an infant a special formula low in
phenylalanine can prevent mental retardation. A low-phenylalanine diet will need to be
followed throughout childhood and adolescence and perhaps into adult life. This diet cuts
out all high-protein foods, so people with PKU often need to take a special artificial formula
as a nutritional substitute. Incidence: 1 in 10,000 to 25,000.
Congenital Hypothyroidism
This is the disorder most commonly identified by routine screening. Affected babies don't
have enough thyroid hormone and so develop retarded growth and brain development. (The
thyroid, a gland at the front of the neck, releases chemical substances that control
metabolism and growth.)
If the disorder is detected early, a baby can be treated with oral doses of thyroid hormone
to permit normal development. Incidence: 1 in 4,000.
Galactosemia
Babies with galactosemia lack the enzyme that converts galactose (one of two sugars found
in lactose) into glucose, a sugar the body is able to use. As a result, milk (including breast
milk) and other dairy products must be eliminated from the diet. Otherwise, galactose can
build up in the system and damage the body's cells and organs, leading to blindness, severe
mental retardation, growth deficiency, and even death.
Incidence: 1 in 60,000 to 80,000. Several less severe forms of galactosemia that may be
detected by newborn screening may not require any intervention.
http://kidshealth.org/parent/growth/feeding/feednewborn.htmlhttp://kidshealth.org/parent/growth/feeding/breast_bottle_feeding.htmlhttp://kidshealth.org/parent/growth/feeding/breast_bottle_feeding.htmlhttp://kidshealth.org/parent/growth/feeding/feednewborn.htmlhttp://kidshealth.org/parent/growth/feeding/breast_bottle_feeding.htmlhttp://kidshealth.org/parent/growth/feeding/breast_bottle_feeding.html7/31/2019 About the Apgar Score
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Sickle Cell Disease
Sickle cell disease is an inherited blood disease in which red blood cells mutate into
abnormal "sickle" shapes and can cause episodes of pain, damage to vital organs such as
the lungs and kidneys, and even death. Young children with sickle cell disease are especially
prone to certain dangerous bacterial infections, such as pneumonia (inflammation of thelungs) and meningitis(inflammation of the brain and spinal cord).
Studies suggest that newborn screening can alert doctors to begin antibiotic treatment
before infections occur and to monitor symptoms of possible worsening more closely. The
screening test can also detect other disorders affecting hemoglobin (the oxygen-carrying
substance in the blood).
Incidence: about 1 in every 500 African-American births and 1 in every 1,000 to 1,400
Hispanic-American births; also occurs with some frequency among people of Mediterranean,
Middle Eastern, and South Asian descent.
Biotinidase Deficiency
Babies with this condition don't have enough biotinidase, an enzyme that recycles biotin (a
B vitamin) in the body. The deficiency may cause seizures, poor muscle control, immune
system impairment, hearing loss, mental retardation, coma, and even death. If the
deficiency is detected in time, however, problems can be prevented by giving the baby extra
biotin. Incidence: 1 in 72,000 to 126,000.
Congenital Adrenal Hyperplasia
This is actually a group of disorders involving a deficiency of certain hormones produced by
the adrenal gland. It can affect the development of the genitals and may cause death due to
loss of salt from the kidneys. Lifelong treatment through supplementation of the missing
hormones manages the condition. Incidence: 1 in 12,000.
Maple Syrup Urine Disease (MSUD)
Babies with MSUD are missing an enzyme needed to process three amino acids that are
essential for the body's normal growth. When not processed properly, these can build up in
the body, causing urine to smell like maple syrup or sweet, burnt sugar. These babies
usually have little appetite and are extremely irritable.
If not detected and treated early, MSUD can cause mental retardation, physical disability,
and even death. A carefully controlled diet that cuts out certain high-protein foods
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containing those amino acids can prevent this. Like people with PKU, those with MSUD are
often given a formula that supplies the necessary nutrients missed in the special diet they
must follow. Incidence: 1 in 250,000.
Tyrosinemia
Babies with this amino acid metabolism disorder have trouble processing the amino acid
tyrosine. If it accumulates in the body, it can cause mild retardation, language skill
difficulties, liver problems, and even death from liver failure. Treatment requires a special
diet and sometimes a liver transplant. Early diagnosis and treatment seem to offset long-
term problems, although more information is needed. Incidence: not yet determined. Some
babies have a mild self-limited form of tyrosinemia.
Cystic Fibrosis
Cystic fibrosis (CF) is a genetic disorder that particularly affects the lungs and digestive
system and makes kids who have it more vulnerable to repeated lung infections. There is no
known cure treatment involves trying to prevent serious lung infections (sometimes with
antibiotics) and providing adequate nutrition. Early detection may help doctors reduce the
problems associated with CF, but the real impact of newborn screening has yet to be
determined. Incidence: 1 in 2,000 Caucasian babies; less common in African-Americans,
Hispanics, and Asians.
MCAD deficiency (medium chain acyl CoA dehydrogenase deficiency)
Children with this fatty acid metabolism disorder are prone to repeated episodes of low
blood sugar (hypoglycemia), which can cause seizures and interfere with normal growth and
development. Treatment makes sure kids don't fast (skip meals) and supplies extra
nutrition (usually by intravenous nutrients) when they're ill. Early detection and treatment
can help affected children live normal lives.
Toxoplasmosis
Toxoplasmosis is a parasitic infection that can be transmitted through the mother's placenta
to an unborn child. The disease-causing organism, which is found in uncooked or
undercooked meat, can invade the brain, eye, and muscle, possibly resulting in blindness
and mental retardation. The benefit of early detection and treatment is uncertain.
Incidence: 1 in 1,000. But only one or two states screen for toxoplasmosis.
These aren't the only disorders that can be detected through newborn screening. Other
conditions that are candidates for newborn screening include:
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Duchenne muscular dystrophy, a childhood form of muscular dystrophy that can be
detected through a blood test
HIV
neuroblastoma, a type of cancer that can be detected with aurine test
Hearing Screening
Most but not all states require newborns' hearing to be screened before they're discharged
from the hospital. If your baby isn't examined then, be sure that he or she does get
screened within the first 3 weeks of life.
Kids develop critical speaking and language skills in their first few years. A hearing loss
that's caught early can be treated to help prevent interference with that development.
Should I Request Additional Tests?
If you answer "yes" to any of these questions, talk to your doctor and perhaps a genetic
counselor about additional tests:
Do you have a family history of an inherited disorder?
Have you previously given birth to a child who's affected by a disorder?
Did an infant in your family die because of a suspected metabolic disorder?
Do you have another reason to believe that your child may be at risk for a certain
condition?
How Newborn Screening Is Performed
In the first 2 or 3 days of life, your baby's heel will be pricked to obtain a small blood
sample for testing. Most states have a state or regional laboratory perform the analyses,
although some use a private lab.
It's generally recommended that the sample be taken after the first 24 hours of life. Some
tests, such as the one for PKU, may not be as sensitive if they're done too soon after birth.
However, because mothers and newborns are often discharged within a day, some babies
may be tested within the first 24 hours. If this happens, the AAP recommends that a repeat
sample be taken no more than 1 to 2 weeks later. It's especially important that the PKU
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screening test be run again for accurate results. Some states routinely do two tests on all
infants.
Getting the Results
Different labs have different procedures for notifying families and pediatricians of the
results. Some may send the results to the hospital where your child was born and not
directly to your child's doctor, which may mean a delay in getting the results to you.
And although some states have a system that allows doctors to access the results via phone
or computer, others may not. Ask your doctor how you'll get the results and when you
should expect them.
If a test result comes back abnormal, try not to panic. This doesnot necessarily mean that
your child has the disorder in question. A screening test is not the same as diagnostic test.
The initial screening provides only preliminary information that must be followed up with
more specific diagnostic testing.
If testing confirms that your child does have a disorder, your child's doctor may refer you to
a specialist for further evaluation and treatment. Keep in mind that dietary restrictions and
supplements, along with proper medical supervision, can often prevent most of the serious
physical and mental problems that were associated with metabolic disorders in the past.
You also may wonder whether the disorder can be passed on to any future children. You'll
want to discuss this with your doctor and perhaps a genetic counselor. Also, if you have
other children who weren't screened for the disorder, consider having testing done. Again,
speak with your doctor.
Know Your Options
Because state programs are subject to change, you'll want to find up-to-date information
about your state's (and individual hospital's) program. Talk to your doctor or contact your
state's department of health for more information.
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In Search of Cuts, Health OfficialsQuestion NICU Overuse
An unlikely battlefield in Texas budget war is a hushed pink-and-blue hospitalnursery, where 1- and 2-pound babies bleat like lambs under heating lamps and
neonatal nurses use tiny rulers to measure limbs that are no bigger than fingers.Enlarge This Image
Caleb Bryant Miller/The Texas Tribune
Adrienne Ball, of Austin, with her baby Mila, who was born three months early in Seton Medical Center Austin's
neonatal intensive care unit.
Caleb Bryant Miller/The Texas Tribune
Natasha Rosen with Matthew, who was born three months premature, in Seton Medical Center Austin's
neonatal I.C.U.
State health officials, searching for solutions to Texas multibillion-dollar budget
shortfall, have set their sights on these neonatal intensive care units, or NICUs,
which they fear are being overbuilt and overused byhospitalseager to profit from
the high-cost care and by doctors who are too quick to offer pregnant mothers
elective inductions and Caesarean sections before their babies are full term.
TheTexas Health and Human Services Commission, under the gun to find savings
in the states huge Medicaidprogram, suggested last month that it could save $36.5
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state health statistics. Meanwhile, the number of NICU beds in Texas hospitals has
surged roughly 84 percent, to 2,510 in 2009 from 1,365 in 1998.
Some state health officials suggest there is a profit motive at play for hospitals. The
average routine delivery costs Medicaid $2,500, according to state records; theaverage NICU stay costs $45,000.
Elective procedures like induction of labor before 39 weeks of gestation or
Caesarean-section delivery at the mothers request contribute to complications that
send babies to the NICU, these health officials say.
In 1998, C-sections accounted for 23.8 percent of Medicaid births, state data show;
more than a decade later, they made up 35 percent. In 2009, 137 Medicaid-covered
newborns suffered complications resulting from elective inductions, according to
state health officials, at a cost of $1.6 million to the Texas Medicaid program, the
joint state-federal health program that covers more than half of Texas births.
Dr. Charles T. Hankins, a longtime neonatologist at Texas Childrens Hospitalin
Houston and an associate professor ofpediatrics at the Baylor College of Medicine,
suggested there is a far more nuanced motive than pure profit. Hospitals hit
hard by low reimbursement rates and high malpractice costs for routine obstetric
care are simply looking for ways to make up the difference. A lot of facilities
realize that if they had a Level 3 nursery, they could help offset their costs, he said.
Dr. Hankins thinks the NICU boom is often driven less by hospitals than by
obstetricians who do their residency training in facilities with NICUs and cannot
imagine not having one available. The doctors want their patients to be happy,
and the hospital administrators want to keep the doctors happy, he said.
The problem is that diagnosing the need for neonatal care can be subjective, Dr.
Hankins said. If a hospital wants to increase its NICU census, providers can admit
more infants or lengthen their stays and parents generally trust those
assessments. He said there is also no state oversight of either admission ordischarge best practices.
Hospitals are willing to work together to accomplish the optimal care for these
babies, Dr. Hankins said, but added that they need proper guidance to do so.
http://www.baylorclinic.com/find-a-doctor/details/index.cfm?id=750http://www.texaschildrens.org/http://www.texaschildrens.org/http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/pediatrics/index.html?inline=nyt-classifierhttp://www.bcm.edu/http://www.baylorclinic.com/find-a-doctor/details/index.cfm?id=750http://www.texaschildrens.org/http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/pediatrics/index.html?inline=nyt-classifierhttp://www.bcm.edu/7/31/2019 About the Apgar Score
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Some state lawmakers are under the impression that Texas Medicaid program is
already offering such guidance. The growth in NICU beds much of it along the
Texas-Mexico border, which has the youngest population in the state, and in
suburban hospitals outside Houston, Dallas and San Antonio comes despite
years of improvements in prenatal care for mothers on Medicaid.
One of the tenets of Medicaid has long been better prenatal care, and less babies
needing NICUs, said Senator Robert Deuell, Republican of Greenville, a family
practice doctor who, in a recent Senate hearing, suggested that the cost savings
health officials are looking for might not be ample in the delivery room.
But Dr.Frank Mazza, vice president and chief patient safety officer for the Seton
Family of Hospitals, said state health officials are on the right path in considering
birth inefficiencies. When Seton made the almost unheard-of move in 2005 ofprohibiting elective inductions before 39 weeks part of a systemwide effort to
improve perinatal safety the number of babies admitted to the NICU fell
dramatically. The hospitals revenue from them also dropped by 96 percent, to
$186,000 per year from roughly $4.5 million per year.
We should have in Texas the safest health care and the most cost-effective health
care, Dr. Mazza said. By keeping babies out of the NICU, you accomplish both.
Still, even Dr. Mazza acknowledged that if his own wife were having a baby today,
he would choose a hospital with all the bells and whistles.
Of course Id want her in a hospital with a NICU, he said, with the latest and
greatest technology.
http://www.texastribune.org/directory/bob-deuell/http://www.seton.net/about_seton/seton_leadership_team/frank_mazzahttp://www.seton.net/about_seton/seton_leadership_team/frank_mazzahttp://www.seton.net/http://www.seton.net/http://www.texastribune.org/directory/bob-deuell/http://www.seton.net/about_seton/seton_leadership_team/frank_mazzahttp://www.seton.net/http://www.seton.net/7/31/2019 About the Apgar Score
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Congenital Abnormalities
Spina BifidaIn this condition, there is a raw swelling over a portion of the spine at birth. This results in paralysis of the
legs (either partial or complete), inability to control bladder functioning and inability to feel anything below
the spina bifida. In some cases, there is a build up and retention of water in the brain, which is known as
hydrocephalus. This swelling can be closed by an operation by specialists.
Umbilical hernias
In this condition, parts of the digestive system are lying outside the stomach cavity. This is because the
area around the navel is not very strong. Normally, cases of umbilical hernias around the navel heal on their
own; if they dont, surgery is required.
Sickle cell disease
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This is a hereditary condition that is most commonly found among people of West African or African
Caribbean descent. The hemoglobin in the red blood corpuscles disintegrates at a quicker rate than normal.
Hemoglobin is important, as it carries oxygen to the different parts of the body. Reduction in hemoglobin
causes anemia and blocks blood vessels in the hands, legs and stomach. An attack can last for a few days
and can be treated with painkillers. This is also known as Sickle Cell disease.
Cystic Fibrosis
This is another hereditary illness, in which the tissues in the body produce unusually thick mucus. The
commonly affected organs are the lungs, the intestines and pancreas. If the lungs are affected, the air ducts
are blocked and hence, vulnerable to infection. Children with this condition have an inability to digest food
completely and have bad smelling bowel movements and constipation. They are well below the normal
weight for their age. This illness has no cure, but if detected in the initial stages, lung damage can be
reduced. These children are susceptible to chest infections and have to be treated with antibiotics. Chest
physiotherapy is required regularly to remove thick phlegm.
Coeliac disease
In this condition, the child's intestine reacts strongly to gluten, a protein found in wheat. These children have
a severe case of diarrhea, where the stools are fatty, pale and don't flush away. The child does not put on
weight as required. The illness can be detected by a blood test. After being detected, the child will have to
completely give up gluten containing food. Once this is done, stools return to normal and the child will put
on weight.
Clubfoot
In this condition, the foot curves inwards or outwards. All babies are checked for this at birth, more so, if
they were born in the breech position, as it occurs more frequently with these babies. Often, they can be
manipulated into the proper position, with little or no treatment. Surgery may be required in severe cases.
This condition is also known as Talipes.
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Cleft palate
In this condition, the cleft lip and the cleft palate are fused, thus the baby cannot be breast-fed. Various
support groups will help you deal with the situation and corrective plastic surgery is possible.
Congenital dislocation of the hip
All babies are screened for this condition at birth and when they are eight weeks old. If this condition goes
undetected, walking can become a problem later in life. If diagnosed with this problem, the baby will have to
wear a special splint for sometime. Most recover without having to be operated on, but some do need an
operation. This condition is prevalent more among girls and breech babies.
Cerebral palsy
In this condition, the parts of the brain that control body movements are damaged. This can happen before
birth, during birth, or in the first two years after birth. In some cases, damage may not be noticed at birth,
but as the child grows, it becomes evident. It is difficult to pinpoint as to what causes this damage. There
are a few tests that can be conducted when the baby is eight weeks old to screen him for cerebral palsy.