About the Apgar Score

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.
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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.
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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.
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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.

Documents

About the Apgar Score