# The 5-min Apgar score and primary school performance: a Dutch nationwide cohort study

## TL;DR

This study finds that lower 5-minute Apgar scores at birth are linked to poorer primary school performance and higher rates of special education use.

## Contribution

The study shows that even moderate Apgar scores (7-9) are associated with increased risk of special education and lower academic track placement.

## Key findings

- Children with Apgar scores of 0-3 had the highest rate of special education (14.3%) and lowest high track recommendation (40.7%).
- Apgar scores of 7-9 showed significantly lower odds of high track recommendations compared to a score of 10.
- Lower Apgar scores correlated with higher odds of needing special education, even after adjusting for confounding factors.

## Abstract

The purpose of this study is to investigate the association between the 5-min Apgar score and primary school performance. The national cohort study involves singletons born between 35+ 0–42 + 6 weeks of gestation from 2000 to 2009. The Dutch Perinatal Registry was linked with Statistics Netherland’s database to study educational outcomes at primary school, focusing on special education use and a high track recommendation for secondary school at age 12. Multivariate (adjusted) logistic regression assessed the association between Apgar score (grouped as 0–3, 4–6, 7, 8, 9, and 10) and these outcomes. Of the 1,618,087 children available, a total of 6.4% attended special education at primary school. The highest rate of 14.3% was observed in the group with the lowest Apgar scores (0–3), gradually decreasing to the lowest rate of 6.0% in the group with the highest Apgar score. Compared with a score of 10, the lowest scores had the highest odds ratio for use of special education (adjusted OR 2.4; 95% CI 2.1–2.8). Similarly, lower Apgar scores were associated with a reduced likelihood of receiving a high track recommendation for secondary school. The lowest rate of a high track recommendation (40.7%) was found in children with Apgar score of 0–3, increasing to 45.0% in those with score of 10. Even Apgar scores of 7, 8 and 9 showed significantly lower odds for, compared with a score of 10.

Conclusion: There is an association between the Apgar score and primary school performance, with lower Apgar scores linked to poorer educational outcomes.

What is Known:

• The 5-min Apgar score has been linked to educational performance, with poorer outcomes being reported in children with lower scores.

• An increasing trend in low Apgar scores has been observed in the Netherlands.

What is New:

• There is an association between the full range of Apgar scores and primary school performance, with lower scores being linked to poorer educational performance.

• Children born with Apgar score of 7, 8 or 9 had a significantly higher risk of attending special education and lower risk of getting a high track recommendation for secondary school, compared to children with score of 10.

The online version contains supplementary material available at 10.1007/s00431-025-06526-6.