Ballard Gestational Age Assessment -1: sticky, friable, transparent

0 : gelatinous, red, translucent

PHYSICAL MATURITY 1 : smooth pink, visible veins
 Skin 2 : superficial peeling & / or rash, few veins
 Lanugo 3 : Cracking, pale areas, rare veins
 Plantar Surface 4 : parchment, deep cracking, no vessels
 Breast 5 : leathery, cracked, wrinkled
 Eye/Ear
 Genitals-Male
PRINCIPLES OF EXAM
 Timing
o Most reliable if performed by 12 hrs of life
 Keep infant warm

LANUGO
SKIN  Lanugo is the fine hair covering the body of
 Maturation of fetal skin involves the the fetus.
development of its intrinsic structures  begins to appear at approximately the 24th to
concurrent with the gradual loss of its 25th week
protective coating, the vernix caseosa.  abundant across the shoulders and upper
 it thickens, dries and becomes wrinkled and/or back, by the 28th week of gestation.
peels, and may develop a rash as fetal  At term, most of the fetal back is devoid of
maturation progresses lanugo.
 Before the development of the epidermis with  With increasing gestation
its stratum corneum, the skin is transparent o Lower back areas thin first
and adheres somewhat to the examiner's o Bald areas appear appear over lumbo-sacral
finger. area
 Later it smoothes, thickens and produces a o Mostly bald by term
lubricant, the vernix, that dissipates toward  Amount and location may vary w/ nutritional
the end of gestation. status, ethnicity, hormonal & metabolic factors
 At term and post-term, the fetus may expel o For example, infants of diabetic mothers
meconium into the amniotic fluid. This may characteristically have abundant lanugo on
add an accelerating effect to the drying their pinnae and upper back until close to or
process, causing peeling, cracking, beyond full-term gestation.
dehydration, and imparting a parchment,  When scoring for lanugo, the examiner selects
then leathery appearance to the skin. the square that most closely describes the
 relative amounts of lanugo on the upper and 0 : >50 mm, no crease
lower areas of the infant's back. 1 : faint red marks
2 : anterior transverse crease only
-1 : none
3 : creases ant. 2/3
0 : sparse
4 : creases over entire sole
1 : abundant
2 : thinning
3: bald areas
4: mostly bald

PLANTAR SURFACE BREAST

 first appearance of a crease appears on the  The breast bud consists of:
anterior sole at the ball of the foot. This may o breast tissue that is stimulated to grow by

be related to foot flexion in utero, but is maternal estrogen

contributed to by dehydration of the skin.
 Infants of non-white origin have been reported
to have fewer foot creases at birth.
 acceleration of neuromuscular maturity
African American infants usually compensates
for this, resulting in a cancellation of the
o maternal estrogen effect may produce
neonatal gynecomastia on the second to
fourth day of extrauterine life.
o fatty tissue which is dependent upon fetal
in nutritional status.
 The size of the areola and the presence or
absence of stippling (created by the

delayed foot crease effect. Hence, there is developing papillae of Montgomery).

 Under- and over-nutrition of the fetus may
usually no over- or under-estimation of
affect breast size variation at a given gestation.
gestational age due to race when the total
-1 : imperceptable
score is performed.
0 : barely perceptible
 Very premature no detectable foot
1 : flat areola, no bud
creases.
2 : stippled areola, 1-2 mm bud
• Measure the foot length or heel-toe
3 : raised areola, 3-4 mm bud
distance.
4 : full areola, 5-10 mm b
• Heel-toe distances:
o less than 40 mm (-2)
o between 40 and 50 mm (-1)

-1 : heel-toe ,40–50 mm: -1, < 40 mm: -2

  The left testicle precedes the right and usually
enters the scrotum during the 32nd week.
 Both testicles are usually palpable in the upper
to lower inguinal canals by the end of the
33rd to 34th weeks of gestation.
 Concurrently, the scrotal skin thickens and
Eye / Ear develops deeper and more numerous rugae.
 The pinna of the fetal ear changes it  Testicles found inside the rugated zone are
configuration considered descended.
 Increasing maturity increases in cartilage  In extreme prematurity the scrotum is flat,
content smooth and appears sexually undifferentiated.
 In very premature infants, the pinnae may  At term to post-term, the scrotum may
remain folded when released. become pendulous and may actually touch the
 eyelid development as an additional indicator mattress when the infant lies supine.
of fetal maturation.  Note: In true cryptorchidism, the scrotum on
 The extremely immature infant will have the affected side appears uninhabited,
tightly fused eyelids hypoplastic and with underdeveloped rugae
 the rate of eyelid un-fusion may be affected compared to the normal side, or, for a given
by certain stress-related intrauterine and gestation, when bilateral.
humoral factors.
-1 : lids fused loosely: -1 ; tightly: -2 -1 : Scrotum flat, smooth
0 : lids open; pinna flat, stays folded 0 : scrotum empty, faint rugae
1 : slightly curved pinna; soft; slow recoil 1 : testes in upper canal, rare rugae
2: well-curved pinna; soft but ready recoil 2 : testes descending,few rugae
3: formed & firm; instant recoil 3 : testes down, good rugae
4: thick cartilage; ear stiff 4: testes pendulous,deep rugae

GENITALS: (FEMALE)
GENITALS: (MALE)  In extreme prematurity, the labia are flat and
 Fetal testicles begin their descent from the the clitoris is very prominent and may
peritoneal cavity into the scrotal sack at resemble the male phallus.
approximately 30th week of gestation.
 As maturation progresses, the clitoris becomes
less prominent and labia minora become more
prominent.
 Nearing term, both clitoris and labia minora
recede and are eventually enveloped by the
enlarging labia majora.
 The labia majora contain fat and their size are
NEUROMASCULAR MATURITY
affected by intrauterine nutrition.
 Posture
 Over-nutrition may result in large labia majora
 Square Window
earlier in gestation, whereas under-nutrition, as
 Arm Recoil
in intrauterine growth retardation or post-
 Popliteal Angle
maturity, may result in small labia majora with
 Scarf Sign
relatively prominent clitoris and labia minora
 Heel to Ear
late into gestation.
Principles of Neuromascular Exam
 Lower score on this item in the chronically
 Positioning
stressed or growth retarded fetus may be
o Head midline
counter-balanced by a higher score on certain
o Hips flat
neuro-muscular items.
 Reliability of exam altered by:
 Hips should be only partially abducted, i.e., to
o Sedation
approximately 45° from the horizontal with the
o Anesthesisa
infant lying supine.
o Paralysis
 Exaggerated abduction may cause the clitoris
o Criticall ill state
and labia minora to appear more prominent,
o Breech position
whereas adduction may cause the labia majora
 Note: Neuromuscular assessment may be too
to cover over them.
stressful for premature and sick infants
o Should performed by skilled neonatal ICU
-1 : clitoris prominent & labia flat
personnel once infant stabilized and able to
0 : prominent clitoris & small labia minora
tolerate the exam.
1 : prominent clitoris & enlarging minora
2 :majora & minora equally prominent
3 : majora large, minora small
POSTURE: (AT REST)
4 : majora cover clitoris & minora
 As maturation progresses increasing passive
flexor toneIncreasing passive flexor tone 
proceeds to centripetal direction.
 The preterm infant: exhibits unopposed
passive extensor tone,
 Infant approaching term shows progressively
less opposed passive flexor tone.
 Lower extremities slightly ahead of upper
extremities (caudo cephalad)
 the infant is placed supine (if found prone)
and the examiner waits until the infant settles
into a relaxed or preferred posture.
 If the infant is found supine, gentle
manipulation (flex if extended; extend if flexed)
of the extremities will allow the infant to seek
the baseline position of comfort.
 Score #3: Hip flexion without adduction
results in the frog-leg position
 Score #4: Hip adduction accompanying flexion
is depicted by the acute angle at the hips in
posture square
SQUARE WINDOW
 Wrist flexibility and/or resistance to extensor
stretching are responsible for the resulting
angle of flexion at the wrist.
 From extremely pre-term to post-term, the
resulting angle between the palm of the
infant's hand and forearm is estimated at;
1) >90°, (0) 90°, (1) 60°, (2) 45°, (3) 30°, (4) 0°.
 At term and post term, the infant has
maximum passive Flexor tone and minimum
passive Extensor tone.
 Flex the hand at the wrist. Exert pressure
sufficient to get as much flexion as possible.
The angle between the hypothenar eminence
and the anterior aspect of the forearm is
measured and scored.
ARM RECOIL
 Tests Passive Flexor Tone of biceps muscle
o Test one arm at a time in order to avoid
the Moro reflex
o Supine position
o Hold infant’s hand
 Briefly flex the elbowthen momentarily
extent arm Release hand
 The angle of recoil to which the forearm
springs back into flexion is noted
 The extremely pre-term infant will not exhibit
any arm recoil.
 Score #4: selected only if there is contact
(-
between the infant's fist and face. This is seen
in term and post term infants.
 Care must be taken not to hold the arm in the
extended position for a prolonged period, as
this causes flexor fatigue and results in a
falsely low score due to poor flexor recoil.

POPLITEAL ANGLE
 assesses maturation of passive flexor tone
about the knee joint by testing for resistance
to extension of the lower extremity
o refrain from touching hamstrings (muscle
group being tested) during maneuver
o thigh placed in knee-chest position w/
knee fully flexed
o allow infant to relax, then grasp foot at
sides
o extend leg until resistance is felt
o estimate angle behind the knee
 It is important that the examiner wait until
the infant stops kicking actively before
extending the leg.
 The prenatal frank breech position unreliable
for the first 24 to 48 hours of age due to
prolonged intrauterine flexor fatigue. The test
should be repeated once recovery
occurred.
SCARF SIGN
 tests the passive tone of the posterior
shoulder girdle flexor muscle.
o Supine position w/ head midline
o Hold infant’s hand across chest and use
thumb of other hand to gently push
elbow across chest
o Or gently pull arm across chest
o Stop when resistance is felt
 Scores based on position of elbow at
landmarks
 Landmarks noted in order of increasing
maturity are:
o -1 :full scarf at the level of the neck
o 0 : contralateral axillary line
o 1 :contralateral nipple line
o 2 :xyphoid process
o 3 :ipsilateral nipple line
o 4: ipsilateral axillary line
has
  Neuromuscular score +
Physical Maturity
 Total score correlates to weeks of
gestation

HEEL-TO-EAR
Appendix
 Test for passive flexion or resistance to
extension of posterior hip flexor muscles
SAMPLE SCORING
o Refrain from touching gluteus mucles (muscle
group being tested) during maneuver
o Rest leg alongside body
o Grasp foor along both sides
o Gently pull toward ear until resistance felt
 Scores based on location of heel to
landmarks
o Measurement unreliable if frank breech in
utero
 Landmarks noted in order of increasing
maturity include resistance felt when the heel
is at or near the:
o (-1) ear
o (0) nose
o (1) chin level
o (2) nipple line
o (3) umbilical area
o (4) femoral crease

GESTATIONAL AGE EVALUATION

 Sum score
References :

Dr. Gaspar’s ppt

Ballard JL, Khoury JC, Wedig K, et al: New

Ballard Score, expanded to include extremely
premature infants. J Pediatrics 1991; 119:417-
423.