Gestational age estimation- pediatrics.pptx

Assessment of gestational age in newborn
Sreelakshmi C K
4th year student-40th batch
Govt. Medical college, Thrissur

1. ESTIMATION OF NEONATAL GESTATIONAL AGE Presented by: Sreelakshmi C K Roll no:130 40 th batch

2. Prenatal Gestational Age Assessment Estimated date of term delivery (EDD) is calculated by adding 9 calendar months and seven days to the 1 st day of mother’s last menstrual period (LMP)- Naegele’s rule Collection of prenatal data First fetal movement (16-20 weeks) Fetal heart sounds (20 weeks) (with doppler 9-12 weeks)
Fundal height
Amniotic fluid creatinine levels
Maternal serum and urine estriols Fetal US

3. Fetal US Measurements Crown to rump length Biparietal diameter
Femur length
Abdominal Circumference
Head Circumference
Placental grade

4. Classification of newborns based on gestational age Newborns are divided into following based on gestational age Preterm < 36 weeks+6 days Term 37-41 weeks+6days Post term after 42 weeks Gestational age is calculated from last menstrual period.

5. Using the gestational age score the weight, height and head circumference can be plotted on the infants growth chart
This information is how the infant is diagnosed as SGA, LGA, or AGA SGA- small for gestational age-weight below 10 th percentile
AGA-weight between 10 and 90 th percentiles
LGA-weight above 90 th percentile
IUGR-deviation in expected fetal growth pattern, caused by multiple adverse conditions

6. Postnatal assessment of Gestational Age- Expanded new Ballard Score and dubowitz score Ballard scoring system is accurate to within 2 wk of actual gestational age The physical maturity part of the examination should be done in the first two hours of birth
The neuromuscular maturity examination should be completed with 24 hours after delivery
Derived to look at various stages in an infants gestational maturity and observe how physical characteristics change with gestational age
Neonates who are more physically mature normally have higher scores than premature infants

7. Neurological Criteria in New Ballard Score 1. Posture 2.Square window 3. Arm recoil 4. Popliteal angle 5.Scarf sign 6. Heel to ear maneuver

8. 1.Posture Muscle tone is reflected in the infant’s preferred posture at rest. As maturation progresses, the fetus gradually assumes increasing passive flexor tone at rest that proceeds in a centripetal direction, with lower extremities slightly ahead of upper extremities

9. 2. Scarf Sign Scarf sign tests the passive tone of the flexors about the shoulder girdle. With the infant lying supine, the examiner adjusts the infant’s head to the midline and supports the infant’s hand across the upper chest with one hand The thumb of the examiner’s other hand is placed on the infant’s elbow. The examiner tries to pull the elbow gently across the chest, feeling for the resistance

10. Full scarf at the level of the neck (-1)
contralateral axillary line (0)
contralateral nipple line (1) xyphoid process (2)
ipsilateral nipple line (3)
ipsilateral axillary line (4)

11. 3. Square Window Wrist flexibility and/or resistance to extensor stretching are responsible for the resulting angle of flexion at the wrist. The examiner straightens the infant’s fingers and applies gentle pressure on the dorsum of the hand, close to the fingers. From extremely pre-term to post-term, the resulting angle between the palm of the infant’s hand and forearm is gradually diminished.

12. 4. Arm Recoil Arm recoil examines the passive flexor tone of the biceps muscle by measuring the angle of recoil following very brief extension of the upper extremity. With the infant lying supine, the examiner places one hand beneath the infant’s elbow for support. Taking the infant’s hand, the examiner briefly sets the elbow in flexion, then momentarily extends the arm before releasing it. The angle of recoil, to which the forearm springs back into flexion, is noted

13. 5. Popliteal Angle This maneuver assesses the maturation of passive flexor tone of the knee extensor muscles by testing for resistance to extension of the lower extremity. With the neonate lying supine, the thigh is placed gently on the abdomen with the knee fully flexed. The examiner gently grasps the foot at the sides with one hand while supporting the side of the thigh with the other. Care is taken not to exert pressure on the hamstrings. The leg is extended until a definite resistance to extension is appreciated. At this point the angle formed at the knee by the upper and lower leg is measured In some infants, hamstring contraction may be visualized during this maneuver .

14. 6. Heel to Ear This maneuver measures the passive flexor tone of the posterior hip flexor muscles. The infant is placed supine and the flexed lower extremity is brought to rest on the cot. The examiner supports the infant’s thigh laterally alongside the body with the palm of one hand. The other hand is used to grasp the infant’s foot at the sides and to pull it toward the ipsilateral ear. The examiner feels for the resistance to extension of the posterior pelvic girdle flexors and notes the location of the heel where significant resistance is appreciated

15. Landmarks noted in order of increasing Maturity include resistance felt when the heel is at or near the:
ear (-1)
nose (0)
chin level (1)
nipple line (2)
umbilical area (3)
femoral crease (4)

16. Physical Criteria in New Ballard Score 1. Texture of skin
2. Lanugo hair
3. Ear cartilage
4. Breast bud
5. External genitalia
6. Plantar creases

17. 1. Skin With maturation, the fetal skin gets thickened, dried and there is a gradual loss of its protective coating, the vernix caseosa . Skin of a post-term fetus may be wrinkled, cracked with peeling imparting a leathery and parchment-like appearance. Before the development of the epidermis and stratum corneum , the skin is transparent and sticky. Later on, it becomes smooth and thick

18. 2. Lanugo Lanugo is the fine hair covering the body of a fetus . It is absent in extremely preterm neonates. Lanugo begins to appear at 24-25 weeks of gestation. Abundant lanugo hair is seen over the shoulders and back, by the gestation of 28 weeks,after which it again gets thinned, starting from the lower back. At term, most of the fetal body lacks any lanugo.

19. 3. Ear Recoil The cartilage content of the pinna of the fetal ear increases with the advancement of fetal gestation. In a term neonate the pinna is thick and well-formed. When the pinna is folded forward and released in a term neonate, it recoils back to its original position immediately On the other hand, in very premature infants, pinna is very soft and remains folded after release

20. 4. Breast Bud The breast bud is the button-like structure beneath the areola. It consists of the growth of breast tissue developed by the influence of maternal estrogens and deposition of fatty tissue which is dependent upon fetal nutritional status. The breast tissue beneath the skin is palpated by holding it between thumb and forefinger, estimating its diameter, Breast bud of a term neonate usually measures between 0.5 and 1 cm while that of preterm is below 0.5 cm

21. 5. Genitalia Male In extremely premature neonates, the scrotum is small in size, surface is smooth, non- pigmented with scanty rugae . Fetal testicles begin to descend from the peritoneal cavity into the scrotal sack at approximately 30 th week of gestation. Both testicles are usually palpable in the upper to lower inguinal canals by the end of the 33 rd to 34 th weeks of gestation. The scrotum becomes pendulous, the scrotal skin thickens, becomes pigmented and develops deeper and more numerous rugae .

22. Female In extremely premature neonates the labia are flat and the clitoris is prominent. As maturation progresses, the clitoris and labia minora become less prominent. In term female neonates, both clitoris and labia minora recede, and are eventually enveloped by the enlarging labia majora The labia majora contain fat and the size is affected by intrauterine nutrition. Intrauterine growth retardation or post-maturity, may result in small labia majora with relatively prominent clitoris and labia minora even in late gestation

23. 6. Sole Creases Extremely preterm neonates have no detectable deep sole creases. The first appearance of a deep crease occurs on the anterior part of the sole at the ball of the foot. With the advancement of gestation, the whole of the sole gets filled with deep sole creases

24. Dubowitz score was based on assessment of 22 items (10 neurological signs and 12 external signs). It was cumbersome and time consuming. It was gradually replaced by the Ballard score, which is easier to perform.

25. References Clinical methods in pediatrics - Piyush Gupta-4 th edition Nelson textbook of pediatrics-21 st edition Ghai essentials of pediatrics-10 th edition New Ballard score to estimate gestational age in preterm babies. Dr Sridhar K-https://youtu.be/C1zyH-9J7Y0?si=bT5Jk3y9fbgBbro6

26. THANKYOU😊