Modified Ballard score and newborn maturity

ballard score, newborn

1. NEW BALLARD SCORE Dr. RAKSHA S K

2. INTRODUCTION Clinical tool to determine Gestational age Developed by Jeanne L. Ballard MD Ballard JL, Khoury JC, Wedig K,  et al : New Ballard Score, expanded to include extremely premature infants.  J Pediatrics  1991; 119:417-423

3. BALLARD SCORE Six physical and six neurologic criteria Examination is most reliable when performed between 30 and 42 hours of age Scores of each feature are added to calculate a maturity rating that correlates with gestational age and is accurate within two weeks Simplified assessment can be accomplished more quickly (3.5 minutes) Easier to perform on sick infants

4. NEW BALLARD SCORE Ballard system was modified as the new Ballard score (NBS) to improve assessment of infants as preterm as 20 weeks Expands the description of physical and neurologic features Tested in infants from 20 to 44 weeks gestation 6 neurological and physical criteria

5. DIFFERENCE BETWEEN BALLARD AND NEW BALLARD SCORE COMPONENT BALLARD SCORE NEW BALLARD SCORE RANGE SCORE: WEEKS: 5 to 50 26-44 weeks -10 to 50 20- 44 weeks score -1 Optimal age for assessment Between 30 and 42 hours of age Birth to 96 hours Extreme preterm Inacccurate Accurate

6. NEUROMUSCULAR MATURITY

7. PHYSICAL MATURITY

8. NEUROMUSCULAR MATURITY Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear

9. POSTURE Total body muscle tone is reflected in infants posture at rest and resistance to stretch of individual muscles As maturation progresses,fetus gradually assumes increasing passive flexor tone Preterm infant--  unopposed passive extensor tone Term baby- passive flexor tone

10. POSTURE

11. SQUARE WINDOW Wrist flexibility and resistance to extensor stretching are responsible for angle flexion at the wrist Examiner straightens infants fingers and applies gentle pressure on the dorsum of hand ,close to fingers From extreme preterm to post term – angle between palm of the infants hand and forearm is estimated >90,90,60,45,30 and 0

12. SQUARE WINDOW

13. ARM RECOIL Flexor tone of the biceps by measuring the angle of recoil following very brief extension of upper extremity Supine position Place one hand beneath infants elbow for support

14. ARM RECOIL Taking the infant's hand, examiner should set elbow in flexion, then momentarily extends the arm before releasing the hand Angle of recoil to which forearm springs back into flexion is noted Appropriate square is selected on score sheet

15. ARM RECOIL

16. POPLITEAL ANGLE Assesses maturation of passive flexor tone of knee joint by testing for resistance to extension of lower extremity Infant lying supine, thigh is placed gently on the infant's abdomen with knee fully flexed After the infant relaxed in this position, gently grasp the foot at sides with one hand while supporting the side of the thigh with other

17. POPLITEAL ANGLE

18. SCARF SIGN Passive tone of the flexors about the shoulder girdle Examine- Supine The point on the chest to which elbow moves easily prior to significant resistance is noted -1 to 4

19. SCARF SIGN

20. HEEL TO EAR Passive flexor tone about the pelvic girdle by testing passive flexion or resistance to extension of posterior hip flexor muscles Note location of heel where significant resistance present -1 to 4 Ear,nose,chin level,Nipple line,Umbilical area,femoral crease

21. HEEL TO EAR

22. PHYSICAL MATURITY Skin Lanugo Plantar surface Breast Eyes/ ears Genitals

23. SKIN Maturation of fetal skin involves development of intrinsic structures concurrent with the gradual loss of its protetive coating – vernix caseosa Hence it thickens,dries,and become wrinkled and or peels As fetal maturation progresses- develop rash Skin is transparent – before development of stratum corneum

24. SKIN Later it smoothes,thickens and produces vernix 36-37 Weeks- skin loses transparency and underlying vessels not visible At term,fetus expel meconium in to amniotic fluid – which accelerates drying process

25. SKIN

26. LANUGO Fine hair covering the body of the fetus Extreme premature- lacks Lanugo Appear at 24-25 th week By 28 th week- abundant,especially across the shoulders and upper back Term- Most of fetal back is devoid of lanugo IDM : Abundant lanugo over pinna and upper back

27. PLANTAR SURFACE Major foot creases on the sole of the foot First appearance – anterior sole at ball of the foot Very premature and extremely immature – no detectable foot crease Measure the foot length or heel toe distance Heel toe distance Less than 40mm  (-2) Between 40 and 50 mm (-1)

28. PLANTAR SURFACE

29. PLANTAR SURFACE 28-30 weeks,creases appear and cover the anterior portion of plantar surface Extend towards the heel as gesational age progresses Not valid indicator after 12 hours- due to drying of skin

30. BREAST

31. BREAST Consists of breast tissue and fatty tissue Growth is stimulated by maternal estrogens and fetal nutritional status Note- size of areola Palpate breast tissue by holding between thumb and forefinger Estimate diameter in millimeters

32. BREAST Under and over nutrition  size variation Areola is raised by 34 weeks 1-2 mm nodule of breast tissue is palpable by 36 weeks By 40 weeks- nodule is 10mm

33. EAR AND EYES The pinna of the fetal ear changes it configuration and increases in cartilage content as maturation progresses Assessment cartilage thickness,fold pinna forward toward face and release Notes the rapidity with which folded pinna snaps back away from the face when release Very premature infants- pinnae may remain folded

34. EAR AND EYES Note state of eyelid development as an additional indicator Place thumb and forefinger on upper and lower lids, gently move them apart to separate them Extremely immature infant will have tightly fused eyelids, i.E. , The examiner will not be able to separate either palpebral fissure with gentle traction

35. EARS/EYES

36. GENITALS-MALE Fetal testicles begin their descent from peritoneal cavity in to scrotal sac – 30 th week Left testicle precedes right and scrotum during 32 nd week Testicles are palpable in inguinal canal by the end of 33-34 weeks of gestation Scrotal skin thickens and develop deeper and more numerous rugae towards term

37. GENITALS-MALE

38. GENITALS - FEMALE Examine in supine position- Hips partially abducted Extreme prematurity- Labia flat and clitoris is prominent May resemble male phallus As maturation progresses,clitoris become less prominent and labia minora become more prominent At term- both clitoris and labia recede Eventually enveloped by enlarging labia majora

39. GENITALS - FEMALE

40. SCORING TOTAL SCORE WEEKS -10 20 -5 22 24 5 26 10 28 15 30 20 32 25 34 30 36 35 38 40 40 45 42 50 44

41. REFERENCES WWW.BALLARDSCORE.COM CLOHERTY J.P MANUAL OF NEONATAL CARE MEHARBAN SINGH - TEXT BOOK OF NEW BORN CARE Ballard , jeanne et al : A simplified score for assessment of fetal maturation of newly born infants . J pediatrics 1979 ,volume 95,issue 5,769-774 Ballard JL, khoury jc , wedig k,  et al : New Ballard score, expanded to include extremely premature infants .  J pediatrics   1991; 119:417-423

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