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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
 Timing
o Most reliable if performed by 12 hrs of life
 Keep infant warm

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


 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

o maternal estrogen effect may produce
contributed to by dehydration of the skin.
neonatal gynecomastia on the second to
 Infants of non-white origin have been reported
fourth day of extrauterine life.
to have fewer foot creases at birth.
o fatty tissue which is dependent upon fetal
 acceleration of neuromuscular maturity in nutritional status.
African American infants usually compensates  The size of the areola and the presence or
for this, resulting in a cancellation of the 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
2 : stippled areola, 1-2 mm bud
• Measure the foot length or heel-toe
3 : raised areola, 3-4 mm bud
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: (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
 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
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
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  Flex the hand at the wrist. Exert pressure
less opposed passive flexor tone. sufficient to get as much flexion as possible.
 Lower extremities slightly ahead of upper The angle between the hypothenar eminence
extremities (caudo cephalad) and the anterior aspect of the forearm is
 the infant is placed supine (if found prone) measured and scored.
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

 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
 Wrist flexibility and/or resistance to extensor
extent arm Release hand
stretching are responsible for the resulting  The angle of recoil to which the forearm
angle of flexion at the wrist. springs back into flexion is noted
 From extremely pre-term to post-term, the  The extremely pre-term infant will not exhibit

resulting angle between the palm of the any arm recoil.

 Score #4: selected only if there is contact
infant's hand and forearm is estimated at; (-
between the infant's fist and face. This is seen
1) >90°, (0) 90°, (1) 60°, (2) 45°, (3) 30°, (4) 0°.
in term and post term infants.
 At term and post term, the infant has
 Care must be taken not to hold the arm in the
maximum passive Flexor tone and minimum extended position for a prolonged period, as
passive Extensor tone. this causes flexor fatigue and results in a
falsely low score due to poor flexor recoil.
 tests the passive tone of the posterior
shoulder girdle flexor muscle.
POPLITEAL ANGLE o Supine position w/ head midline
 assesses maturation of passive flexor tone o Hold infant’s hand across chest and use
about the knee joint by testing for resistance thumb of other hand to gently push
to extension of the lower extremity elbow across chest
o refrain from touching hamstrings (muscle o Or gently pull arm across chest
group being tested) during maneuver o Stop when resistance is felt
o thigh placed in knee-chest position w/  Scores based on position of elbow at
knee fully flexed landmarks
o allow infant to relax, then grasp foot at  Landmarks noted in order of increasing
sides maturity are:
o extend leg until resistance is felt o -1 :full scarf at the level of the neck
o estimate angle behind the knee o 0 : contralateral axillary line
 It is important that the examiner wait until o 1 :contralateral nipple line
the infant stops kicking actively before o 2 :xyphoid process
extending the leg. o 3 :ipsilateral nipple line
 The prenatal frank breech position unreliable o 4: ipsilateral axillary line
for the first 24 to 48 hours of age due to
prolonged intrauterine flexor fatigue. The test
should be repeated once recovery has
 Neuromuscular score +
Physical Maturity
 Total score correlates to weeks of

 Test for passive flexion or resistance to
extension of posterior hip flexor muscles
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
o Measurement unreliable if frank breech in
 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


 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-

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