BALLARD SCORE

Dr.Padmesh.V

Simple examination to assess Gestational ageAccurate to +/- 2 weeks

Dr. Jeanne L Ballard

NOV 1979

SEPT 1991

• Comparison : Original & New

• Scores ranged from 5 to 50 -10 to 50 26-44 wks 20-44 wk

• Score starts with 0 Starts with -1

• Inaccurate in extremely preterm More accurate

• Comparison : Original & New

• Optimal age for maturational assessment: Btwn 30 and 42 hours of age. Birth to 96 hours (Validated upto 7th PND in Mod Preterms)

• Eyes: not included Included

NEW BALLARD SCORE

• Takes in to account 2 things:• 1. Neuromuscular maturity

• 2.Physical maturity

1. Posture 4. Popliteal angle

2. Square Window Test 5. Scarf Sign3. Arm recoil 6. Heal to ear test

1. Skin 4. Breast2. Lanugo 5. Eye/Ears3. Plantar surface 6. Genitals

Neurological signs are more reliable than physical

NEW BALLARD SCORE

NEURO MUSCULAR MATURITY

• NEURO MUSCULAR MATURITY:

As gestational age progresses

Brain growth progresses

Neuromuscular maturity progresses

• NEURO MUSCULAR MATURITY:• 1.POSTURE: (AT REST)• As maturation progresses increasing passive flexor

tone

• Increasing passive flexor tone -centripetal direction.

• Lower extremities slightly ahead of upper extremities (caudo cephalad)

• NEURO MUSCULAR MATURITY:• 1.POSTURE:

• NEURO MUSCULAR MATURITY:• 1.POSTURE:

• NEURO MUSCULAR MATURITY:• 2. SQUARE WINDOW TEST:• Tests wrist flexibility &/or resistance to extensor

stretch.• At term and post term, the infant has maximum

passive Flexor tone and minimum passive Extensor tone.

• NEURO MUSCULAR MATURITY:• 3.ARM RECOIL:• Focuses on Passive Flexor Tone of biceps muscle• Briefly flex the elbow extend briefly Release

• NEURO MUSCULAR MATURITY:• 4. POPLITEAL ANGLE:• This maneuver assesses maturation of passive flexor

tone about the knee joint by testing for resistance to extension of the lower extremity.

• NEURO MUSCULAR MATURITY:• 5. SCARF SIGN:• Tests the passive tone of the flexors about the

shoulder girdle.• The point on the chest to which the elbow moves

easily prior to significant resistance is noted.

• NEURO MUSCULAR MATURITY:• 5. SCARF SIGN:• Landmarks noted in order of increasing maturity: – 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)

• NEURO MUSCULAR MATURITY:• 6. HEEL TO EAR:• Measures passive flexor tone about the pelvic girdle

by testing for passive flexion or resistance to extension of posterior hip flexor muscles.

• NEURO MUSCULAR MATURITY:• 6. HEEL TO EAR:• Note location of heel where significant resistance+• Landmarks noted in order of increasing maturity

include resistance felt when the heel is at or near:– ear (-1)– nose (0)– chin level (1)– nipple line (2)– umbilical area (3)– femoral crease (4)

NEW BALLARD SCORE

PHYSICAL MATURITY

• PHYSICAL MATURITY:• 1. SKIN:

• PHYSICAL MATURITY:• 2. LANUGO:• Fine hair covering the body of the fetus.• In extreme immaturity, the skin lacks any lanugo. • Begins to appear at approximately 24th to 25th week.• Abundant, especially across the shoulders and upper back

by the 28th week of gestation.• At term, most of the fetal back is devoid of lanugo.

• PHYSICAL MATURITY:• 3. PLANTAR SURFACE:• Very premature no detectable foot creases. • Measure the foot length or heel-toe distance. • Heel-toe distances:– less than 40 mm (-2) – between 40 and 50 mm (-1)

• PHYSICAL MATURITY:• 4. BREAST:• The breast bud consists of:– breast tissue that is stimulated to grow by maternal estrogens – fatty tissue which is dependent upon fetal nutritional status.

• PHYSICAL MATURITY:• 5. EYE / EAR:• Increasing maturity Increasing cartilage content of ear.

• In very premature infants, the pinnae may remain folded when released. In such infants, state of eyelid development is an additional indicator of fetal maturation.

• PHYSICAL MATURITY:• 6. GENITALS: (MALE)• Fetal testicles begin their descent from the peritoneal cavity

into the scrotal sack at approximately 30th week of gestation.

• 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 develops deeper and more numerous rugae.

• PHYSICAL MATURITY:• 6. GENITALS: (MALE)

• PHYSICAL MATURITY:• 6. GENITALS: (FEMALE)• In extreme prematurity, the labia are flat and the clitoris is

very prominent and may resemble the male phallus. • 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.

• PHYSICAL MATURITY:• 6. GENITALS: (FEMALE)• Hips should be only partially abducted, i.e., to

approximately 45° from the horizontal with the infant lying supine.

• Exaggerated abduction may cause the clitoris and labia minora to appear more prominent, whereas adduction may cause the labia majora to cover over them.

STUDIES

• LITERATURE & STUDIES:• New Ballard Score assessed 578 newborns

• Mean differences between gestational age by NBS and C-GLMP were 0.32 +/- 1.58 weeks among the extremely premature infants.

• Mean differences between gestational age by NBS and C-GLMP were 0.15 +/- 1.46 weeks among the total population.

J Pediatr. 1991 Sep;119(3):417-23.

• LITERATURE & STUDIES:• Inter-rater reliability of NBS, as determined by

correlation between raters who rated the same subgroup of infants, was 0.95.

• For infants less than 26 weeks of gestational age, the greatest validity (97% within 2 weeks of C-GLMP) was seen when the examination was performed before 12 hours of postnatal age.

J Pediatr. 1991 Sep;119(3):417-23.

• LITERATURE & STUDIES:

• In infants with lower weight or GA, and in those whose mothers had received prenatal corticosteroid therapy, NBS tended to overestimate GA compared with US/LMP (MD = 1.2-2.9).

An Pediatr (Barc). 2006 Feb;64(2):140-5.

• LITERATURE & STUDIES:

• NBS is a valid and reliable clinical tool for GA assessment until day 7.

• It slightly overestimates the GA with increasing PNA.

Arch Dis Child Fetal Neonatal Ed. 2009 Jan;94(1)

• LITERATURE & STUDIES:

• At each week from 22 to 28 weeks GA by accurate menstrual history, NBS estimates exceeded GA by dates by 1.3 to 3.3 weeks

• Inaccuracies in GA determined by the NBS should be considered when treating extremely premature infants, particularly in decisions to forego or administer intensive care. Refinement of GA scoring systems is needed to optimize clinical benefit

J Pediatr. 1999 Aug;135 (2 Pt 1):147-52.

OTHER WAYS OF GA CALCULATION

1. Dubowitz Score : neurological signs: 10 ,external signs: 12

2. Parkin Score: skin texture, skin colour, ear firmness and breast size

3. Anterior Lens capsule vascularity4. Amiel-Tison5. Farr / Finnstrom

THANK YOU