CASE STUDY

The following discussion appears in the order in which the examination should be conducted. Please follow along with the New Ballard Score (Figure 1).

NEW BALLARD SCORE

Figure 1

Source: [Reprinted from The Journal of Pediatrics, 119(3), J.L. Ballard, J.C. Khoury, K. Wedif, C. Jarg, B.L. Walsman, and R. Lipp, “New Ballard Score Expanded to Include Extremely Premature Infants.”] Copyright 1991 by Mosby, Inc., with permission from Elsevier.

Resting posture should be evaluated first before the infant is disturbed. The infant should be supine on a flat surface [33]. There are five choices, ranging from 0 points, for a flaccid infant, to 4 points, for a completely flexed infant. Infant A is lying quietly on her back with her arms out to her sides at a greater than 90-degree angle. Her legs are bent at the knee with only a small amount of flexion. She should be awarded 2 points for posture.

The skin should be evaluated next. There are seven subclassifications in the skin category. The extremely premature infant has transparent, friable skin and woulsd be awarded -1 points. The postmature infant presents with leathery, tough, cracked skin and would receive 5 points. Infant A has a fine rash. There appears to be some peeling, with few veins visible on the abdomen. She is awarded 2 points for her skin maturity.

The presence or absence of lanugo (i.e., fine body hair) is evaluated next, with six categories from which to choose. The extremely premature infant is bald, not having had the opportunity to develop lanugo. The postmature infant is also mostly bald because the majority of lanugo has fallen out prior to birth. Infant A has large bald patches but still has a significant amount of hair on her back and ears. She receives 3 points.

Next, the soles of Infant A's feet are examined. Creases begin forming at the top of the newborn's foot and progress to the sole with maturity [33]. There are seven categories from which to choose in this area of assessment, ranging from -2 to 4 points. The extremely premature infant has a smooth sole and should be given points based on the size of the foot. The postmature infant has creases over the entire foot, which often appears cracked and leathery. Infant A has creases over the majority of her foot but not the entire sole. She receives 3 points for her feet.

Observing the presence and size of the breast bud is the next indicator of physical maturity. There are six categories from which to choose in this area. The extremely premature infant will have imperceptible breast buds, while the postmature infant will have well-developed 5–10 mm breast buds and a full areola. Infant A has a noticeable areola and a small bud measuring 2 mm. She is given 2 points.

The development of the newborn's eyes and ears are important markers of gestational age. There are seven categories from which to choose in this area. The extremely premature infant will have fused eyelids; the scoring on these infants is dependent on how tightly or loosely the eyes are closed. The postmature infant will have thick cartilage in the ears and they will be stiff. Infant A has open eyes, and her ears are soft but they do recoil easily. She is awarded 2 points for her eyes and ears.

The last area in the physical maturity assessment is genitalia. There are six categories from which to choose in this area. The extremely premature male infant will have a flat and smooth scrotum; the testes will not have descended into the scrotum. The extremely premature female infant will have an extremely prominent clitoris and flat labia. The postmature male infant will have descended testes and pendulous scrotum with deep rugae. The postmature female will show a labia majora that completely covers her clitoris and labia minora. Infant A has a large labia majora and a small labia minora. Her clitoris is not visible. She is awarded 3 points.

Returning to the neuromuscular maturity section of the New Ballard Score, the square window is measured by bending the wrist and visualizing how far forward the infant's hand can go. The extremely premature infant will have little flexibility in the wrist and show a greater than 90-degree angle. The postmature infant will have great flexibility and the hand will be completely in contact with the forearm. Infant A demonstrates a 30-degree angle when assessing the square window sign. She receives 3 points.

Arm recoil has much to do with the infant's flexion. One performs this test by actively extending the infant's arm to a straight position and letting go in order to evaluate how far back to full flexion the arm returns. In the extremely premature infant, there will be no recoil, and in the postmature infant, there will be full recoil. Again, an observation of the angle determines the point assignment. Infant A recoils to a 140-degree angle. She is given 2 points.

Actively extending the infant's leg and placing the foot near the head may measure popliteal angle. The extremely premature infant will have great flexibility and will be able to demonstrate a completely straight leg in this posture. The postmature infant will show little flexibility and will be unable to extend the knee to greater than 90 degrees. Infant A extends her leg to a 100-degree angle and is given 3 points.

Scarf sign may be measured by extending the infant's arm across the body and measuring how far across the elbow falls. The extremely premature infant will demonstrate great flexibility, and the elbow will be able to stretch all the way across the body. The postmature infant will show little flexibility and will barely get the elbow to meet the inner chest wall. Infant A is able to get her elbow to midline and is awarded 2 points.

The last marker of neuromuscular maturity is the heel to ear sign. This sign is measured by actively extending the infant's foot and attempting to reach the ear. The extremely premature infant will be able to touch his or her foot to the ear, while the postmature infant will be unable to extend a foot anywhere near the ear. Infant A can only extend her foot to a right angle above her body and is given 3 points.

Finally, the points for each category are added to give an estimated gestational age. In our example, Infant A received 15 points in the neuromuscular maturity area and 15 points in the physical maturity section. This is a grand total of 30 points, making her approximately 36 weeks' gestation.