1. The Ballard Maturation Assessment provides a standardized method for assessing gestational age in newborns from 26-44 weeks gestation based on neuromuscular and physical signs of maturity. 2. Neuromuscular signs like posture, arm recoil, and heel-to-ear test assess the infant's increasing passive flexor tone as maturity progresses. Physical signs examined include skin, lanugo, breast development, and genital maturity. 3. Neurological signs are more reliable indicators of gestational age than physical signs alone, as physical development can be impacted by nutritional status while neurological development is genetically determined.

1. Assessment of
gestational age

2. Simple examination to assess Gestational age
Accurate to +/- 2 weeks
Dr. Jeanne L Ballard

3. • Comparison : Original & New
• Scores ranged from 5 to 50
26-44 wks
-10 to 50
20-44 wk
• Score starts with 0 Starts with -1
• Inaccurate in extremely preterm More accurate

4. • 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

6. • Takes in to account 2 things:
• 1. Neuromuscular maturity
• 2.Physical maturity
1. Posture
2. Square Window Test
3. Arm recoil
4. Popliteal angle
5. Scarf Sign
6. Heal to ear test
1. Skin
2. Lanugo
3. Plantar surface
4. Breast
5. Eye/Ears
6. Genitals
Neurological signs are more reliable than physical

8. • NEURO MUSCULAR MATURITY:
As gestational age progresses
Brain growth progresses
Neuromuscular maturity progresses

9. • 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)

10. • NEURO MUSCULAR MATURITY:
• 1.POSTURE:

11. • NEURO MUSCULAR MATURITY:
• 1.POSTURE:

12. • 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.

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

16. • 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.

18. • 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.

19. • 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)

21. • 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.

22. • 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)

25. • PHYSICAL MATURITY:
• 1. SKIN:

27. • 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.

29. • 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)

31. • 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.

33. • 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.

35. • 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.

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

37. • 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.

38. • 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.