This document describes the Ballard Score, an examination used to assess gestational age in newborns. It compares the original Ballard Score to the new Ballard Score. The new score is more accurate, assessing gestational age from birth to 96 hours rather than 26-44 weeks. It also includes additional assessments of the eyes. The Ballard Score considers neuromuscular maturity and physical maturity. Studies show the new Ballard Score has high inter-rater reliability and is generally valid for assessing gestational age, though it may overestimate age in some populations.

1. BALLARD SCORE
Dr.Padmesh.V

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

5. • 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

6. • 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

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

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

11. • 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)

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

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

14. • 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.

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

18. • 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.

20. • 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.

21. • 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)

23. • 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.

24. • 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)

27. • PHYSICAL MATURITY:
• 1. SKIN:

29. • 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.

31. • 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)

33. • 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.

35. • 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.

37. • 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.

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

39. • 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.

40. • 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.

43. • 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.

44. • 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.

45. • 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.

46. • 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)

47. • 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.

48. 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 vascularity
4. Amiel-Tison
5. Farr / Finnstrom