Neuromuscular Maturity


Square window (wrist)

Arm recoil

Popliteal angle

Scarf sign

Heel to ear

r hi

Figure 24-3 Ballard Clinical Assessment. (Reprinted with permission from Ballard J, Novak K, Driver M: A simplified score for assessment of fetal maturation of newly born infants. J Pediatr 95:769, 1979.) Following are some notes on techniques for assessing the neurologic criteria:

Posture: Observed with infant quiet and in supine position. Score 0, arms and legs extended; 1, beginning of flexion of hips and knees, arms extended; 2, stronger flexion of legs, arms extended; 3, arms slightly flexed, legs flexed and abducted; 4, full flexion of arms and legs.

Square window: The hand is flexed on the forearm between the thumb and index finger of the examiner. Enough pressure is applied to get as full a flexion as possible, and the angle between the hypothenar eminence and the ventral aspect of the forearm is measured and graded according to the diagram. (Care is taken not to rotate the infant's wrist while performing this maneuver.) Arm recoil: With the infant in the supine position, the forearms are first flexed for 5 seconds, then fully extended by pulling on the hands, and then released. The sign is fully positive if the arms return briskly to full flexion (score 2). If the arms return to incomplete flexion or the response is sluggish, it is scored as 1. If they remain extended or show only random movements, the score is 0. Popliteal angle: With the infant supine and the pelvis flat on the examining couch, the thigh is held in the knee-to-chest position, with the examiner's left index finger and thumb supporting the knee. The leg is then extended by gentle pressure from the examiner's right index finger behind the ankle, and the popliteal angle is measured.

Scarf sign: With the infant supine, the examiner takes the infant's hand and tries to put it around the neck and as far posteriorly as possible around the opposite shoulder. This maneuver is assisted by lifting the elbow across the body. How far the elbow goes across is measured and graded according to the illustrations. Score 0, elbow reaches opposite axillary line; 1, elbow reaches between midline and opposite axillary line; 2, elbow reaches midline; 3, elbow does not reach midline.

Heel-to-ear maneuver: With the infant supine, the examiner draws the infant's foot as near to the head as it will go without forcing it. The examiner observes the distance between the foot and the head, as well as the degree of extension at the knee, and grades according to the diagram. Note that the knee is left free and may draw down alongside the abdomen.

38 to 42 weeks defines a term infant (see Fig. 24-4). A child with a gestational age of less than 37 weeks is preterm; one with a gestational age of more than 41 weeks (or 42 weeks) is post-term.

The newborn infant is also weighed, but weight alone does not determine maturational age. The birth weight is correlated with gestational age according to the standard classification of Battaglia and Lubchenco, which is shown in Figure 24-5. By this method, the infant is classified as being small, appropriate, or large for gestational age. If the birth weight is between the 10th and 90th percentiles, the infant is appropriate for gestational age (AGA). If the birth weight is lower than the 10th percentile on the intrauterine growth curve, the newborn is classified small for gestational age (SGA). If the birth weight is higher than the 90th percentile, the newborn is called large for gestational age (LGA).

The value of the weight for gestational age determination lies in its ability to predict certain risk groups. Many babies who are LGA are infants of diabetic mothers. Such infants are at risk for a number of complications, both in the immediate neonatal period and later in life.

Table 24-3 Scoring System for External Criteria of Ballard Clinical Assessment External Sign


Lanugo Plantar creases


Gelatinous red, transparent


No crease

Barely perceptible

Pinna flat, stays folded

Smooth, pink, visible veins


Faint red marks

Flat areola, no bud

Sl. curved pinna; soft c slow recoil

Genitals (male) Genitals (female)

Maturity Rating

Scrotum empty, no rugae

Prominent clitoris and labia minora






















Superficial peeling and/or rash, few veins


Anterior transverse crease only

Stippled areola, 1-2 mm bud

Well-curv. pinna; soft but ready recoil

Testes descending, few rugae

Majora and minora equally prominent

Cracking pale area, rare veins

Bald areas

Creases anterior 2/3

Raised areola, 3-4 mm bud

Formed and firm c instant recoil

Testes down, good rugae

Majora large, minora small

Parchment deep cracking, no vessels

Mostly bald

Creases cover entire sole

Full areola, 5-10 mm bud

Thick cartilage ear stiff

Testes pendulous, deep rugae

Clitoris and minora completely covered

Leathery, cracked, wrinkled

Reprinted with permission from Ballard J, Novak K, Driver M: A simplified score for assessment of fetal maturation of newly born infants. J Pediatr 95:769, 1979.

Figure 24-4 Graph for determining gestational age on the basis of neurologic criteria and external signs.

o 34

30 40 Total score

30 40 Total score

GRAMS 5000

Figure 24-5 Classification of newborns by birth weight and gestational age.

4750 4500 4250 4000 3750 3500 3250 3000 2750 2500 2250 2000 1750 1500 1250 1000 750 500













th %
















24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 WEEKS OF GESTATION




These infants must be carefully monitored for hypoglycemia and polycythemia; they are more likely to have hyperbilirubinemia in the first 3 days after birth, and they are three to five times more likely to have a congenital malformation than are infants in the general population. In infants who are SGA, major considerations include the presence of a chromosomal abnormality, such as trisomy 13 or trisomy 18, or exposure to a teratogenic agent, such as alcohol or a congenital infection during gestation. Children who were SGA must also be monitored for hypo-glycemia during the immediate neonatal period. Also, all preterm newborns, even if they do not have low birth weight (<2500 g), are at risk for respiratory distress secondary to surfactant deficiency, for hypoglycemia, and for hypocalcemia.

The remainder of the examination is usually performed in the warmed environment of the nursery, often within 24 hours after birth. Before examining the child, review some key historical facts with the mother and the nurses:

How is the child feeding? Is there any coughing or choking during feedings? How much weight has the baby lost?'' (Newborns often lose weight, up to 10% of birth weight, in the first week. They should regain birth weight by the end of the second week.)

' 'Has the child vomited?'' If so, ' 'What has the child vomited?''

''Is there any drooling?'' Drooling in the newborn can be a sign of esophageal atresia.

Has there been any respiratory distress, noisy breathing, or cyanosis?''

' 'Has the child voided?'' Failure to void within 48 hours of birth may signify renal failure or urinary tract obstruction.

Has there been any abdominal distention?''

' 'Has the child passed meconium?'' Failure to pass meconium (the first material to be evacuated from the bowels) by 48 hours of age may indicate bowel obstruction, meconium ileus (seen in cystic fibrosis), or Hirschsprung's disease.

' 'Have there been any tremors or seizure-like activity?'' Tremors may indicate hypoglycemia or hypocalcemia, either of which necessitates prompt attention.

Thus, this review of systems for a newborn is brief but significant.

The comprehensive examination begins with inspection. If the infant has achieved temperature stability, then he or she should be undressed except for the diaper. Is there evidence of respiratory distress or cyanosis? (If so, immediate intervention is indicated. If not, proceed with the rest of the examination.) The following description of the examination is in a head-to-toe sequence. However, the examiner must usually vary the order when actually performing the examination, using the infant's quiet state to listen to the heart and lungs, catching glimpses of the eyes when the infant opens them, and taking advantage of crying spells to examine the mouth.

The respiratory rate and degree of respiratory effort are carefully assessed while the infant is undressed. The respiratory rate of a newborn usually averages from 30 to 50 breaths per minute. Observe the respiratory rate for 1 to 2 minutes, because periods of apnea and periodic breathing are common, especially among preterm infants. Look for grunting respirations and for chest retractions, each of which is evidence of respiratory distress.

Determine the pulse by auscultation of the heart. The average heart rate of a newborn ranges from 120 to 140 beats per minute. There are wide fluctuations;the rate increases to as fast as 190 during crying and decreases to as low as 90 during sleep. A heart rate lower than 90 is of concern.

Measure the temperature by using a rectal thermometer. The infant is placed in a prone position on an examining table or in the examiner's lap. The infant's buttocks are spread, and a well-lubricated thermometer is inserted slowly through the anal sphincter to approximately 1 inch (2.5 cm). Note that this also establishes that the anus is patent, thereby ruling out the existence of imperforate anus. After 1 minute, the temperature may be read. Newborn infants often have relative thermal instability, and for this reason the ambient temperature should also be determined. Achieving temperature stability is one of the early adaptational challenges for a term infant and takes much longer for preterm infants. (Note that the nursing staff usually measures the newborn's temperature.)

Basic measurements are taken next. The infant's length is measured from the top of the head to the bottom of the feet;the length is usually between 18.5 and 20.5 inches (47 and 52 cm).

The head is measured at its greatest circumference around the occipitofrontal area. In general, three measurements are taken, the largest of which is recorded. The head circumference is usually 13.5 to 14.5 inches (34 to 37 cm). The chest circumference is normally smaller than the head circumference by 0.75 to 1.20 inches (2 to 3 cm). The chest measurement is taken at the level of the nipples midway between inspiration and expiration. By the time the child is 1 year of age, the chest circumference exceeds the head circumference. These and all other measurements performed during the physical examination should be plotted on appropriate growth curves, correcting for the gestational age.

Note the posture. A normal term newborn keeps the arms and legs symmetrically flexed. Relaxation of the limbs is suggestive of neurologic depression and necessitates further evaluation. The finding of one side flexed while the other side is relaxed is abnormal;such posture is suggestive of an injury, either neurologic or musculoskeletal, that occurred before or during the birthing process.

Note the movements. Normally, all four limbs should be moving in a random and asymmetric manner. Fine movements of the face and fingers are usually present. Abnormal movements include jerky, symmetric, coarse movements. All extremities should be moving, with full range of motion seen at some time. Injury to the brachial plexus may cause paralysis of the upper arm. This injury may result from lateral traction on the head and neck during delivery of the shoulder. Erb's palsy produces an inability to spontaneously abduct the arm at the shoulder, rotate the arm externally, flex the elbow, and supinate the forearm. This injury to the fifth and sixth cervical nerves results in a characteristic position of arm adduction, with elbow extension, forearm pronation, and arm internal rotation. The grasp reflex is usually preserved. Klumpke's paralysis results from injury to the seventh and eighth cervical nerves, producing paralysis of the hand and forearm. The grasp reflex is absent. Involvement of the first thoracic nerve with Klumpke's paralysis may also result in ipsilateral ptosis and miosis, or Horner's syndrome. The prognosis of any brachial plexus palsy depends on whether the nerve or nerves were lacerated or only bruised. If the palsy is related only to edema of the nerve fibers and not to actual injury, function usually returns within a few months.

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