FETAL AND NEONATAL MEDICINE
New Ballard Score, expanded to include extremely premature infants J. L. Ballard, MD, J. C. Khoury, MSc, K, Wedig, MD, L. Wang, MD, B. L. Eilers-Walsman, MD, and R. Lipp, MD From the Division of Neonatology, Department of Pediatrics, and the Division of Epidemiology and Biostatistics, Department of Environmental Health, University of Cincinnati College of Medicine, the Children's Hospital Research Foundation, the Crosley Memorial Nursery of the University of Cincinnati Hospital, the Regional Intensive Care Nursery of the Children's Hospital Medical Center, the Bethesda Hospital Special Care Nursery,and the Perinatal Center of Good Samaritan Hospital, Cincinnati, Ohio The Ballard Maturational Score was refined and expanded to achieve greater accuracy and to include extremely premature neonates. To test validity, accuracy, interrater reliability, and optimal postnatal age at examination, the resulting New Ballard Score (NBS) was assessed for 578 newly born infants and the results were a~alyzed. Gestational ages ranged from 20 to 44 weeks and postnatal ages at e~xamination ranged from birth to 96 hours. In 530 infants, gestational age by last menstrual period was confirmed by agreement within 2 weeks with gestational age by prenatal ultrasonography (C-GLMP). For these infants, correlation between gestational age by NBS and C-GLMP was 0.97. Mean differences between gestational age by NB5 and C-GLMP were 0.32 • 1,58 weeks and 0.45 • 1.46 weeks among the extremely premature infants ( g0 o
~90
o
b
60 o
5
b
48 ~
b
30 o
F
0o
+
Arm Recoil 180 o (f~)
140 ~- t 80 ~
110 o - 140 ~
9 0 - t 10 ~
< 90 ~
120 ~
100 ~
90 ~
5Omm
40-50mm:- 1 < 4 0 ram:-2
no crease
imperceptible
lids fused Eye/Ear
loosely:- 1 tig~ltly:-2 scrotum
Genitals male
fiat, smooth clitoris
Genitals female
gelatinous red, s m o o t h pink, translucent visible veins
Drominenf
labia flat
superficial peeling 8./or rash. few veins
abundant
thinning
faint red marks
anterior transverse crease only
bald areas
creases ant, 2/3
~ score - 1_0 __ weeks _ 20 222 _6_24_-_-
mostly bald
creases over entire sole
2s
15
30
20
32
stippled areola 1-2ram bud
raised areola 3-4mm bud
full areola 5 - lOmm bud
sk curved pinna; soft; slow recoil
well-curved pinna; soft but ready recoil
formed &firm instant recoil
thick cartilage ear stiff
25
34
30
36
scrotum testes in empty I upper canal faint rugae rare rugae
testes descending few rugae
testes down good rugae
testes pendulous deep rugae
35
3B
40
40
majora & minors equally prominent
majors large minors small
majors cover clitoos & minors
45
42
barely perceptible
flat areola no bud
lids open pinna flat stays folded
prominent clitoris small labia minors
prominent clitoris enlarging minors
i
Uo-44
Fig. I. Expanded NBS includes extremely premature infants and has been refined to improve accuracy in moremature infants. for estimating gestational age 3 to include gestational ages of less than 26 weeks. This study was undertaken to validate the new tool, to test its interrater reliability, and to determine the optimal postnatal ages for gestational examination of extremely premature infants and of the entire infant population. METHODS Expansion of the gestational assessment tool involved careful examination of extremely premature infants, including many who were determined to be nonviable by their attending physicians. We sought neurologic and physical characteristics that might differentiate extremely premature infants from more mature infants. It was noted that flexibility was virtually absent at the wrist and that passive
flexor tone was virtually absent at the knee, shoulder, and hip. This information enabled us to expand four of the neuromuscular criteria by adding a score of - 1 . On careful physical examination, the extremely immature infants were noted to have sticky, transparent skin, to be free of any lanugo, and to have imperceptible breast markings and nearly undifferentiated genitalia. These observations in turn allowed expansion of the relevant physical items with the addition of a score of - 1 (Fig. 1). Two physical maturational criteria of the existing score, "plantar surface" and "ear," were expanded. The relationship between foot length and gestational age has been shown by Streeter 4 and confirmed by Hem. 5 According to these authors, fetuses between 20 and 26 weeks have foot lengths between 30 and 50 ram. Foot length was measured from the
Volume 119 Number 3
New Ballard Score for gestational age
'O
44.
1 observation o 2 - 5 observations 9 6 - 1 0 observations 9 1 1 + observations O
k..-
42-
.0 0 133
40.
[]
38-
[]
3r
.s tO ~ 0
I"I I"1
o
32-
0 [] []
[]
30-
0 0
o
o
M
9
[]
9
28-
[]
0
26-
[]
9
[]
0
9
I"I 0 9
[] 0 []
0 0
[] []
[] 17
o
[]
*
0 9
9 9
9
0 [] []
=/__ 9 9
[] [] []
In r-I
9 9
0
0
[] 0
o
i-I 0
[]
0 n rl
[] []
[]
o o ~ ~" o
,36-
9 Z
o o
4 19
9
0 o
0
0
D
0
24(D (.9
22 "0
2O 20
I
I
I
I
I
I
I
I
I
1
I
I
22
24
26
28
30
32
34
36
38
40
42
44
Confirmed-GLMP (weeks) Fig. 2. Regression for gestational age by NBS versus C-GLMP.
T a b l e I. Population demographic data (N = 578) Parameter
Gender (% male) Race (% white) Apgar score
New Ballard Score, expanded to include extremely premature infants J. L. Ballard, MD, J. C. Khoury, MSc, K, Wedig, MD, L. Wang, MD, B. L. Eilers-Walsman, MD, and R. Lipp, MD From the Division of Neonatology, Department of Pediatrics, and the Division of Epidemiology and Biostatistics, Department of Environmental Health, University of Cincinnati College of Medicine, the Children's Hospital Research Foundation, the Crosley Memorial Nursery of the University of Cincinnati Hospital, the Regional Intensive Care Nursery of the Children's Hospital Medical Center, the Bethesda Hospital Special Care Nursery,and the Perinatal Center of Good Samaritan Hospital, Cincinnati, Ohio The Ballard Maturational Score was refined and expanded to achieve greater accuracy and to include extremely premature neonates. To test validity, accuracy, interrater reliability, and optimal postnatal age at examination, the resulting New Ballard Score (NBS) was assessed for 578 newly born infants and the results were a~alyzed. Gestational ages ranged from 20 to 44 weeks and postnatal ages at e~xamination ranged from birth to 96 hours. In 530 infants, gestational age by last menstrual period was confirmed by agreement within 2 weeks with gestational age by prenatal ultrasonography (C-GLMP). For these infants, correlation between gestational age by NBS and C-GLMP was 0.97. Mean differences between gestational age by NB5 and C-GLMP were 0.32 • 1,58 weeks and 0.45 • 1.46 weeks among the extremely premature infants ( g0 o
~90
o
b
60 o
5
b
48 ~
b
30 o
F
0o
+
Arm Recoil 180 o (f~)
140 ~- t 80 ~
110 o - 140 ~
9 0 - t 10 ~
< 90 ~
120 ~
100 ~
90 ~
5Omm
40-50mm:- 1 < 4 0 ram:-2
no crease
imperceptible
lids fused Eye/Ear
loosely:- 1 tig~ltly:-2 scrotum
Genitals male
fiat, smooth clitoris
Genitals female
gelatinous red, s m o o t h pink, translucent visible veins
Drominenf
labia flat
superficial peeling 8./or rash. few veins
abundant
thinning
faint red marks
anterior transverse crease only
bald areas
creases ant, 2/3
~ score - 1_0 __ weeks _ 20 222 _6_24_-_-
mostly bald
creases over entire sole
2s
15
30
20
32
stippled areola 1-2ram bud
raised areola 3-4mm bud
full areola 5 - lOmm bud
sk curved pinna; soft; slow recoil
well-curved pinna; soft but ready recoil
formed &firm instant recoil
thick cartilage ear stiff
25
34
30
36
scrotum testes in empty I upper canal faint rugae rare rugae
testes descending few rugae
testes down good rugae
testes pendulous deep rugae
35
3B
40
40
majora & minors equally prominent
majors large minors small
majors cover clitoos & minors
45
42
barely perceptible
flat areola no bud
lids open pinna flat stays folded
prominent clitoris small labia minors
prominent clitoris enlarging minors
i
Uo-44
Fig. I. Expanded NBS includes extremely premature infants and has been refined to improve accuracy in moremature infants. for estimating gestational age 3 to include gestational ages of less than 26 weeks. This study was undertaken to validate the new tool, to test its interrater reliability, and to determine the optimal postnatal ages for gestational examination of extremely premature infants and of the entire infant population. METHODS Expansion of the gestational assessment tool involved careful examination of extremely premature infants, including many who were determined to be nonviable by their attending physicians. We sought neurologic and physical characteristics that might differentiate extremely premature infants from more mature infants. It was noted that flexibility was virtually absent at the wrist and that passive
flexor tone was virtually absent at the knee, shoulder, and hip. This information enabled us to expand four of the neuromuscular criteria by adding a score of - 1 . On careful physical examination, the extremely immature infants were noted to have sticky, transparent skin, to be free of any lanugo, and to have imperceptible breast markings and nearly undifferentiated genitalia. These observations in turn allowed expansion of the relevant physical items with the addition of a score of - 1 (Fig. 1). Two physical maturational criteria of the existing score, "plantar surface" and "ear," were expanded. The relationship between foot length and gestational age has been shown by Streeter 4 and confirmed by Hem. 5 According to these authors, fetuses between 20 and 26 weeks have foot lengths between 30 and 50 ram. Foot length was measured from the
Volume 119 Number 3
New Ballard Score for gestational age
'O
44.
1 observation o 2 - 5 observations 9 6 - 1 0 observations 9 1 1 + observations O
k..-
42-
.0 0 133
40.
[]
38-
[]
3r
.s tO ~ 0
I"I I"1
o
32-
0 [] []
[]
30-
0 0
o
o
M
9
[]
9
28-
[]
0
26-
[]
9
[]
0
9
I"I 0 9
[] 0 []
0 0
[] []
[] 17
o
[]
*
0 9
9 9
9
0 [] []
=/__ 9 9
[] [] []
In r-I
9 9
0
0
[] 0
o
i-I 0
[]
0 n rl
[] []
[]
o o ~ ~" o
,36-
9 Z
o o
4 19
9
0 o
0
0
D
0
24(D (.9
22 "0
2O 20
I
I
I
I
I
I
I
I
I
1
I
I
22
24
26
28
30
32
34
36
38
40
42
44
Confirmed-GLMP (weeks) Fig. 2. Regression for gestational age by NBS versus C-GLMP.
T a b l e I. Population demographic data (N = 578) Parameter
Gender (% male) Race (% white) Apgar score
