BALLARD

SCORE

Jeanne L. Ballard MD
Jeanne L. Ballard MD,
author of the New
Ballard Score, is an
associate professor of
Pediatrics, Obstetrics and
Gynecology at the
University of Cincinnati
College of Medicine.

Ballard Score
The Ballard Score is a set of procedures to
determine Gestational Age through
neuromuscular and physical assessment of a
newborn fetus
Consists of :
1. Neuromuscularity Maturity Score Sheet
2. Physical Maturity Score Sheet

NEUROMUSCULAR MATURITY

POSTURE
Total body muscle tone is reflected
in the infant's preferred posture at
rest and resistance to stretch of
individual muscle groups.
The infant is placed supine (if found
prone) and the examiner waits until
the infant settles into a relaxed or
preferred posture.
If the infant is found supine, gentle
manipulation (flex if extended;
extend if flexed) of the extremities
will allow the infant to seek the
baseline position of comfort.

SQUARE WINDOW

The examiner straightens the

infant's fingers and applies gentle
pressure on the dorsum of the
hand, close to the fingers. From
extremely pre-term to post-term,
the resulting angle between the
palm of the infant's hand and
forearm is estimated at;
>90, 90, 60, 45, 30, and 0.
The appropriate square on the
score sheet is selected

ARM RECOIL
This manoeuvre focuses on passive flexor
tone of the biceps muscle by measuring
the angle of recoil following very brief
extension of the upper extremity.
With the infant lying supine, the examiner
places one hand beneath the infant's
elbow for support. Taking the infant's
hand, the examiner briefly sets the elbow
in flexion, then momentarily extends the
arm before releasing the hand. The angle
of recoil to which the forearm springs back
into flexion is noted, and the appropriate
square is selected on the score sheet.

POPLITEAL ANGLE
This manoeuvre assesses maturation of
passive flexor tone about the knee joint
by testing for resistance to extension of
the lower extremity.
With the infant lying supine, and with
diaper removed, the thigh is placed
gently on the infant's abdomen with the
knee fully flexed. After the infant has
relaxed into this position, the examiner
gently grasps the foot at the sides with
one hand while supporting the side of
the thigh with the other. The leg is
extended until a definite resistance to
extension is appreciated. At this point
the angle formed at the knee by the
upper and lower leg is measured.

SCARF SIGN
This maneuver tests the passive tone of the
flexors about the shoulder girdle.
With the infant lying supine, the examiner
adjusts the infant's head to the midline and
supports the infant's hand across the upper
chest with one hand. The thumb of the
examiner's other hand is placed on the
infant's elbow.
The examiner nudges the elbow across the
chest, felling for passive flexion or
resistance to extension of posterior
shoulder girdle flexor muscles.
The point on the chest to which the elbow
moves easily prior to significant resistance
is noted

HEEL TO EAR
This maneuver measures passive flexor
tone about the pelvic girdle by testing for
passive flexion or resistance to extension
of posterior hip flexor muscles.
The infant is placed supine and the flexed
lower extremity is brought to rest on the
mattress alongside the infant's trunk.
The examiner supports the infant's thigh
laterally alongside the body with the palm
of one hand. The other hand is used to
grasp the infant's foot at the sides and to
pull it toward the ipsilateral ear.
The examiner fells for resistance to
extension of the posterior pelvic girdle
flexors and notes the location of the heel
where significant resistance is
appreciated.

PHYSICAL MATURITY

SKIN
Before the development of the
epidermis with its stratum
corneum, the skin is transparent
and adheres somewhat to the
examiner's finger. Later it
smoothes, thickens and produces a
lubricant, the vernix, that
dissipates toward the end of
gestation.
At term and post-term, the fetus
may expel meconium into the
amniotic fluid. This may add an
accelerating effect to the drying
process, causing peeling, cracking,
dehydration, and imparting a
parchment, then leathery,
appearance to the skin.

SIGN

SKIN

PHYSICAL MATURITY SCORE

-1
Sticky,
friable,
transparent

Superfi
Gelatin
cial
smooth
-ous,
peeling
pink,
red,
&/or
visible
translurash,
veins
cent
few
veins

Cracking,
pale
areas,
rare
veins

Parchment,
deep
cracking
, no
vessels

leathery,
cracked,
wrinkled

SIGN
SCORE

PHYSICAL : LANUGO
Lanugo is the fine hair covering the
body of the fetus.
In extreme immaturity, the skin lacks
any lanugo. At term, most of the fetal
back is devoid of lanugo, i.e., the back is
mostly bald.
Variability in amount and location of
lanugo at a given gestational age may
be attributed in part to familial or
national traits and to certain hormonal,
metabolic, and nutritional influences.
When scoring for lanugo, the examiner
selects the square that most closely
describes the relative amounts of
lanugo on the upper and lower areas of
the infant's back.

SIGN

LANUGO

PHYSICAL MATURITY SCORE

-1
none

sparse abundant

thinning

bald
areas

mostly
bald

SIGN
SCORE

PLANTAR SURFACE
This item pertains to the major foot
creases on the sole of the foot. The
first appearance of a crease appears
on the anterior sole at the ball of the
foot.
Very premature and extremely
immature infants have no detectable
foot creases. To further help define
the gestational age of these infants,
measuring the foot length or heel-toe
distance is helpful. For heel-toe
distances less than 40 mm, a minus
two score (-2) is assigned; for those
between 40 and 50 mm, a minus one
score (-1) is assigned.

SIGN

PLANTAR
SURFACE

PHYSICAL MATURITY SCORE

-1
heeltoe
4050mm:
-1
<40mm
: -2

>50
faint
mm
red
no
marks
crease

2
anterior
transverse
crease
only

creases
ant. 2/3

creases
over
entire
sole

SIGN
SCORE

PHYSICAL : BREAST

The breast bud consists of breast

tissue that is stimulated to grow by
maternal estrogens and fatty tissue
which is dependent upon fetal
nutritional status.
The examiner notes the size of the
areola and the presence or absence
of stippling.The examiner then
palpates the breast tissue beneath
the skin by holding it between
thumb and forefinger, estimating its
diameter in millimeters, and selects
the appropriate square on the score
sheet.

SIGN

BREAST

PHYSICAL MATURITY SCORE

-1

barely
Imperpercept
ceptable
able

1
flat
areola
no bud

stippled
areola
1-2 mm
bud

raised
areola
3-4
mm
bud

full
areola
5-10 mm
bud

SIGN
SCORE

EYE / EAR
The pinna of the fetal ear changes it
configuration and increases in
cartilage content as maturation
progresses. Assessment includes
palpation for cartilage thickness,
then folding the pinna forward
toward the face and releasing it. The
examiner notes the rapidity with
which the folded pinna snaps back
away from the face when released,
then selects the square that most
closely describes the degree of
cartilagenous development.

SIGN

EYE /
EAR

PHYSICAL MATURITY SCORE

-1

lids
open
lids fused
pinna
loosely: -1
flat
tightly: -2
stays
folded

sl.
curved
pinna;
soft;
slow
recoil

wellcurved
pinna;
soft but
ready
recoil

formed
& firm
instant
recoil

thick
cartilage
ear stiff

SIGN
SCORE

MALE GENITAL
Testicles found inside the
rugated zone are considered
descended. . Concurrently, the
scrotal skin thickens and
develops deeper and more
numerous rugae. In extreme
prematurity the scrotum is flat,
smooth and appears sexually
undifferentiated. At term to
post-term, the scrotum may
become pendulous and may
actually touch the mattress
when the infant lies supine

SIGN

MALE
GENITALS

PHYSICAL MATURITY SCORE

-1
scrotum
flat,
smooth

scrotum
empty,
faint
rugae

testes
in
upper
canal,
rare
rugae

testes
descend
-ing,
few
rugae

3
testes
down,
good
rugae

4
testes
pendulous,
deep
rugae

SCORE

FEMALE GENITALS
To examine the infant female, the
hips should be only partially
abducted, i.e., to approximately
45 from the horizontal with the
infant lying supine.
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.

PHYSICAL MATURITY SCORE

SIGN

FEMALE
GENITAL

SCORE
-1

clitoris
promi nent &
labia
flat

prominent
clitoris &
small labia
minora

Promi nent
clitoris &
enlarging
minora

majora &
minora
equally
prominent

majora
majora
cover
large,
clitoris
minora
&
small
minora

TOTAL SCORE
(NEUROMUSCULAR + PHYSICAL)

WEEKS

-10

20

-5

22

24

26

10

28

15

30

20

32

25

34

30

36

35

38

40

40

45

42

50

44