Objectives
By the end of this presentation the learner should….
Understand the prenatal gestational age assessment tools
Classify the size differences between IUGR, SGA, AGA, &
LGA infant
Complete the physical maturity portion of the neonatal
gestational age assessment tool
Conduct the neuromuscular portion of the neonatal
gestational age assessment
Compile the maturity score on the neonatal gestational age
assessment tool
Identify those common differential findings found on
newborn exam
Prenatal Gestational Age
Assessment
Calculation by the mother estimated date of confinement
(EDC)
Collection of prenatal data
First fetal movement (16-20 weeks)
Fetal heart tones (20 weeks) (with doppler 9-12 weeks)
Fundal height (One cm = 1 week after 18-20 weeks)
20 weeks (fundus normally at umbilicus)
Term (fundus at xyphoid)
Amniotic fludi creatinine levels
Maternal serum and urine estriols
Fetal US
Prenatal Gestational Age
Assessment
Fetal US Measurements
 Crown to rump length
 Biparietal diameter
 Femur length
 Abdominal Circumference
 Head Circumference
 Placental grade
Basics of Newborn Physical Exam
 Review the perinatal history for clues to potential
pathology
 Begins with conception and includes events that
occurred throughout gestation
 Genetic history
 Labor & delivery history
 Assess the infant’s color for clues for potential pathology
 Auscultate in a quiet environment
 Keep infant warm during exam
 Calm the infant before exam
 Handle gently
Classification of Size
Classification of size for
gestational age
 Growth for dates can be determined by weight, length,
and head circumference
 Plotted on a graph appropriate for gestation
• Preterm before 37 weeks
• Term 38-41 weeks
• Post term after 42 weeks
Classification of size for
gestational age
 Using the gestational
age score the weight,
height and head
circumference can be
plotted on the infants
growth chart
 This information is
how the infant is
diagnosed as SGA,
LGA, or AGA
Classification of size for
gestational age
 SGA- small for gestational age-weight below 10th
percentile
 AGA-weight between 10 and 90th percentiles (between
5lb 12oz (2.5kg ) and 8lb 12 oz (4kg).
 LGA-weight above 90th percentile
 IUGR-deviation in expected fetal growth pattern,
caused by multiple adverse conditions, not all IUGR
infants are SGA, may or may not be “head sparing”
Neonatal Gestational AgeBallard Exam
 The physical maturity part of the examination should
be done in the first two hours of birth
 The neuromuscular maturity examination should be
completed with 24 hours after delivery
 Derived to look at various stages in an infants
gestational maturity and observe how physical
characteristics change with gestational age
 Neonates who are more physically mature normally
have higher scores than premature infants
 Points are awarded in each area -2 for extreme
prematurity to 5 for postmature infants
Physical Maturity
 Skin
 Lanugo
 Plantar surface
 Breast
 Eyes & Ears
 Genital
Neonatal Gestational Age
Physical Maturity
Physical Maturity-Skin
 Examine the texture, color and opacity
 As the infant matures:


More subcutaneous tissue develops
Veins become less visible and the skin
becomes more opaque
Neonatal Gestational Age
Assessment
 Physical Maturity
 Skin



Before 28 weeksgelatinous red, friable
28-37 weeks-skin over
abdomen thin,
translucent, pink with
visible veins
37-39 weeks smooth,
pink, increased
thickness, rare veins over
abdominal wall
Neonatal Gestational Age
Assessment
 Physical Maturity
 Skin

40 Weeks-vessels
have now
appeared, skin
may be leathery
with deep cracking
Differential Skin Findings
 Scalp Electrode
Differential Skin Findings
 Forcep Marks
Differential Skin Findings
 Vacuum Bruising
Differential Skin Findings
 Milia-exposed
sebaceous glands
 No treatment
necessary
Differential Skin Findings
 Sebaceous hyperplasia
 More yellow than
milia
 Result of maternal
androgen in utero
 Resolves in time
Differential Skin Findings
 Mongolian Blue-Grey
Spots
 Most common in
Asian, Hispanic, and
African descent
 Gradual fade over the
first years
Differential Skin Findings
 Skin Tags
 Most common on
ears
 Usually tied off or
clipped
Differential Skin Findings
 Salmon patches or nevus
simplex
 Angel kisses
 Stork bites
Differential Skin Findings
 Erythema
toxicum
 White or yellow
papule or pustule
 With
erythematous
base
 No treatment
necessary
Differential Skin Findings
 Café Au Lait spots
 Increased amount of
melanin, may increase in
number in age
 Presence of 6 or moregreater then 0.5 cm in size
may be indicative of
neurofibromatosis
Neonatal Gestational Age
Assessment
• Physical Maturity
• Lanugo
• After 20 weeks-begins to
appear
• 28 weeks-abundant
• After 28 weeks-thinning,
starts to disappear from the
face first
• 38 weeks-bald areas slight
amount may be present on
shoulders
Neonatal Gestational Age
Assessment
 Vernix
 Before 34 weeks-vernix thick
and covers entire body
 34-38 weeks-vernix is absorbed
gradually, portions over
shoulder and neck is the last to
be absorbed
 38-40 weeks-vernix only present
in folds of skin
 After 40 weeks-no vernix
present
Neonatal Gestational Age
Assessment
 Plantar Surface
 Before 28 weeks-no creases
 28-32 weeks-virtually no sole
creases, faint thin red lines over
anterior aspect of foot
 34-37 weeks-1-2 anterior creases
 37-39 weeks-creases now over
the anterior 2/3 of the sole
Differential Findings
Bilateral Club Feet
Polysyndactyly
Syndactyly
Neonatal Gestational Age
Assessment
 Physical Maturity
 Breast




Before 28 weeks-nipples imperceptible
28-32 weeks-nipple barely visible, no areola
32-37 weeks-well defined nipple areola
38-40 weeks-well defined nipple raised areola
Neonatal Gestational Age
Assessment
 Physical Maturity
 Eyes
 Eyes are evaluated as either fused as seen in extremely
premature infants or open
 Before 26 weeks eyes are fused
Differential Findings
 Congenital Cataracts
 Eyelid Edema
 Subconjunctival Hemorrhage
Neonatal Gestational Age
Assessment
 Physical Maturity
 Ears
 Before 34 weeks-pinna is
very immature cartilage
not present, lies flat,
remains folded
 34-37 weeks-pinna curved
with soft recoil
 37-40 weeks-formed, firm
instant recoil
 After 40 weeks-thick
cartilage ear stiff
Differential Findings
 Ear Tags
 Ear Pits (Preauricular pits)
 Lop Ear
 Prominent Ear
Neonatal Gestational Age
Assessment
 Physical Maturity
 Genitalia-Male
 Before 28 weeks-scrotum
empty and flat
 28-30 weeks-testes
undescended into scrotal sac
 30-36 weeks testes descending
with a few rugae over the
scrotum
 36-39 weeks-testes have
descended into scrotum which
is now pendulous and complete
with rugae
 Genitalia-Female
• Before 28 weeks-clitoris
prominent labia flat
• 28-32 weeks-prominent clitoris,
enlarging labia minora
• 33-36 weeks-labia majora widely
spaced with equally prominent
labia minora
• 33-39 weeks-labia extends over
the labia minora but not over
the clitoris
• 39 weeks-labia majora
completely covers the labia
minora and clitoris
Differential Findings
Hydrocele
Hypospadias
Undescended testicles
Hymenal Tag
Neonatal Gestational Age
Neuromuscular Assessment
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Posture & Tone
 Square Window
 Arm Recoil
 Popliteal Angle
 Scarf Sign
 Heel to Ear
Neonatal Gestational Age
Assessment
• Neuromuscular Maturity
• Posture/Tone-Total body muscle tone is reflected in the
infants preferred posture at rest and resistance to stretch
of individual muscle groups
• Make sure infant is quiet
• The more mature an infant is the greater their tone will be
• A more flexed position indicated greater tone
Neonatal Gestational Age
Assessment
• Neuromuscular Maturity
• Posture & Tone
• Before 30 weekshypotonic, little or no
flexion seen
• 30-38 weeks-varying
degrees of flexed
extremities
• 38-42 weeks-may appear
hypertonic
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Square Window-wrist
flexibility and/or resistance to
extensor stretching resulting
in angle or flexion at wrist

Flex hand down to wristmeasure the angle between
the forearm & palm



Before 26 weeks-wrist can’t
be flexed more than 90
degrees
Before 30 weeks-wrist can be
flexed no more than 90
degrees
36-38 weeks-wrist can be
flexed no more than
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Arm Recoil-measures the angle of recoil following a
brief extension of the upper extremity
 For 5 seconds flex the arms while infant is in the supine
position, pulling the hands fully extend the arms to the
side, then release-measure the degree of arm flexion &
strength (recoil)





Before 28 weeks-no recoil
28-32 weeks-slight recoil
32-36 weeks-recoil does not pass 90 degrees
36-40 weeks-recoils to 90 degrees
After 40 weeks-rapid full recoil
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Popliteal Angle-assesses
maturation of passive flexor tone
about the knee joint by testing
resistance to extension of the leg
 The angle decreases with
advancing gestational age
 Before 26 weeks-angle 180
degrees
 26-28 weeks-angle 160 degrees
 28-32 weeks-angle 140 degrees
 32-36 weeks angle 120 degrees
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Scarf Sign-tests the passive tone of the
flexors about the shoulder girdle
 Increased resistance to this maneuver
with advancing gestational age
 Before 28 weeks-elbow passes torso
 28-34 weeks-elbow passes opposite
nipple line
 34-36 weeks-elbow can be pulled past
midline, no resistance
 36-40 weeks-elbow to midline with
some resistance
 After 40 weeks-doesn’t reach midline
Neonatal Gestational Age
Assessment
 Neuromuscular Maturity
 Heel to Ear-measures
passive flexor tone about
the pelvic girdle by testing
passive flexion or
resistance to extension of
the posterior hip flexor
muscles
 Breech infants will score
lower than normal
 Before 34 weeks-no
resistance
 40 weeks-great resistance
may be difficult to perform
References
Aby, J. (2008). Stanford School of Medicine. Newborn
Nursery at LPCH. Retrieved October 10th, 2009 from
http://newborns.stanford.edu/RNMDEducation.html
Ballard J. (1991). New Ballard Score, expanded to include
extremely premature infants. Journal of Pediatrics, 119,
417-423.
Tappero, E. & Honeyfield, M. (1996). Physical
assessment of the newborn. Santa Rosa, CA: NICU Ink
Publishers.