BALLARD SCORING

Proposed by Dr. Jenne L. Ballard. A standard method that helps detect infants who were
thought to be term but actually a pre-term

Purpose:
• To assess infant’s gestational age

Assessment:
It assesses gestational age from 20 to 44 weeks. The process of rating the infant will be
completed shortly after birth, including 6 physical and neuromuscular signs of maturity. The total
score may range from -10 to 50. Premature babies have low scores. Babies born late have high
scores.

Implementations

NEUROMUSCULAR ACTIVITY
Posture: How the baby holds his or her arms and legs.
Observe the posture. Handling the infant may improve the assessment. As maturational
progresses it increases the flexor tone
• Arms and legs are extended = 0
• Slight or moderate flexion of hips and knees = 2
• Legs flexed and abducted, arms slightly flexed = 3
• Full flexion or arms and legs = 4

Square window: How far the baby's hands can be flexed toward the wrist.
Flex the hand at the wrist. Exert pressure sufficient to get as much flexion as possible. The angle
between the hypothenar eminence and the anterior aspect of the forearm is measured and
scored.
• Greater than 90 degrees = -1
• 90 degree = 0
• 60 degree = 1
• 45 degree = 2
• 30 degree = 3
• 0 degree = 4

Arm recoil: How well the baby's arms spring back to a flexed position.
Fully flex the forearms with the hands at the shoulders for 5 seconds, then fully extend by pulling
the hands. Release as soon as the elbows are fully extended, and observe the recoil (degree of
flexion at the elbows). Random movements do not count.
• Remain extended or random movement = 0
• Incomplete or partial flexia = 2
• Brisk return to full extension = 4

Popliteal angle: How well the baby's knees bend and straighten.
With infant supine and the pelvis flat on the examining surface, use one hand to bring the knee
onto the abdomen. With the other hand, gently push behind the ankle to bring the foot towards
the face.
• 180 degree = -1
• 160 degree - 0
 • 140 degree = 1
• 120 degree = 2
• 100 degree = 3
• 90 degree = 4
• Less than 90 degree = 5

Scarf sign: How far the elbows can be moved across the baby's chest.
Take the infant's hand and draw it across the neck and as far across the opposite shoulder as
possible, like a scarf. Assistance to the elbow is permissible by lifting it across the body. Score
according to the location of the elbow.
• Elbow reaches opposite anterior axillary line = 0
• Elbow between opposite anterior axillary line and midline of the thorax = 1
• Elbow at the midline of the thorax = 2
• Elbow does not reach midline of the thorax = 3
• Elbow at the proximal axillary line = 4

Heel to ear: How close the baby's feet can be moved to the ears.
Hold the infant's foot with one hand and move it as near to the head as possible without forcing
it. The knee may slide down the side of the abdomen. Keep the pelvis flat on the examining
surface. Note the location of the heel where significant resistance is appreciated. Landmarks
noted in order of increasing maturity include resistance felt
• Ear = -1
• Nose = 0
• Chin = 1
• Nipple line = 2
• Umbilical area = 3
• Femoral crease = 4

PHYSICAL MATURITY
Skin: Skin may be sticky, smooth, or peeling.
Inspect the skin of the newborn, noting what is seen.
• Sticky, friable, transparent = -1
• Gelatinous, red, translucent = 0
• smooth, pink, visible veins = 1
• Superficial peeling and few veins = 2
• cracking, pale areas, rare veins = 3
• Parchment deep, cracking, no vessels = 4
• Leathery, cracked and wrinkled = 5

Lanugo: This is the soft downy hair on a baby's body. It's absent in premature babies. It's present
in full-term babies, but not in babies born late.
Inspects for the fine hair covering the body. Turn the newborn to one side. In extreme immaturity,
the skin lacks any lanugo. 24th -25th week: Fine hair begins to appear. 26th week: Abundant hair
across the shoulders and upper back. At term, most of the fetal back is devoid of lanugo.
• None = -1
• Sparse = 0
• Abundant = 1
• Thinning = 2
• Bald areas = 3
 • Mostly bald = 4
Plantar creases: These are the creases on the soles of the feet. They range from absent to
covering the entire foot
Inspects for the plantar creases on both feet. 28 – 30 weeks – creases appear and cover the
anterior portion of the plantar surface of the foot. Creases extend toward the heel as the
gestational age increases. After 12 hours the sole creases are not valid indicator due to drying of
the skin
• Heel-Toe 40-50mm = -1; Less than 40mm = -2
• More than 50mm or no crease = 0
• Faint red marks = 1
• Anterior transverse crease only = 2
• Creases anterior ⅔ = 3
• Creases on the entire sole = 4

Breast: The thickness and size of the breast tissue and the areola (the darkened area around
each nipple) are assessed.
Inspect for the appearance and the estimated size of the areola.
• Imperceptible = -1
• Barely perceptible = 0
• Flat areola, no bead = 1
• Stippled areola, 1-2mm bead = 2
• Raised areola, 2-4mm bead = 3
• Full areola, 5-10mm bead = 4

Eyes and ears: Eyelids are checked to see if they are open or fused shut (more likely in a
premature baby). The amount of cartilage and stiffness of the ear tissue are also noted.
Inspects the eyelids. Place the thumb and forefinger on the upper and lower eyelids gently move
them apart to separate them
Inspects the appearance of the pinna of the ears. Palpate the pinna of the ears for recoil/ presence
of cartilage.
• Lids fused: Loosely = -1; tightly fused = 2
• Lids are open, pinna flat but remain folded = 0
• Slightly curved pinna, soft and slow recoil = 1
• Well curved pinna, soft but ready recoil = 2
• Formed and firm, instant recoil = 3
• Thick cartilage and ear stiff = 4

Genitals (Male): The presence of testes and the look of the scrotum, from smooth to wrinkled, is
verified.
Inspects the scrotal skin and note for the rugae.
• Scrotum flat and smooth = -1
• Scrotum is empty, rare rugae = 0
• Testes upper canal, faint rugae = 1
• Testes descending, few rugae = 2
• Testes is down, good rugae = 3
• Testes pendulous, deep rugae = 4

Genitals (Female): The appearance and size of the clitoris and the labia are noted
Inspects the presence/absence of the clitoris, labia minora and labia majora. 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
• Clitoris is prominent, labia flat = -1
• Prominent clitoris, small labia minora = 0
• Prominent clitoris, enlarging labia minora = 1
• Majora and minora are equally prominent = 2
• Majora large, minora small = 3
• Majora covers the clitoris and minora small = 4

Score Weeks

-10 20

-5 22

0 24

5 26

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50 44

Interpretation:
Premature: < 34 weeks’ gestation
Late preterm: 34 to < 37 weeks
Early term: 37 0/7 weeks through 38 6/7 weeks
Full term: 39 0/7 weeks through 40 6/7 weeks
Late term: 41 0/7 weeks through 41 6/7 weeks
Post term: 42 0/7 weeks and beyond
Post term: 42 0/7 weeks and beyond
Postmature: > 42 weeks