new ballard score by nelson book of pediatrics

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Here is a complete overview of the New Ballard Score (NBS) based on authoritative textbook sources (Textbook of Family Medicine 9e, citing Ballard JL et al., J Pediatr. 1991;119:417-423 - the same reference used in Nelson's Pediatrics):

New Ballard Score (NBS)

The NBS is used to assess gestational age in newborns, including extremely premature infants (as early as 20 weeks). It evaluates two domains - neuromuscular maturity and physical maturity - and sums the scores to estimate gestational age.

Key rule: If gestational age by dates vs. by exam differs by >1 week, use the earlier gestational age.

Part 1: Neuromuscular Maturity

Scores range from -1 to 5 for each criterion. Assign scores with the infant relaxed and quiet.

Criterion	How to Examine	Score Progression
Posture	Observe infant when relaxed and quiet	Score 0 (fully extended) → 4 (fully flexed)
Square window (wrist)	Flex wrist between hypothenar eminence and forearm; measure angle	>90° = 0 → 90° → 60° → 45° → 30° → 0° = 4
Arm recoil	Flex forearms for 5 sec, fully extend arms, release; score position	180° = 0 → 140-180° → 110-140° → 90-110° → <90° = 4
Popliteal angle	Hip fully flexed, extend knee with gentle pressure; measure popliteal angle	180° = -1 → 160° → 140° → 120° → 100° → 90° → <90° = 5
Scarf sign	Move arm over opposite shoulder; keep scapula on table	Arm crosses well past midline = -1 → arm reaches midline = 2 → cannot reach midline = 4
Heel to ear	Move foot toward head; keep pelvis on table; do not force	Foot easily reaches ear = -1 → progressively more resistance with maturity

Part 2: Physical Maturity

Scores range from -1 to 4 or 5 depending on criterion.

Criterion	Immature → Mature
Skin	Sticky, friable, transparent → Gelatinous, red, translucent → Smooth, pink, visible veins → Superficial peeling/rash, few veins → Cracking, pale areas, rare veins → Parchment, deep cracking, no vessels → Leathery, cracked, wrinkled
Lanugo (over back/scapulae)	None → Sparse → Abundant → Thinning → Bald areas → Mostly bald
Plantar surface (tip of great toe to back of heel)	Heel-toe <40 mm = -2; 40-50 mm = -1 → >50 mm, no crease → Faint red marks → Anterior transverse crease only → Creases over anterior 2/3 → Creases over entire sole
Breast	Imperceptible → Barely perceptible → Flat areola, no bud → Stippled areola, 1-2 mm bud → Raised areola, 3-4 mm bud → Full areola, 5-10 mm bud
Eye/Ear	Lids fused tightly = -2; loosely = -1; Lids open, pinna flat, stays folded = 0 → Slightly curved pinna, soft, slow recoil → Well-curved, soft but ready recoil → Formed & firm, instant recoil → Thick cartilage, ear stiff
Genitals (Male)	Scrotum flat, smooth → Empty, faint rugae → Testes in upper canal, rare rugae → Testes descending, few rugae → Testes down, good rugae → Testes pendulous, deep rugae
Genitals (Female)	Clitoris prominent, labia flat → Prominent clitoris, small labia minora → Prominent clitoris, enlarging minora → Majora & minora equally prominent → Majora large, minora small → Majora covers clitoris & minora

Part 3: Maturity Rating (Score → Gestational Age)

Total Score	Gestational Age (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

Summary of Scoring

Neuromuscular criteria: 6 items (Posture, Square window, Arm recoil, Popliteal angle, Scarf sign, Heel to ear)
Physical criteria: 6 items (Skin, Lanugo, Plantar surface, Breast, Eye/Ear, Genitalia)
Total possible score: -10 to +50
Covers gestational age range: 20 to 44 weeks

The NBS was expanded from the original Ballard Score to include extremely premature infants (as young as 20 weeks / score -10), which is its key advantage over the older version.

Source: Textbook of Family Medicine 9e, p. 527, citing Ballard JL, Khoury JC, Wedig K et al. New Ballard Score, expanded to include extremely premature infants. J Pediatr. 1991;119:417-423.

APGAR TABLE FROM NELSON OR BATES

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I have all the data. Here is the complete APGAR Score Table from both sources:

APGAR Score

Devised by Virginia Apgar in 1952, it provides a standardized method to assess the physical condition of newborns immediately after birth and their response to resuscitation.

The APGAR Table

Each of the 5 signs is scored 0, 1, or 2. Maximum possible score = 10.

Sign	0	1	2
Heart Rate	Absent	<100 bpm	≥100 bpm
Respiratory Effort	Absent	Irregular / slow	Strong, crying
Muscle Tone	Limp	Some flexion of extremities	Active motion / good flexion
Reflex Irritability (response to stimulation / nose suction)	No response	Grimace	Cough, sneeze, or cry
Color	Blue or pale (all cyanotic)	Acrocyanosis (blue extremities, pink body)	Completely pink

Mnemonic - APGAR: Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), Respiration

When to Assess

Timing	Action
1 minute	First score - reflects intrauterine/intrapartum condition
5 minutes	Second score - reflects response to resuscitation
Every 5 min up to 20 min	If score remains <7 at 5 min, repeat at 5-min intervals while resuscitation continues

Score Interpretation

Score	Interpretation	Action
7 - 10	Normal / reassuring	Routine newborn care
4 - 6	Moderately depressed	Stimulation + supplemental oxygen; reassess
0 - 3	Severely depressed	Immediate resuscitation required

Important Clinical Notes

Do not delay assessment of airway, breathing, and circulation to calculate the Apgar score - resuscitation always takes priority.
The score can be affected by: gestational age, maternal medications, neurologic/cardiorespiratory conditions, trauma, infection, and ongoing resuscitation.
A low score (0-3) does not predict neurologic outcome and cannot determine if a hypoxic event occurred in utero.
A score of 0-3 at 5 minutes may correlate with increased neonatal death.
It is considered negligence to omit Apgar scoring of a newborn, especially low birth weight infants.

Sources: Textbook of Family Medicine 9e, p. 526-527 (citing AAP/AHA Neonatal Resuscitation, 2011); The Harriet Lane Handbook 23e, Table 18.2 (citing Apgar V, Anesth Analg 1953;32:260); Park's Textbook of Preventive and Social Medicine, Table 3.

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