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Neonatal Gestational Age Assessment

Objectives
By the end of this presentation the learner should:
a. Understand the prenatal gestational age assessment tools
b. Classify the size differences between IUGR, SGA, AGA, & LGA infant
c. Complete the physical maturity portion of the neonatal gestational age
assessment tool
d. Conduct the neuromuscular portion of the neonatal gestational age
assessment
e. Compile the maturity score on the neonatal gestational age assessment tool
f. Identify those common differential findings found on newborn exam
Prenatal Gestational Age Assessment
Prenatal Gestational Age Assessment
Fetal Measurements
Crown to rump length
Biparietal diameter
Femur length
Abdominal Circumference
Head Circumference
Placental grade
Basics of Newborn Physical Exam
o Review the perinatal history for clues to potential pathology
o Begins with conception and includes events that occurred throughout
gestation
o Genetic history
o Labor & delivery history
o Assess the infants color for clues for potential pathology
o Auscultate in a quiet environment
o Keep infant warm during exam
o Calm the infant before exam
o Handle gently
Classification of size for gestational age
1. Growth for dates can be determined by weight, length, and head
circumference
Plotted on a graph appropriate for gestation
a) Preterm before 37 weeks
b) Term 38-41 weeks
c) Post term after 42 weeks
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
a) SGA- small for gestational age-weight below 10th percentile
b) AGA-weight between 10 and 90th percentiles (between 5lb 12oz (2.5kg )
and 8lb 12 oz (4kg).

c) 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
Ballard 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
Skin
Lanugo
Plantar surface
Breast
Eyes & Ears
Genital
Neonatal Gestational Age
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
Before 28 weeks-gelatinous 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
40 Weeks-vessels have now appeared, skin may be leathery with
deep cracking
Differential Skin Findings
Scalp Electrode
Forcep Marks
Vacuum Bruising
Milia-exposed sebaceous glands-No treatment necessary
Sebaceous hyperplasia
More yellow than milia
Result of maternal androgen in utero
Resolves in time
f) Mongolian Blue-Grey Spots
a)
b)
c)
d)
e)

Most common in Asian, Hispanic, and African descent


Gradual fade over the first years
Bluish-black or gray-blue pigmentation found on dorsal area on buttocks. May be
mistaken as bruising and should be documented on newborns char.
g. Skin Tags
Most common on ears
Usually tied off or clipped
h. Salmon patches or nevus simplex
Angel kisses
Stork bites
Telangiectatic Nevi- frequently found on eye lids, nose, lower occipital bone, and
nape of neck. Common in light complexioned infants, most noticeable when crying.
No clinical significance, usually fade by second birthday.
i. Erythema toxicum
White or yellow papule or pustule
With erythematous base
No treatment necessary
Eruption of lesions in the area surrounding a hair follicle, that are firm, vary in
size 1 mm-3mm. Often called newborn rash or flea bite, over trunk & diaper
area. Peak incidence is 24-48 hours of life. Cause unknown, smear shows numerous
eosinophils.
j. Caf Au Lait spots
Increased amount of melanin, may increase in number in age
Presence of 6 or more- greater than 0.5 cm in size may be indicative of
neurofibromatosis
k. 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
l. 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
Vernix caseosa is the pasty, cheese-like, material present in varying degrees
on the skin at birth (here a small amount of vernix is seen on the back shortly
after delivery). It is a mixture of sebum produced by the infant's skin and cellular
debris that has accumulated in utero. Normally, vernix is a creamy white color.
The yellowish brown tint seen in this photo is a result of meconium staining.
m. 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
n. Bilateral Club Feet
Bilateral club feet-feet are plantar-flexed and inverted, this is a bone
deformity.
syndactyly is found occasionally on the physical examination, this is a subtle
finding. If the exam is not a careful one, this can easily be missed since both
digits are otherwise normally formed.Digits are fused in addition to being too
numerous, the term polysyndactyly is used.
o. 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
p. Eyes
Eyes are evaluated as either fused as seen in extremely premature infants or
open
Before 26 weeks eyes are fused
q. Congenital Cataracts
Eyelid Edema
Subconjunctival Hemorrhage
Congenital cataracts require early intervention to preserve sight, so immediate
referral to a pediatric ophthalmologist is indicated. It is important to remember
that cataracts that are less dense may not be visibly cloudy, so any time red
reflexes cannot be obtained on exam, even if the eye appears grossly normal,
referral is required.
Most infants exhibit some degree of eyelid edema after birth. The puffiness may
make it seem that the infant has difficulty opening one or both eyes, but with a
gentle examination, the eye can be easily evaluated. Edema resolves over the
first few days of life. Subconjunctival hemorrhage is a frequent finding in normal
newborns. It results from the breakage of small vessels during the pressure of
delivery. The red area may be large or small but is always confined to the limits
of the sclera. It is asymptomatic, does not affect vision, and spontaneously
resolves in several days.
r. 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
A single, small ear tag is an occasional finding on physical examination. It is
often inherited as a familial trait. Ear pits (preauricular pits) are often a rather

subtle finding on physical exam. They are located at the superior attachment of the
pinna to the face and may be unilateral or bilateral. Up to 10% of Asian infants will
have pits -- they are less common among Caucasians and African Americans. Lop
Ear is a pinna deformity where the superior edge of helix is folded down. Prominent
ear", cup ear refers to an auricle shape that stands away from the head at the
superior, posterior, and inferior aspects, only a cosmetic concern.
Ear Tags
Ear Pits (Preauricular pits)
Lop Ear
Prominent Ear
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
Hydroceles are a frequent finding in newborns. It is important on palpation to
identify the normally small testicles (approximately 1 cm) as separate entities from
the large, smooth-walled fluid collections of hydroceles. In many girls, a small tag of
mucosal tissue can be seen protruding from the vaginal area at birth. This is a
hymenal tag, a benign physical finding. With time, this tissue will recede into the
vagina and decrease in size. No further evaluation is necessary.
Neuromuscular Assessment
Neonatal Gestational Age Assessment

Neuromuscular Maturity
a) Posture & Tone
b) Square Window
c) Arm Recoil
d) Popliteal Angle
e) Scarf Sign
f) Heel to Ear
1. 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
Before 30 weeks-hypotonic, little or no flexion seen
30-38 weeks-varying degrees of flexed extremities
38-42 weeks-may appear hypertonic
2. Square Window-wrist flexibility and/or resistance to extensor stretching resulting
in angle or flexion at wrist
Flex hand down to wrist-measure the angle between the forearm & palm
Before 26 weeks-wrist cant 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
3. 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

4. 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
5. 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-doesnt reach midline
6. 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
Apgar Scoring System
APGAR test is a scoring system and a rapid method of assessing the clinical
status of the newborn infant at 1 minute and 5 minutes of age.
Appearance, Pulse, Grimace, Activity, Respiration
Apgar score quantitates clinical signs of neonatal depression such as cyanosis
or pallor, bradycardia, depressed reflex response to stimulation, hypotonia,
and apnea or gasping respirations.
The score is reported at 1 minute and 5 minutes after birth for all infants, and
at 5-minute intervals thereafter until 20 minutes for infants with a score less
than 7 .
Interpretation
a) 1 to 3 are critically low: May need resuscitation
b) 4-6 are below normal: Needs further suctioning
c) 7+ are normal: Well-baby
A low score on the one-minute test may show that the neonate requires medical
attention[3] but does not necessarily indicate a long-term problem, particularly if
the score improves at the five-minute test. An Apgar score that remains below 3
at later timessuch as 10, 15, or 30 minutesmay indicate may indicate longerterm neurological damage, including a small but significant increase in the risk
of cerebral palsy

Newborn Reflexes
1.
Moro
Response to sudden movement or lout noise should be one of symmetric extension
and abduction of arms with fingers extended thane return to normal relaxed flexion
2.
Rooting
Turns in direction of stimulus to check or mouth; opens mouth and begins to suck
rhythmically when finger or nipple is inserted into mouth; difficult to elicit after
feeding; disappears by 4-7 months
3.
Sucking
Sucking is adequate for nutritional intake and meeting oral stimulation needs for
12 months
4.
Palmar grasp
Fingers grasp adult finger when palm is stimulated and held momentarily- lessens
at 3- 4 months
5.
Plantar grasp
Toes curl downward when sole of foot is stimulated lessens by 8 months
6.
Stepping
When held upright and one foot touching a flat surface, will step alternately
disappears at 4-8 weeks of age
7.
Babinski
Fanning and extension of all toes when one side of sole is stroked from heel upward
across ball of foot, disappears at about 12 months
8.
Tonic neck
Fencer postion when head is turned to one side, extremities on same side extend
and on opposite side flex, this may not be eveident during early neonal period
disappears at 3-4 months
9.
Trunk incurvation
In prone postion, stroking of spine causes pelvis to turn to stimuated side

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