The Ballard Score Maturational Assessment of Gestational Age in Newly Born Infants
Ballardscore Publishing Date
Title
Ballardscore Publishing Date
Question
Where and when was the Ballard Score developed, and where was it published?
Answer
The assessment was developed at UC/CCHMC. It was published in the Journal of Pediatrics in the November issue, 1991.

Dr. Ballard
Calculation Standard
Title
Calculation Standard
Question
Is there a standard for determining gestational age score that falls between the score sheet guidelines? My exam total score is 27, which falls between the 25 and 30 point scores. Do I assign 34 weeks or 35 weeks, and why?..
Answer
For scores between numbers on the grid, we interpolate as follows:

25 = 34 weeks
26 = 34 weeks
27 = 34 weeks
28 = 35 weeks
29 = 35 weeks
30 = 36 weeks
The reason we interpolate this way is that we wish to record only completed weeks of gestation and not partial weeks. In addition, this assessment is a clinical one and to record partial weeks would result in false accuracy, since maternal ovulation varies several days among women.

Therefore, we interpret the results of the gestational assessment as follows:

If weeks by exam fall within 2 weeks of KNOWN maternal dates, preferably confirmed by early ultrasound, then the maternal dates are more likely correct. If weeks by exam are greater than 2 weeks outside of maternal dates in either direction, then the clinical gestational assessment is more likely correct.
Dr. Ballard
Computerized Records
Title
Computerized Records
Question
Do most hospitals that you are familiar with keep the Ballard Score on paper, or are they entering the information into the computerized patient record?
Answer
Most of the hospitals I was familiar with before EMR's became the norm kept the gestational assessment form in the paper chart. More recently many hospitals are going over to electronic medical records, and that includes the Ballard Score. Either way is fine, as long as it remains a part of the baby's birth medical record.

Dr. Ballard
Curve or Graph
Title
Curve or Graph
Question
Is there a curve or graph that correlates well with the Ballard Score?
Answer
We used Dr. Lula Lubchenco's growth curves for both clinical care and research activities. We did this because these were the most accessible and most widely used, and had become standard practice. Her graphs also come with weight-length or "ponderal index" percentile curves, which I have found very useful in my research.

Dr. Lubchenco's data were derived from babies born in Denver at mile high altitude. There was some concern that these babies were therefor smaller, rendering the growth curves lower, and resulting in a greater number of LGA babies if born at sea level. However, the mean weight differences between the Denver babies and those born at sea level were not found to be significant.

In short, I believe most people use the Luchencho charts for sizing newborn infants as well as for determining whether or not they are proportionately grown. They are regularly used in conjunction with the Ballard Score.

Dr. Ballard
Deformities
Title
Deformities
Question
When assessing a newborn with no arms or other deformities, how are the related sections scored?
Answer
This is an important question, since the same principle can be applied to a child born frank breech, with genu recurvatum, or with cryptorchidism. In any and all situations where the criterion cannot be performed, it is crucial that the rest of the assessment be performed, and that a score similar to the others be assigned. If it is skipped or given a zero value, the gestational assessment will result in a falsely low score, and hence in a falsely low gestational age.

Dr. Ballard
Downloadable Version
Title
Downloadable Version
Question
Can we reprint the Ballard scoring sheet to teach third year medical students, or for our newborn nursery?
Answer
There is a downloadable PDF version of the scoresheet which can be used for printing hardcopies of the score sheet. Please visit the ScoreSheet page and click on the download PDF link at the bottom of the page.

Dr. Ballard
Extremely Premature Infants
Title
Extremely Premature Infants
Question
Can the assessment be performed on extremely premature infants (pre-20 weeks gestation)? When should it be performed?
Answer
The validity of the Ballard score was tested on newborn babies down to 20 weeks gestational age, verified by early ultrasound examination. In these very immature infants, the correlation coefficient, tested against verified menstrual history, was 0.75 if performed prior to 24 hours postnatal age. After that it fell, largely because of rapid attrition in this vulnerable population. In short, yes it can be done, preferably sometime during the first day of life.

The neuromuscular portion is based upon passive and not active muscle tone.The score is actually designed for infants who are sick and even on ventilators, as long as they are not pharmacologically paralyzed.

Dr. Ballard
Formula for Computer Calculation
Title
Formula for Computer Calculation
Question
Is there a formula that can be applied to this tool if implemented on a computer?
Answer
There is no mathematical formula to convert the score to weeks of gestation, since in the clinical arena, we are assessing the infant's achieved level of maturation, which is a continuum rather than a series of discrete data points. For this reason, we look at completed weeks of gestation, so that we do not make the mistake of artificially overestimating the infant's gestational age.

Another way of arriving at the correct week would be to round DOWN and not up when using the grid to convert the numerical score to weeks of gestation. For bedside clinical and research purposes, we do use odd weeks by extrapolating between the five point increments in the score. In all cases, we record only completed weeks of gestation.

(As this is a clinical tool, trying to arrive at 1/2 weeks would be false accuracy.)

The score lists only even weeks for the sake of simplicity and brevity.

To my knowledge there has not been a need for a complete list of ratings. Clinicians have extrapolated intermediate values similarly to the example given earlier, arriving at odd numbered weeks as shown.

An example of this extrapolation using scores between 15 and 20 would be as follows:

This same pattern can be followed up to 50 = 44 weeks.

Dr. Ballard
Known Date Differs from Score Result
Title
Known Date Differs from Score Result
Question
Which gestational age should be taken as correct if the known dates are different from the weeks by exam score?
Answer
The examination is, by validation studies, accurate within 2 weeks of known dates. Since maternal ovulation can vary over 10+ days, we consider agreement within 2 week between dates by last Normal menstrual period and exam to be closest to dates. If the difference is greater than 2 weeks, then the exam is taken as the gestational age.

Dr. Ballard
Premature Infants
Title
Premature Infants
Question
Can the Ballard Score be used for assessing premature Infants?
Answer
Can the assessment be performed on premature babies (pre-20 weeks gestation)? When should it be performed?
The validity of the Ballard score was tested on newborn babies down to 20 weeks gestational age, verified by early ultrasound examination. In these very immature infants, the correlation coefficient, tested against verified menstrual history, was 0.75 if performed prior to 24 hours postnatal age. After that it fell, largely because of rapid attrition in this vulnerable population. In short, yes it can be done, preferably sometime during the first day of life.
The neuromuscular portion is based upon passive and not active muscle tone. The score is actually designed for infants who are sick and even on ventilators, as long as they are not pharmacologically paralyzed.

Dr. Ballard
Recommended Timeframe
Title
Recommended Timeframe
Question
What is the best timeframe to conduct the new ballard score assessment?
Answer
We analyzed validity of the New Ballard Score, performed from 30 minutes to 96 hours of age. Our studies showed that, overall, the score was equally valid when performed anytime between 30 minutes and 96 hours of postnatal age. When infants less than 26 weeks were analyzed separately, the validity deceased after 24 hours of extra uterine life.

Correlation coefficients were r => 0.96 at all postnatal ages when all gestational ages were taken together. When infants < 26 weeks gestational age were analyzed separately however, correlation fell to 0.75 after 24 hours of life. This taught us that, where extremely premature infants are concerned, it is best to perform the assessment prior to 24 hours of postnatal age.

Dr. Ballard
Square Window
Title
Square Window
Question
Why does the score increase as the square window angle actually decreases?
Answer
Although it seems counterintuitive, the square window which measures the angle to which the wrist can be flexed passively, does indeed DECREASE as maturation progresses.

This is so because Passive Flexor tone increases progressively during fetal maturation. The entire neuromuscular portion of the assessment is based upon this fact. At term and post term, the infant has maximum passive Flexor tone and minimum passive Extensor tone.

AFTER term and post term, this maximum PASSIVE FLEXOR TONE DIMINISHES over the first year of life until there is a balance between passive flexor and extensor tone.

Dr. Ballard
Timeframe for Breach Assessment
Title
Timeframe for Breach Assessment
Question
At what time frame is it best to perform a Ballard Assessment on an infant that was breech?
Answer
This is a very pertinent question, as the newborn who was frank breech (legs straight up) will have transient flexor fatigue in both the hamstrings and gluteus muscles. This will result in significantly lower scores for the popliteal angle and the heel to ear criteria, respectively. In such a case, you have two options:

1. Perform the remainder of the neuromuscular criteria, then assign a similar score to the popliteal angle and heel to ear.

2. Wait 24 to 48 hours or until flexor tone has returned to the hamstrings and gluteus muscles, and repeat the assessment.

(These infants are also at risk for hip instability or dislocation.)

In cases of complete or footling breech, there should be no flexor fatigue of said muscles. Thus, the assessment should be valid in the usual time frame ( from 30 minutes to 96 hours of postnatal age).

Dr. Ballard
Why Only Even Weeks
Title
Why Only Even Weeks
Question
The paper form doesn't allow for odd week results. Why does the scoresheet only list the even weeks?
Answer
For bedside clinical and research purposes, we do use odd weeks by extrapolating between the five point increments in the score. In all cases, we record only completed weeks of gestation.

(As this is a clinical tool, trying to arrive at 1/2 weeks would be false accuracy.)

The score lists only even weeks for the sake of simplicity and brevity.

To my knowledge there has not been a need for a complete list of ratings. Clinicians have extrapolated intermediate values similarly to the example given earlier, arriving at odd numbered weeks. Dr. Ballard