1. Neonatal Gestational Age Assessment

2. 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

3. 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 weeks)
20 weeks (fundus normally at umbilicus)
Term (fundus at xyphoid)
Amniotic fludi creatinine levels
Maternal serum and urine estriols
Fetal US

4. Prenatal Gestational Age Assessment
Fetal US Measurements
Crown to rump length
Biparietal diameter
Femur length
Abdominal Circumference
Head Circumference
Placental grade

5. 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

6. Classification of Size

7. 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 weeks
Post term after 42 weeks

8. 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

9. 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”

10. Neonatal Gestational Age- 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

11. Physical Maturity Skin Lanugo Plantar surface Breast Eyes & Ears
Genital

12. Neonatal Gestational Age Physical Maturity

13. 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

14. Neonatal Gestational Age Assessment
Physical Maturity
Skin
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

15. Neonatal Gestational Age Assessment
Physical Maturity
Skin
40 Weeks-vessels have now appeared, skin may be leathery with deep cracking

16. Differential Skin Findings
Scalp Electrode

17. Differential Skin Findings
Forcep Marks

18. Differential Skin Findings
Vacuum Bruising

19. Differential Skin Findings
Milia-exposed sebaceous glands
No treatment necessary

20. Differential Skin Findings
Sebaceous hyperplasia
More yellow than milia
Result of maternal androgen in utero
Resolves in time

21. Differential Skin Findings
Mongolian Blue-Grey Spots
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 newborn’s char.

22. Differential Skin Findings
Skin Tags
Most common on ears
Usually tied off or clipped

23. Differential Skin Findings
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.

24. Differential Skin Findings
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 hours of life. Cause unknown, smear shows numerous eosinophils.

25. Differential Skin Findings
Café Au Lait spots
Increased amount of melanin, may increase in number in age
Presence of 6 or more- greater then 0.5 cm in size may be indicative of neurofibromatosis

26. 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

27. 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
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.

28. 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

29. Differential Findings
Bilateral Club Feet
Syndactyly
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.
Polysyndactyly

30. 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

31. 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

32. Differential Findings
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.

33. 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

34. Differential Findings
Ear Tags
Ear Pits (Preauricular pits)
Lop Ear
Prominent Ear
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.

35. 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

36. Differential Findings
Hydrocele
Undescended testicles
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.
Hypospadias
Hymenal Tag

37. Neonatal Gestational Age Neuromuscular Assessment

38. Neonatal Gestational Age Assessment
Neuromuscular Maturity
Posture & Tone
Square Window
Arm Recoil
Popliteal Angle
Scarf Sign
Heel to Ear

39. 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

40. Neonatal Gestational Age Assessment
Neuromuscular Maturity
Posture & Tone
Before 30 weeks-hypotonic, little or no flexion seen
30-38 weeks-varying degrees of flexed extremities
38-42 weeks-may appear hypertonic

41. 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 wrist-measure 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

42. 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

43. 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

44. 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

45. 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

46. References
Aby, J. (2008). Stanford School of Medicine. Newborn Nursery at LPCH. Retrieved October 10th, 2009 from
Ballard J. (1991). New Ballard Score, expanded to include extremely premature infants. Journal of Pediatrics, 119,
Tappero, E. & Honeyfield, M. (1996). Physical assessment of the newborn. Santa Rosa, CA: NICU Ink Publishers.