Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

1. Skills workshop:
Gestational age
and weight
Objectives Nipple clearly seen
Palpable breast bud
Yes
Yes
No
No
Descended testes Yes No
When you have completed this skills Covered labia minora Yes No
workshop you should be able to:
• Assess an infant’s gestational age using Postterm infants can usually be recognised
by their long finger nails. With experience,
the Ballard scoring method.
most preterm infants can be identified by their
• Accurately measure weight and head general appearance and behaviour on clinical
circumference. inspection.
• Plot weight and head circumference for
gestational age. 2-b Scoring gestational age
To obtain a more accurate idea of the
gestational age, the Ballard scoring method
ASSESSING THE can be used. The accuracy of the method
depends on the experience of the examiner.
GESTATIONAL AGE With practice and careful attention to detail,
the infant’s correct gestational age can be
estimated with an accuracy of about 2 weeks.
2-a Assessing gestational age by simple If the scored age is within 2 weeks of the
inspection gestational age suggested by the mother’s
There are a number of easily observable dates, then accept her dates as correct.
clinical signs that can help you decide whether However, if the scored age is more than 2
an infant is term or preterm: weeks higher or lower than the mother’s dates,
then her dates are probably incorrect and
Term Preterm the scored age should be used. The scored
Sucks well Yes No gestational age can also be used to decide
Flexes arms and legs Yes No whether the gestational age, determined by
Veins seen under skin No Yes obstetric assessment, is correct or not.

2. 54 NEWBORN CARE
Other scoring methods such as the Finnstrom • Score 1 if the wrist can be flexed to 60°.
method and the Dubowitz method can also • Score 2 if the wrist can be flexed halfway to
be used. the forearm.
• Score 3 if the wrist can be flexed to 30°.
2-c Use of the Ballard method • Score 4 if the palm of the hand can be
pressed against the arm.
The Ballard scoring method uses both
neurological features and external features. The Arm recoil: Fully bend the arm at the elbow so
descriptions given below describe how to assess that the infant’s hand reaches the shoulder, and
the features illustrated in Figure 2.A. Each keep it flexed for 5 seconds. Then fully extend
feature is given a score and these individual the arm by pulling on the fingers. Release the
scores are added up to give a final total score. hand as soon as the arm is fully extended and
This final total score can then be converted to observe the degree of flexion at the elbow
an estimated gestational age by consulting the (recoil). Arm recoil is better in more mature
table in Figure 2.A. Where possible, examine infants. Note that a score of 1 is not given.
both the left and right sides of the body when • Score 0 if there is no arm recoil at all.
doing the Ballard score and give the average • Score 2 if there is some arm recoil.
score observed on either side. Half scores can • Score 3 if the arm recoil is good and the
be used. Note that some features have negative arm is flexed halfway back to the shoulder.
scores for very preterm infants. • Score 4 if there is a brisk arm recoil and
the infant pulls the arm back almost to the
2-d Neurological features shoulder.
All 6 neurological features are assessed with Popliteal angle: With your one hand hold the
the infant lying supine (the infant’s back on the infant’s knee against the abdomen. With the
bed). The infant should be awake but not crying. index finger of the other hand gently push
Posture: Handle the infant and observe the behind the infant’s ankle to bring the foot
position of the arms and legs. More mature towards the face. Observe the angle formed
infants (with a higher gestational age) have behind the knee by the upper and lower legs
better flexion (tone) of their limbs. (the popliteal angle). More mature infants have
a smaller popliteal angle with less extension of
• Score 0 if both arms and legs are fully the knee.
extended.
• Score 1 if there is slight flexion of the legs • Score –1 if the leg can be fully extended to
only. form an angle of 180°.
• Score 2 if there is moderate flexion of the • Score 0 if the knee can only be extended to
legs. 160°.
• Score 3 if the legs are flexed to 90° and the • Score 1 if the knee can only be extended to
arms are partially flexed. 140°.
• Score 4 if all limbs are fully flexed against • Score 2 if the knee can only be extended to
the body. 120°.
• Score 3 if the knee can only be extended to
Square window: Gently press on the back of 100°.
the infant’s hand to push the palm towards the • Score 4 if the knee can be extended to 90°.
forearm. Observe the degree of wrist flexion. • Score 5 if the knee cannot be extended to
More mature infants have greater wrist flexion. 90°.
• Score –1 if the wrist cannot be flexed to 90°. Scarf sign: Take the infant’s hand and gently
• Score 0 if the wrist can only be flexed to pull the arm across the front of the chest and
90° only, giving the appearance of a ‘square around the neck like a scarf. With your other
window’. hand gently press on the infant’s elbow to help

3. SK ILLS WORKSHOP : GESTATIONAL AGE AND WEIGHT 55
the arm around the neck. In more mature Skin: Examine the skin over the front of the
infants the arm cannot be easily pulled across chest and abdomen, and also look at the limbs.
the chest. More mature infants have thicker skins.
• Score –1 if the arm can be wrapped tightly • Score –1 if the skin is sticky and transparent.
around the neck (like a scarf). • Score 0 if the skin appears very thin, red
• Score 0 if the elbow can only be pulled and gelatinous (jelly-like).
beyond the chest but not fully wrapped • Score 1 if the skin is thin and smooth with
around the neck. many small blood vessels visible.
• Score 1 if the elbow reaches the other side • Score 2 if the skin is thicker with only a
of the chest but cannot be pulled beyond few blood vessels seen. Fine peeling of the
the chest. skin is often noticed, especially around the
• Score 2 if the elbow can reach the midline ankles.
of the chest. • Score 3 if the skin is pale and slightly dry
• Score 3 if the elbow cannot reach the with only a few bigger blood vessels seen.
midline of the chest. • Score 4 if the skin is dry and cracked with
• Score 4 if the elbow cannot be pulled as far no blood vessels visible.
as the side of the chest. • Score 5 if the skin is very thick and looks
like leather.
Heel to ear: Hold the infant’s toes and gently
pull the foot towards the ear. Allow the knee Lanugo: This is the fine, fluffy hair that is seen
to slide down at the side of the abdomen. over the back of small infants. Except for very
Unlike the illustration, the infant’s pelvis may immature infants that have no lanugo, preterm
be allowed to lift off the bed. Observe how infants have a lot of lanugo and this decreases
close the heel can be pulled towards the ear. with maturity.
More mature infants have less flexion of the
• Score –1 if no lanugo is seen in a very
hips and, therefore, you cannot bring the heel
small infant.
towards the ear.
• Score 0 if there is only some lanugo in a
• Score –1 if the heel can easily be pulled to very small infant.
the ear. • Score 1 if the lanugo is thick and present
• Score 0 1 if the heel can almost reach the over most of the back.
ear. • Score 2 if the lanugo is thinning, especially
• Score 1 if the heel gets close to the ear. over the lower back.
• Score 2 if the heel can be pulled just • Score 3 if there are bald areas with no
beyond halfway to the ear. lanugo.
• Score 3 if the heel can be pulled halfway to • Score 4 if very little lanugo is seen. These
the ear. are always bigger infants.
• Score 4 if the heel cannot not be pulled
Plantar creases: Use your thumbs to stretch
halfway to the ear.
the skin on the bottom of the infant’s foot.
Only note definite creases and not very fine
2-e External features wrinkles, that disappear when the skin is
Six external features are examined. The infant stretched. More mature infants have more
has to be turned over to examine the amount creases. To measure the length of the foot in
of lanugo on the back. If the infant is too sick very small infants place a ruler on the sole and
to be turned over, then the amount of lanugo measure the distance in mm from the back of
is not scored. the heel to the tip of the big toe.
• Score –2 if there are no creases at all (there
may be fine wrinkles) and the heel-toe
distance is less than 40 mm.

4. 56 NEWBORN CARE
• Score –1 if there are no creases at all and • Score 1 if the ear slowly unfolds, and the
the heel-toe distance is 40 to 50 mm. upper margin of the ear (pinna) has started
• Score 0 if shallow, red creases are present, to curl in.
especially over the anterior sole, and the • Score 2 if the upper margin of the ear is
heel to toe distance is more than 50 mm. well curled and the ear unfolds quickly.
• Score 1 if shallow, red creases are present, Areas of cartilage still feel soft, especially
especially over the anterior sole. towards the edge of the ear.
• Score 2 if deeper creases are present on the • Score 3 if the cartilage feels firm
anterior third of the sole only. throughout the ear, and the ear springs
• Score 3 if deep creases are present over two back rapidly if folded.
thirds of the sole. • Score 4 if the ear feels stiff and the whole
• Score 4 if the whole sole is covered with ear margin is well curled in.
deep creases.
Genitalia: Male and female genitalia are scored
Breast: Both the appearance of the breast differently. With maturity the testes descend in
and the size of the breast bud are considered. the male and the scrotum becomes wrinkled.
Palpate for the breast bud by gently feeling In females the labia majora increase in size with
under the nipple with your index finger and maturity. Note that a score of 1 is not given.
thumb. More mature infants have a bigger
Males:
areola and breast bud.
• Score –1 if the scrotum is very small, flat
• Score –1 if the areola (pink skin around the
and smooth with no testes palpable.
nipple) cannot be seen.
• Score 0 if the scrotum has faint wrinkles
• Score 0 if the areola is very small but can
(rugae) with no testes palpable.
be seen.
• Score 1 if there are a few wrinkles on the
• Score 1 if the areola is small and flat, and
scrotum and the testes are felt high in the
no breast bud can be felt.
groin.
• Score 2 if the breast bud can just be felt and
• Score 2 if there are a few wrinkles and the
the areola is stippled (has fine bumps).
testes are felt high in the scrotum.
• Score 3 if the areola is raised above the
• Score 3 if the testes are in the scrotum and
surrounding skin and the breast bud is
the skin of the scrotum has a lot of wrinkles.
easily felt (3–4 mm).
• Score 4 if the scrotum hangs low with fully
• Score 4 if the areola appears distended
descended testes.
and the breast bud is the size of a pea
(5–10 mm). Females:
Ears and eyes: Both the shape and thickness • Score –1 if the clitoris is prominent and the
of the external ear are considered. With labia flat.
increasing maturity the edge of the ear curls • Score 0 if the clitoris is prominent and the
in. In addition, the cartilage in the ear thickens labia minora (inner labia) still small.
with maturity so that the ear springs back into • Score 1 if the clitoris is prominent and the
the normal position after it is folded against labia minora are larger.
the infant’s head. The eyelids separate with • Score 2 if the labia majora (outer labia) and
increasing maturity. labia minora are of equal size.
• Score 3 if the labia majora are bigger than
• Score –2 if the eyelids are tightly fused
the labia minora.
(stuck together).
• Score 4 if the labia majora cover the clitoris
• Score –1 if the eyelids are still partly fused.
and labia minora.
• Score 0 if the eyelids are open and the ear
is soft and flat and stays folded. Each separate criteria is given a score after
examining that sign on the infant. These

5. SK ILLS WORKSHOP : GESTATIONAL AGE AND WEIGHT 57
separate scores are then added together to give PLOTTING WEIGHT AND
a total score. From the total score the estimated
gestational age can be read off the table. HEAD CIRCUMFERENCE
MEASURING WEIGHT AND 2-h Plotting weight for gestational age
On the chart in Figure 2.B an infant’s birth
HEAD CIRCUMFERENCE weight of 3000 g and gestational age of 39 weeks
have been recorded. Note that lines have been
2-f Weighing an infant drawn from the given weight and gestational
age. The weight for gestational age is recorded
The naked infant is weighed, to the nearest at the point where these 2 lines meet.
10 g, on a scale. Usually a digital scale is
used. If a spring scale is used, it should be Practise plotting weight for gestational age
standardised with a known weight every on the above chart by recording the following
month. If possible, the infant should always be infants’ weight and gestational age. Decide
weighed on the same scale. The birth weight whether each infant is overweight, appropriate
must be recorded on the infant record card. weight, or underweight for gestational age.
Remember that the centile lines mark the
See Figure 2.B for a weight for gestational age outer limit of the normal (or appropriate)
chart. weight for gestational age.
NOTE Measurements made on a spring scale are 1. Weight 1500 g and gestational age 30 weeks.
called weight while measurements recorded 2. Weight 1500 g and gestational age
with a balance scale are called mass. The result is
34.5 weeks.
the same and both are read in grams (g). In this
programme all measurements are called weight.
3. Weight 3950 g and gestational age 39 weeks.
4. Weight 4000 g and gestational age
42.2 weeks.
2-g Measuring head circumference
5. Weight 3000 g and gestational age 43 weeks.
The occipito-frontal head circumference is
measured with a tape measure or a special 2-i Plotting head circumference for
plastic head circumference tape to the nearest gestational age
1 mm. The largest head circumference must
be measured around the forehead and back of Practise plotting head circumference for
the occiput. Usually the head circumference gestational age by recording the following
is measured after delivery when the weight infants’ head circumference and gestational
is recorded. However, the measurement of age on the chart in Figure 2.C. Decide whether
head circumference should be postponed each infant’s head is large, appropriate or small
for 24 hours if marked moulding or severe for gestational age.
caput are present at birth as they may result 1. Head circumference 27 cm and gestational
in an incorrect reading. If possible, the head age 29.5 weeks.
circumference should be recorded on the 2. Head circumference 25.5 cm and
infant record card. gestational age 29 weeks.
The crown-heel length is usually not 3. Head circumference 30 cm and gestational
measured routinely as this is very inaccurate age 32 weeks.
unless a special measuring box is used. 4. Head circumference 30 cm and gestational
Infant length is measured only in special age 35.7 weeks.
circumstances, e.g. when dwarfism is 5. Head circumference 36 cm and gestational
suspected or for research on growth. age 38 weeks.

6. –1 0 1 2 3 4 5
Posture
Square
window
(wrist) >90° 90° 60° 45° 30° 0°
Arm recoil
180° 140–180° 110–140° 90–110° <90°
Popliteal
angle
180° 160° 140° 120° 100° 90° <90°
Scarf sign
Heel to
ear
Physical maturity
–1 0 1 2 3 4 5
Skin Sticky, Gelatinous, Smooth, Superficial Cracking Parchment, Leathery,
friable, trans- red, trans- pink, visible peeling pale areas, deep cracked,
parent lucent veins and/or rash, rare veins cracking, no wrinkled
few veins vessels
Lanugo None Sparse Abundant Thinning Bald areas Mostly bald
Plantar Heel–toe >50 mm Faint red Anterior Creases Creases over
surface 40–50 mm: No crease marks transverse anterior 2/3 entire sole
–1 crease only
<40 mm: –2
Breast Imper- Barely per- Flat areola,
Stippled Raised Full areola
ceptible ceptible no bud areola areola 5–10 mm
1–2 mm bud 3–4 mm bud bud
Eye/ear Lids fused Lids open; Slightly Well-curved Formed and Thick
loosely: –1 pinna flat, curved pinna; soft firm, instant cartilage, ear
tightly: –2 stays folded pinna, soft, but ready recoil stiff
slow recoil recoil
Genitals: Scrotum flat, Scrotum Testes in Testes Testes down, Testes
male smooth empty, faint upper canal, descending, good rugae pendulous,
rugae rare rugae few rugae deep rugae
Genitals: Clitoris Prominent Prominent Majora and Majora Majora
female prominent, clitoris, small clitoris, minora large, cover clitoris
labia flat labia minora enlarging equally minora and minora
minora prominent small
Maturity rating
Score –10 –5 0 5 10 15 20 25 30 35 40 45 50
Weeks 20 22 24 26 28 30 32 34 36 38 40 42 44
Figure 2.A: The Ballard scoring method

7. Birth weight (g)
5000
4000
3000
2000
1000
500
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Gestational age (weeks)
Figure 2.B: Weight for gestational age chart
Birth weight (g)
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
Gestational age (weeks)
Figure 2.C: Head circumference for gestational age chart

8. 60 NEWBORN CARE
REFERENCES
The Ballard scoring method – J Pediatr 1991;
119: 417–423.
Weight for gestational age chart – Acta
Paediatr Scand Suppl 1985; 31: 180.
Head circumference for gestational age chart
– Pediatr Res 1978; 12: 987.