High-Pitched Crying

 

Despite the name of this item, the pitch of the cry does not matter​

 

Do not score if baby is crying during diaper change, while hungry, or any other time when most babies would cry.

 

Score 2:

The baby continues to cry for 5 minutes despite strategies to soothe like holding or pacifier use at any time while fed and in a clean diaper during scoring interval.

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This item score should be given whether cry is high-pitched or not, but not if cry is high-pitched and soothed in less than 5 minutes.

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Score 3:

The baby continues to cry for more than 5 minutes despite strategies to soothe like holding or pacifier use at any time during scoring interval.

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This item score should be given whether cry is high-pitched or not

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Sleep

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Score based on longest uninterrupted period of sleep within entire scoring interval. 

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Do not combine sleep periods for scoring.

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If a 3 hour scoring period is used due to a 3 hour feeding or medication schedule, do not score the item “sleeps less than 3 hours” unless infant wakes up on their own after sleeping for at least 2 hours. 

 

         Score 3    if the baby sleeps less than 1 hour
        Score 2    if the baby sleeps less than 2 hours
       Score 1    if the baby sleeps less than 3 hours

 

Moro Reflex

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Moro reflex is also known as the "startle" reflex. Babies commonly do this when there is a noise, movement, or sometimes for no reason at all. It is normal and expected from about 28 weeks gestation to 6 months of age. Parents should be taught how to elicit and assess the Moro reflex.

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Score 2

If the baby’s hands have jitters for longer than 5 seconds.

If more than 2 spontaneous Moro reflexes are observed during exam.

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Score 3

If the baby has jitters and more than 8-10 clonus beats of hands and/or arms.

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Clonus is repetitive back and forth motion of a hand or foot.

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Tremors

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Tremors and jitters are shaky movements of an arm or leg that can be stopped by placing a hand on the limb.

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Do not score startle or jerking movements, particularly of jerking legs normally seen during sleep.

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Score 1 

If the baby’s hand or foot has tremors while the baby is being handled.

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Score 2

If the baby has tremors of one or both arms or legs while the baby is being handled.

Score 3

If the baby’s hand or foot has tremors 30 seconds after handling.

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Score 4 

If the baby has tremors of one or both arms or legs 30 seconds after handling.

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Myoclonic Jerks

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These are different from jitters and tremors because they do not stop when you lay a hand on the arm or leg. This item should only be scored by a nurse or provider.

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Score 3 if the baby has repetitive twitching or jerking movements in their face, arm, or leg.

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Convulsions (Seizures) 

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This item should only be scored by a nurse or provider.

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Score 5

• If the baby tightens and then relaxes all of their muscles repeatedly.

• If the baby’s eyes twitch repeatedly in the same way.

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Increased Muscle Tone 

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Muscle tone is increased if the muscle is flexing and decreased if the muscle is floppy.

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There are many ways to check muscle tone. The baby will receive only one score regardless of which method/s you use.

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Testing Method - Pull-to-sit: 

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This method is preferred for scoring unless there is a contraindication, like arm or shoulder injury.

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With the baby on their back, pull them up to sitting position by the hands or arms. 

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Score 2 if the baby has tightly bent arms and their head is not drooping after 5 seconds.

 

Testing Method - Upright suspension 

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Hold the baby upright with your hands on their chest just under arms.

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Score 2 if the baby remains rigid with bent legs and without their head drooping after 5 seconds.

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 Testing Method - Flexion and extension

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With the baby on their back, straighten and release the legs one at a time.

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Score 2 if you are unable to gently straighten the leg because the baby is flexing too strongly.

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Excoriation

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This is a skin injury caused by rubbing and should be scored until it is healed.

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Score 1 if the baby has marks on their chin, knees, cheeks, elbows, toes, nose, or armpit (not including diaper area).

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Sweating

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Do not score if the baby is overdressed or being warmed by an isolette or radiant warmer.

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Score 1 if the baby is sweaty on their face, chest, or armpits.

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Fever

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Do not score if the baby is overdressed or being warmed by an isolette or radiant warmer.

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Be sure that all caregivers are using the same equipment and method to check temperature. Do not use the rectal method.

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 Score 1 for temperature of 37.3-38 C or 99.2-100.4 F.   

 Score 2 for temperature more than 38 C or 100.4 F.

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Frequent Yawning

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Score 1 if the baby yawns more than 3 times in the scoring interval

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Mottling

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Mottling is a marbled appearance of the skin.

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Score 1 if the baby has mottling on their chest, trunk, arms or legs

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Nasal Stuffiness

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Score 1 if the baby has a stuffy nose that you can hear as they breathe when calm.

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Sneezing

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Score 1 if the baby sneezes more than 3 times within the scoring interval.

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Nasal Flaring

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Score 2 if the baby flares their nostrils for more than 3 breaths in a row while calm at any time during the scoring interval.

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Respiratory Rate

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Retractions are extra muscle movements in the chest while breathing. Parents should be taught how to identify and assess retractions.

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Score 1 If the baby is breathing faster than 60 times a minute while calm.
Score 2 If the baby is breathing faster than 60 times a minute and is having retractions while calm.

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Excessive Sucking

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This item is very subjective. It should be scored if the baby is rooting and sucking for more than 5 minutes after feeding.

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Score 1

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Poor Feeding

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This item can be scored for the interval before or after the feeding in question. All caregivers should use the same method.

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Score 2:

• If the baby is unable to eat for at least 15 minutes at the breast/chest or is unable to eat the recommended volume from a bottle.

• If the baby makes a lot of choking or slurping noises.

• If the baby spills too much from a bottle.

• If the baby takes longer than 30 minutes to finish a bottle.

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Regurgitation

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Do not score if the spit up happens while burping or otherwise stimulating the baby.

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Score 2 if the baby spits up more than 2 times during the feeding.

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Projectile vomiting

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Score 3 if the baby’s vomit travels more than 3 feet.

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Stools

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Score 2 if the baby has poop with more liquid than a normal baby poop. 

Score 3 If the baby has poop with a water ring on diaper.