Decision making in NICU- Role of neonatal scores in predicting/maintaining neonate’s health

by | Mar 24, 2017 | Articles | 0 comments

In our last blog on Respiratory diseases in neonates and Role of Clinical Rules in iNICU, we mentioned about various neonatal diseases of NICU, which leads to high infant mortality rate in India (1). Diseases like Respiratory distress, Intra- Ventricular Hemorrhage, Neonatal Jaundice, Sepsis etc. are few common neonatal diseases which may result in life- threatening situations if not captured and treated timely.
When a baby acquires any such conditions, the challenges for clinical staff are critical. It is the responsibility of the health care providers to safeguard the deteriorating health of the neonate. At the same time data captured from multiple sources such as clinical, devices and observational parameters should be maintained.

Neonatal Scores are used to quantify the morbidity of the neonates, by estimating the probability of the specific outcome of the infant. Scoring systems built by using weighted demographic, physiological, and clinical data and have been majorly accepted across the globe.

These predefined Neonatal Scores help NICU staff to check the criticality of the baby’s health conditions at various levels. For example, APGAR and BALLARD score are used immediately after birth to check physical and Neuro- muscular activities, whereas some disease-specific scores used in NICU like Downes and Silverman-Anderson scores for RDS, and many others.

Brief description about neonatal scores:
Ballard score is a commonly used technique for gestational age assessment. It divides the score into two criteria:
Physical score based on anatomical changes.
Neurological score relies on muscle tone.
Sum of both the criteria extrapolated with the gestational age of the fetus. Scoring allows estimation of age in the range of 26-44 weeks. (2)



APGAR score quickly summarize the health of the infant. In this score, we evaluate the baby on five simple criteria on scale of 0 to 2.(3)
5 criteria are:
– Appearance
– Pulse
– Grimace
– Activity
– Respiration

Test is generally done at 1 min and 5 min after birth, and may be repeated after the interval of 5 min if score remains low.
Results: 7 and above (NORMAL), 4-6 (LOW), 3 and below (CRITICALLY LOW)(3).


Downes score and Silverman Anderson (SAS) are two important clinical scores to assess the severity of respiratory distress. SAS score is ideal for preterm infants and Downes score for term infants.
Downes Score : There are 5 criterion: Respiratory Rate, Retractions, Cyanosis, Air entry, Grunting. Each of these is rated on a scale of 0, 1, 2. The total score is then evaluated.
— Score < 4 No respiratory distress
— Score 4-7 Respiratory distress
— Score >7 Impending respiratory failure

Silverman Anderson Score: 5 Clinical Parameters for Silverman Score: Upper Chest, Lower Chest, Xiphoid Retractions, Nares Dilation, Expiratory Grunting.

— Score 10 = Severe Respiratory stress
— Score ≥ 7 = Impending Respiratory Failure
— Score 0 = No respiratory distress
IVH is the neonatal intracranial hemorrhage common in pre- term infants ≤ 32 weeks of gestation.

Volpes classification used to categorize the condition based on its severity. Classification is based on ultra sound images.
IVH Grading:
— Grade 1: Bleeding confined to periventricular area
— Grade 2: Intraventricular Bleeding (10-50% of ventricular area on sagittal view
— Grade 3: Intraventricular bleeding ( > 50% of ventricular area)
— Grade 4: Intra- Parenchymal echodensity (IPE) (4)
HIE Scoring by Sarnat & Sarnat
Sarnat scoring is a system used to grade the severity of an HIE injury. Sarnat scoring system combines clinical and EEG findings.

Stage 1: Mild
— Hyper-alert
— Eyes wide open
— Does not sleep
— Irritable
— No seizures
— Usually lasts < 24 hours

Stage 2: Moderate
— Lethargy (difficult to rouse)
— Reduced tone of the extremities and/or trunk
— Diminished brainstem reflexes (pupil/gag/suck)
— Possible clinical seizures

Stage 3: Severe
— Coma (cannot be roused)
— Weak or absent respiratory drive
— No response to stimuli (may have spinal reflex to painful stimuli)
— Flaccid tone of the extremities and trunk (floppy)
— Diminished or absent brain stem reflexes (pupil/gag/suck)
— Diminished tendon reflexes
— EEG severely abnormal (suppressed or flat EEG with or without seizures)

Sepsis Score by Rodwell
Neonates are easily prone to bacterial infections. Diagnosis of neonatal sepsis is difficult as early signs are subtle and different at different gestational age.

Timely diagnosis of neonatal sepsis is critical as illness is rapidly progressive and in some cases fatal.
Rodwell scoring system also known as hematological scoring system (HSS) used for early diagnosis of condition and treatment. (8)
Hematological Scoring System includes the following:

— White Blood Cells and Platelet count
— White Blood Differential Count
— Nucleated Red blood cell Count
— Assessment of neutrophil morphology for degenerative changes
Interpretation :

— Score: ≤ 2 Sepsis is unlikely
— Score: 3 or 4 Sepsis is possible
— Score: ≥ 5 Sepsis is very likely

Pain Score
Pain is a complex multidimensional phenomenon. In infants, nature of pain is difficult to articulate. Pain score help the health care providers to inferred the pain through observational and behavioral indicators.(6)
Infant Pain Profile is based on observational and clinical parameters.
Observational Parameters : Behavioral State (Activity, Eye open, facial movement), Brow Bulge, Eye Squeeze, Nasolabial furrow.

Clinical Parameters : Gestational Age, Heart Rate, Oxygen Saturation
Range: 0, 1, 2, 3
Bell’s Staging for Necrotizing Enterocolitis (NEC)
In preterm infants, Necrotizing Enterocolitis is the common and serious acquired gastrointestinal tract disease.
Bell’s staging criteria includes systemic, intestinal, and radiographic signs, to present uniform and consistent descriptive and therapeutic criteria for neonatal NEC.(7)

There are 3 stages of NEC:
— Stage 1: Suspected NEC
— Stage 2: Definite NEC
— Stage 3: Advanced NEC
Above 3 Stages categorized based on
— Systemic signs (Temperature, Heart Rate, Lethargy),
— Intestinal signs (Residuals, Abdominal Distensions, Bowel Sound)
— Radiological Signs (Intestinal Dilation, Pneumatosis Intestinalis, portal vein gas)
BIND Score for Bilirubin Encephalopathy
Clinical BIND Score is used to check the onset, severity, and progression of Acute Bilirubin Encephalopathy (ABE) in infants with Hyperbilirubinemia.(9)

Clinical Signs observed in the score are:
— Mental Status
— Muscle Tone
— Cry Pattern

ABE Status:
— None
— Subtle
— Moderate
— Advance

Range of BIND Score: 0, 1, 2, 3
— Score 7-9: Advance ABE
— Score 4-6: Moderate ABE
— Score 1-3: Consistent with Subtle signs of ABE

To help the neonatologists and team we created a platform (iNICU) with a vision to increase clinical care time in NICU, prevent hospital induced infections, promote digitization by capturing live data and predict future complications of above- mentioned diseases.

To predict problems, we need to distinguish variability in outcome, related to the diagnostic and\or therapeutic intervention. We introduced clinical severity scores (CSS) to iNICU which identify and classify neonates with similar clinical conditions of comparable severity and equivalent expected prognosis.

2. Ballard JL, Novak KK, Driver M (November 1979). “A simplified score for assessment of fetal maturation of newly born infants”. J. Pediatr. 95 (5 Pt 1): 769–74.
3. Apgar, Virginia (1953). “A proposal for a new method of evaluation of the newborn infant”. Curr. Res. Anesth. Analg. it takes less than 2 seconds and for experienced midwives it would take about less than 1 second. 32 (4): 260–267. doi:10.1213/00000539-195301000-00041. PMID 13083014
4. Finster, M.; Wood, M. (May 2005). “The Apgar score has survived the test of time”. Anesthesiology. 102 (4): 855–857. doi:10.1097/00000542-200504000-00022. PMID 15791116
5. Intensive Care Nursery House Staff Manual. (2004). Intraventricular Hemorrhage (IVH) . Retrieved from Link
6. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971-9. Get it! UofT Libraries Bibliographic Links
7. Bell MJ, Ternberg JL, Feigin RD, et al: Neonatal necrotizing enterocolitis: Therapeutic decisions based upon clinical staging. Ann Surg 1978; 187:1-7.
8. Speer CP, Gahr M, Schrotter W. Early diagnosis of neonatal infection. Monatsschr Kinderheilkd. 1985;133(9):665–668
9. Clinical report from the pilot USA Kernicterus Registry (1992 to 2004). L Johnson, V K Bhutani, K Karp, E M Sivieri and S M Shapiro


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