NEW BALLARD SCORING SYSTEM ; CAN IT BE SIMPLIFIED . . !

Results:-This was a prospective observational study based on single cross sectional sample of recently delivered neonates at the tertiary care hospital. The GA was calculated by NBSS, SSS and LMP correlated with USG. The highest correlation was found with New Ballard score i.e. 0.73 and correlation with Simplified score and GA-LMP were 0.67, 0.72 respectively. The statistical mean difference of Simplified score system underestimated the GA by 0.23 weeks, whereas the New Ballard score underestimated the GA by 0.09 weeks. However this difference was statically not significant.

National Family Health Survey (NFHS) 2005-2006 reports showed a high incidence of small-for-date babies emphasizing real need of a method for estimating GA that is both rapid & accurate 3 . A perfect method for assessment of GA must be accurate, independent of nutrition of baby and is not affected by the babies' general condition. It should be simple, reliable, and easy to learn with less handling of baby. Hence different scores to assess maturity have been developed namely New Ballard Scoring System (NBSS) 2 , Dubowitz Scoring System (DSS) 1 and Meharban Singh scoring System (MSS) 6 . However, with limited technical knowledge and skill, it is difficult for paramedical workers to learn & use NBSS which is time consuming & more disturbing for sick Neonates.
Therefore this study was conducted to assess the accuracy of the Simplified Scoring System (SSS) derived from NBSS which is simple to evaluate, easy to learn and consist of only four criteria's which are: Posture, Skin Texture, Breast and External Genitals. Study procedure:-The study was conducted after obtaining the approval of Institutional Ethics Committee.The sample size was calculated by taking the level of significance as 5%, expected precision as 3% and preterm prevalence as 12.3%. 10% of sample increased by assuming nonresponse. Consecutive 524 babies were selected as per inclusion & exclusion criteria. Informed consent was obtained and care was taken to optimize hygiene and minimize risks related to handling of fragile preterm. Babies were examined naked in supine position with head and body in a straight axis within 24 hours of birth in a warm room with good diffuse light. The observer was not blinded to the GA-LMP and GA-USG of the neonate. Neonates were evaluated for GA by two different scoring systems;
Method I:-From date of LMP, GA was calculated as the number of completed weeks from the first day of mother's LMP. This method is referred to as GA-LMP. The GA obtained by USG before 30 weeks noted and referred as GA-USG.
Method -II:-New Ballard score:-GAs was determined according to the method described by Ballard et al 2 using 6 physical and 6 neurological criteria. The GA corresponding to the total score was obtained from the table and referred as GA-NBSS.

Method -III
The simplified score was developed keeping following points in mind. 1. The SSS contains items from both neurological and physical characteristics, which are simple, easy to learn. 2. Assessment of genitalia allows the variations in estimating GA due to gender differences. 3. As there are lesser items (four), it is quite easy to use as a picture is provided for the posture. Method for Assessment of GA from the Total Score of the simplified score:-We estimated neonates having GA ranging from 22 weeks to 44 weeks. This GA was determined by the reference standard i.e. LMP corroborated by USG. Scoring was distributed evenly with increasing maturity with highest score of >16 corresponding to 44weeks.

Statistical analysis:-
This was done using Microsoft Excel and Graph Pad Prism version 5and analyzed by One way ANOVA with posthoc Dunnet test with P value <0.05 considered significant.
Validity was defined as the percentage of infants for whom GA by method was within 2 weeks of GA by dates of USG.
Accuracy was defined as the mean difference in weeks between GA by method and GA by USG. Smaller the mean difference, more accurate the method.

Results:-
Male preponderance with 286(54.58%) patients being male in our study group and 238 (45.42%) were female with male: female ratio1.2:1 was found.  As compared to GA-USG as reference standard, the NBSS scores was overestimating neonates in <32 weeks GA group by 1.3 weeks. In group ≥32 to <34weeks GA -NBSS and SSS underestimated GA by 0.65 weeks and 0.45 weeks respectively than GA -USG. In group ≥34 to <38, NBSS was overestimating by 1.9 weeks and SSS was underestimating by 0.28 weeks compared with GA-USG. In a group of ≥38 weeks GA the NBSS was overestimating by 0.01 weeks whereas SSS scores were underestimating by 0.12 weeks as compared to GA-USG. P value in NBSS and SSS as compared to USG was not significant (P>0.05). P value in LMP compared to USG was significant i.e. P<0.05 using One way ANOVA with post-hoc Dunnet test. The statistical mean difference of SSS underestimated the GA by 0.23 weeks, whereas the NBSS underestimated the GA by 0.09 weeks. P value in NBSS and SSS compared to USG was not significant (P>0.05). There difference was statistically not significant.

TableIV:-Comparison of Correlation of NBSS, SSS and GA-LMP with GA-USG usingPearson correlation coefficient
The highest correlation was found with the NBSS (0.73) as compared to SSS (0.67) and GA-LMP (0.72). There was moderate reliability between NBSS and SSS as compared to GA-USG.

Discussion:-
In developed countries, it is not the survival of extreme infants that is at stake, but the neurologicaloutcome of the survivors. The question of GA remains fundamental because of high cost of treating a survivor, which is inversely proportional to the GA. On other hand, in developing countries where means are limited, knowledge of GA is still important in deciding how to ration health care. 5 Prioritizingreferral to SNCU / NICU of premature baby will definitely reduce complications associated with the prematurity such as hyaline membrane disease.??
As compared to GA-LMP corroborated by USG as reference standard, the NBSS and SSS were underestimating neonates in ≥38 weeks and overestimating ≥32 to <38 weeks GA groups. The number of babies in SSS was close to that assessed by GA-LMP corroborated by USG as Reference Standard. Erman et al (2006) 10 found NBSS (+1 day and SD 8 days) to be more accurate than Dubowitz/Finnstrom score (+4 days and SD 9 days) in contrast to CGLMPwhich was considered as gold standard.
In our study, it was found that the SSS underestimated the GA by 0.23 weeks, whereas the NBSS underestimated the GA by 0.09 weeks.NBSS accuracy was more than that of SSS.S Bindushaet al (2014) 11 found that the simplified method based on physical criteria underestimated the GA by 0.58 weeks whereas NBSS overestimated the GA by 0.31weeks. Rosenberg RE et al (2009) 12 found that both LMP and Ballard tended to underestimate GA compared to ultrasound while Dubowitz tended to overestimate GA, while LMP underestimated the ultrasound finding by one day with a wide confidence interval (±11 days), NBSS underestimated GA by 2.9 days (±7.8) and the Dubowitz score overestimated GA by 3.9 days (±7).This was because study population consisted only of preterm infant with average GA of <33 weeks. Sunjoh F.et al (2004) 14 found that the Eregie model was the most accurate with the lowest mean difference of 0.259 ± 1.376 weeks followed by the NBSS with mean difference of 0.335 ± 1.518 weeks. The Dubowitz method is fairly accurate with a mean difference of 0.5 ±1.31. In the Farr method mean difference was 1.228± 1.495. The overall low accuracy of Farr method supports the need of neurological criteria in improving the accuracy of a method. However at low GA i.e. < 28 weeks and between 28-31 weeks the Farr method was reasonably accurate.
In the present study we considered GA-USG as Reference Standard, the NBSS was overestimating neonates in <32wks GA group by 1.3 wks. In group ≥32 to <34wks GA NBSS and SSS underestimating by 0.65 wks., 0.45 wks respectively as compared to GA-USG. In group ≥34 to <38 wks NBSS was overestimating by 1.9 wks and SSS were underestimating by 0.28 wks compared to GA USG. In a group of ≥38 wks GA the NBSS was overestimating by 0.01 wks, SSS scores was underestimating by 0.12 wks as compared to GA-USG. P value in NBSS and SSS compared to USG was not significant (P>0.05). However their difference was statistically not significant.  11 studied the GA assessed by the NBSS and the simplified physical method correlated well with the GA estimated from the date of mother's last menstrual period. Pearson coefficient correlated strongly between GLMP with Ballard GA(r=0.92) score and Physical GA score (r=0.91). 14 studied the correlation between the GA by each method and the GA by dates was equally good for the methods of Dubowitz, New Ballard, the Eregie with similar correlation coefficients of 0.94, 0.933, and 0.933, respectively.

Sunjoh F.et al (2004)
We also tried to understand which items within each score had high correlation with GA-LMP,GA-USG as well as the score itself. The items in the NBSS showed lower correlation to GA-LMP and GA-USG as compared to total score itself. The highest correlation by GA-NBSS was shown by posture (0.62).Other were plantar surface (0.58), Lanugo (0.53), square window (0.53), arm recoil (0.53), eye/ear (0.52) and genitals (0.52) all showing moderate correlation i.e. more than 0.5. By GA-USG highest correlation was shown by Lanugo (0.57).Other were popliteal angle (0.49), posture (0.47), breast (0.44) and genitals (0.41).Though the correlation of individual item was low but collectively they were found equally effective as compared to NBSS.As there was no statistical difference. 14 foundhigh correlation in case of external criteria which were skin color (0.801), skin texture (0.800), breast size (0.764) plantar creases (0.760), and ear firmness (0.718) and neurological criteria were posture (0.762), scarf sign (0.718), and ventral suspension (0.705). 7 found that the highest correlation with nipple formation followed by edema and the least correlation with genitalia. Best neurological criteria were ventral suspension and popliteal angle.

Conclusion:-
As compared to NBSS, the new SSSscale has comparablevalidity, accuracy and moderate reliability to the NBSS; while being simple, very easy to use and producing comparable results for assessment of GA.

Recommendation:-
Such SSS if incorporated in clinical practice would be helpful in Minimizing Handling of babies, Minimizing time to assess maturity, with minimal training to the Health Care Worker&Iterators variability; needs to be studied further.