Categories (total 6) | Signs of neonatal encephalopathy (NE) in each category | |||
---|---|---|---|---|
Normal | Mild NE | Moderate NE | Severe NE | |
1. Level of consciousness | ||||
 | Alert, responsive to external stimuli (state dependent, e.g. post feeds) | Hyper-alert, has a stare, jitteriness, high-pitched cry, exaggerated responds to minimal stimuli, inconsolable | Lethargic | Stupor/coma |
2. Spontaneous activity | ||||
 | Changes position when awake | Normal or decreased | Decreased activity | No activity |
3. Posture | ||||
 | Predominantly flexed when quiet | Mild flexion of distal joints (fingers, wrist usually) | Moderate flexion of distal joint, complete extension | Decerebrate |
4. Tone | ||||
 | Strong flexor tone in all extremities + strong flexor hip tone | Normal or slightly increased peripheral tone | Hypotonia (focal or general) or hypertonia | Flaccid Rigid |
5. Primitive reflexes (circle only the highest level in each sign; the maximum score is only 1 in any one category) | ||||
 Suck | Strong, easily illicit | Weak, poor | Weak but has a bite | Absent |
 Moro | Complete | Partial response, low threshold to illicit | Incomplete | Absent |
6. Autonomic system (circle only the highest level in each sign; the maximum score is only 1 in any one category) | ||||
Pupils | In dark: 2.5–4.5 mm; in light: 1.5–2.5 mm | Mydriasis | Constricted | Deviation/dilated/non-reactive to light |
Heart rate | 100–160 bpm | Tachycardia (HR > 160) | Bradycardia (HR < 100) | Variable HR |
Respiration | Regular respirations | Hyperventilation (RR > 60/min) | Periodic breathing | Apnoea or requires ventilator |
Total score |