Scores | Clinical signs |
---|---|
Mental status | |
0 | Normal |
1 | Sleepy, poor feeding |
2 | Lethargic, irritable, jittery |
3 | Unable to feed, apnea, seizures, coma |
Muscle tone | |
0 | Normal flexed tone (awake) |
1 | Hypertonia alternating with hypotonia |
2 | Neck stiffness, flexor spasm, beginning of neck and back arching, hypertonia |
3 | Persistent retrocollis and opisthotonos, bicycling, twitching of hands and feet, fisting, severe hypotonia with limp posture |
Cry pattern | |
0 | Normal |
1 | High pitched cry |
2 | Shrill cry even if intermittent |
3 | Weak or absent cry, inconsolable cry |
Total score | Sum of highest score in each category |