|
| Item | Description | Score |
|
| () Facial activity | Relaxed facial activity | 0 |
| Transient grimaces with frowning, lip purse, and chin quiver | 1 |
| Frequent grimaces, lasting grimaces | 2 |
| Permanent grimaces resembling crying or blank face | 3 |
|
| () Body movements | Relaxed body movements | 0 |
| Transient agitation, often quiet | 1 |
| Frequent agitation but can be calmed down | 2 |
| Permanent agitation with contraction of fingers and toes and hypertonia of limbs or infrequent, slow movements and prostration | 3 |
|
| () Quality of sleep | Falls asleep easily | 0 |
| Falls asleep with difficulty | 1 |
| Frequent, spontaneous arousals, independent of nursing, restless sleep | 2 |
| Sleepless | 3 |
|
| () Quality of contact with nurses | Smiles, attentive to voice | 0 |
| Transient apprehension during interactions with nurses | 1 |
| Difficulty communicating with nurses. Cries in response to minor stimulation | 2 |
| Refuses to communicate with nurses. No interpersonal rapport. Moans without stimulation | 3 |
|
| () Consolability | Quiet, total relaxation | 0 |
| Calms down quickly in response to stroking or voice or with sucking | 1 |
| Calms down with difficulty | 2 |
| Disconsolate. Sucks desperately | 3 |
|
| () Postmenstrual age | Gestational age 37 wks | 0 |
| Gestational age 33–37 wks | 1 |
| Gestational age 33 wks | 2 |
|
