Assess cry character and duration in the 3-4 hours since the last feed.
Duration of sleep after the most recent feeding period.
Elicit the Moro (startle) reflex and note the magnitude of the response.
Observe tremors both at rest and when gently disturbed.
Assess limb tone by passive range-of-motion. Soothe the infant first; a crying baby cannot be tone-assessed reliably.
Skin excoriation on chin, knees, elbows, toes, or nose from rubbing.
Brief, involuntary muscle twitches or jerks.
Grand-mal or other generalized seizure activity. Score 5 if observed.
Visible sweating not explained by ambient temperature.
Axillary or rectal temperature reading during the assessment interval.
More than 3-4 yawns observed during the assessment interval.
Skin mottling (blotchy discoloration) not explained by temperature.
Congested or blocked nasal passages.
More than 3-4 sneezes during the assessment interval.
Visible widening of the nostrils with each breath, a sign of respiratory distress.
Count respirations for one full minute. Note presence of chest-wall retractions.
Non-nutritive sucking that is excessive or frantic.
Incoordinated or ineffective suck, excessive intake time, or feeding refusal.
Passive regurgitation (not forceful). Score if it occurs twice or more.
Forceful ejection of stomach contents. Score 3 if present.
Stool consistency of the most recent diaper or the majority of stools in the interval.