Table 1 The Bedside Paediatric Early Warning System score items
| Â | Â | Item subscore | |||
|---|---|---|---|---|---|
Item | Age group | 0 | 1 | 2 | 4 |
Heart rate (bpm) | 0 to < 3 months | > 110 and < 150 | ≥ 150 or ≤ 110 | ≥ 180 or ≤ 90 | ≥ 190 or ≤ 80 |
|  | 3 to < 12 months | > 100 and < 150 | ≥ 150 or ≤ 100 | ≥ 170 or ≤ 80 | ≥ 180 or ≤ 70 |
|  | 1-4 years | > 90 and < 120 | ≥ 120 or ≤ 90 | ≥ 150 or ≤ 70 | ≥ 170 or ≤ 60 |
|  | > 4-12 years | > 70 and < 110 | ≥ 110 or ≤ 70 | ≥ 130 or ≤ 60 | ≥ 150 or ≤ 50 |
|  | > 12 years | > 60 and < 100 | ≥ 100 or ≤ 60 | ≥ 120 or ≤ 50 | ≥ 140 or ≤ 40 |
Systolic blood pressure (mmHg) | 0 to < 3 months | > 60 and < 80 | ≥ 80 or ≤ 60 | ≥ 100 or ≤ 50 | ≥ 130 or ≤ 45 |
|  | 3 to < 12 months | > 80 and < 100 | ≥ 100 or ≤ 80 | ≥ 120 or ≤ 70 | ≥ 150 or ≤ 60 |
|  | 1 to 4 years | > 90 and < 110 | ≥ 110 or ≤ 90 | ≥ 125 or ≤ 75 | ≥ 160 or ≤ 65 |
|  | > 4 to 12 years | > 90 and < 120 | ≥ 120 or ≤ 90 | ≥ 140 or ≤ 80 | ≥ 170 or ≤ 70 |
|  | > 80 and < 100 | > 100 and < 130 | ≥ 130 or ≤ 100 | ≥ 150 or ≤ 85 | ≥ 190 or ≤ 75 |
Capillary refill time |  | < 3 seconds |  |  | ≥ 3 seconds |
Respiratory rate (breaths/minute) | 0 to < 3 months | > 29 and < 61 | ≥ 61 or ≤ 29 | ≥ 81 or ≤ 19 | ≥ 91 or ≤ 15 |
|  | 3 to < 12 months | > 24 or < 51 | ≥ 51 or ≤ 24 | ≥ 71 or ≤ 19 | ≥ 81 or ≤ 15 |
|  | 1 to 4 years | > 19 or < 41 | ≥ 41 or ≤ 19 | ≥ 61 or ≤ 15 | ≥ 71 or ≤ 12 |
|  | > 4 to 12 years | > 19 or < 31 | ≥ 31 or ≤ 19 | ≥ 41 or ≤ 14 | ≥ 51 or ≤ 10 |
|  | > 12 years | > 11 or < 17 | ≥ 17 or ≤ 11 | ≥ 23 or ≤ 10 | ≥ 30 or ≤ 9 |
Respiratory effort | Â | Normal | Mild increase | Moderate increase | Severe increase/any apnoea |
Oxygen saturation (%) |  | > 94 | 91 to 94 | ≤ 90 |  |
Oxygen therapy |  | Room air |  | Any to < 4 L/minute or < 50% | ≥ 4 L/minute or ≥ 50% |