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Table 1 Candidate items evaluated for Bedside PEWS score

From: Development and initial validation of the Bedside Paediatric Early Warning System score

Item Item sub-score
  Age group 0 1 2 4
Heart rate 0–3 months >110 and <150 ≥ 150 or ≤ 110 ≥ 180 or ≤ 90 ≥ 190 or ≤ 80
  3–12 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 0–3 months >60 and <80 ≥ 80 or ≤ 60 ≥ 100 or ≤ 50 ≥ 130 or ≤ 45
  3–12 months >80 and <100 ≥ 100 or ≤ 80 ≥ 120 or ≤ 70 ≥ 150 or ≤ 60
  1–4 years >90 and <110 ≥ 110 or ≤ 90 ≥ 125 or ≤ 75 ≥ 160 or ≤ 65
  4–12 years >90 and <120 ≥ 120 or ≤ 90 ≥ 140 or ≤ 80 ≥ 170 or ≤ 70
  >12 years >100 and <130 ≥ 130 or ≤ 100 ≥ 150 or ≤ 85 ≥ 190 or ≤ 75
Capillary refill   <3 sec    ≥ 3 sec
Pulses   Normal Weak Doppler or bounding Absent
Bolus fluid   No Yes   
Respiratory 0–3 months >29 and <61 ≥ 61 or ≤ 29 ≥ 81 or ≤ 19 ≥ 91 or ≤ 15
rate 3–12 months >24 or <51 ≥ 51 or ≤ 24 ≥ 71 or ≤ 19 ≥ 81 or ≤ 15
  1–4 years >19 or <41 ≥ 41 or ≤ 19 ≥ 61 or ≤ 15 ≥ 71 or ≤ 12
  4–12 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   Normal Mild increase Moderate increase Severe increase/any apnoea
Saturation   >94 91–94 ≤ 90  
Oxygen therapy   Room air   Any – <4 L/min or <50% ≥ 4 L/min or ≥ 50%
Level of consciousness   Normal Consolable Rouseable Bromage 0,1,S    Bromage score 2–3 Irritable
Temperature °C   ≥ 36 and ≤ 38.5 <36 or >38.5 <35 or >40  
  1. Candidate items for the Bedside Paediatric Early Warning System (PEWS) score are presented. Expert opinion was used to identify cut-off points for scoring each item. Item values that fall in the stated ranges receive the number of points indicated at the top of each column. For example a 13-year-old with a respiratory rate of >11 and <17 breaths per minute will receive 0 respiratory sub-score points, whereas if the respiratory rate was either <9 or >30 breaths per minute then 4 sub-score points would be assigned. Given the limitations of assessment and documentation we were unable to use the Glasgow coma scale as the primary measure of level of consciousness. Consequently, level of consciousness was assessed with the Bromage Sedation Scale and an infant behaviour description used locally. The Bromage Sedation Scale is 0 – awake, 1 – occasionally drowsy, easily rouseable, 2 – frequently drowsy, easily rouseable, 3 – somnolent, difficult to arouse and S – normal sleep. The infant behaviour scale was adapted from local documentation practice to describe a child who was irritable, rouseable, consolable, or 'normal'. These two categories were combined to describe level of consciousness. A Bromage score of 2 or more or an infant behaviour rating of 'irritable' was assigned 4 sub-score points.