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. 2016 Apr 15;42:972–986. doi: 10.1007/s00134-016-4344-1

Table 2.

Panel of behavioural instruments specific to paediatric critical care

COMFORT behavior scale
Categories Score
  Alertness 1–5
  Calmness/agitation 1–5
  Respiratory response or cryinga 1–5
  Physical movement 1–5
  Muscle tone 1–5
  Facial tension 1–5
Total score 6–30
Withdrawal Assessment Tool version 1 (WAT-1)
  Information from patient record
    Loose/watery stools No = 0, yes = 1
    Vomiting/retching/gagging No = 0, yes = 1
    Temperature > 37.8 °C No = 0, yes = 1
  2 min pre-stimulus observation
    State SBS ≤ 0 = 0, SBS ≥ 1 = 1
    Tremor No = 0, moderate/severe = 1
    Any sweating No = 0, yes = 1
    Uncoordinated/repetitive movement No = 0, moderate/severe = 1
    Yawning of sneezing No = 0, yes = 1
  1 min stimulus observation
    Startle to touch No = 0, moderate/severe = 1
    Muscle tone Normal = 0, increased = 1
  Post-stimulus recovery
    Time to gain calm state (SBS ≤ 0) 0–2
Total score 0–12
Sophia Observation withdrawal Symptoms-scale (SOS)
Items Score
  Autonomic dysfunction
    Tachycardia No = 0, yes = 1 (for all items)
    Tachypnoea
    Fever (≥38.5 °C)
    Sweating
  CNS irritability
    Agitation
    Anxiety
    Tremors
    Increased muscle tension
    Inconsolable crying
    Grimacing
    Sleeplessness
    Motor disturbance
    Hallucinations
  Gastrointestinal dysfunction
    Vomiting
    Diarrhoea
Total score 0–15

SBS State Behavioural Scale

aCrying only in spontaneous breathing patients