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. 2021 Feb 22;4(1):e25991. doi: 10.2196/25991

Table 1.

Modified Pediatric Early Warning Score (PEWS).

Category Score
0 1 2 3
Behavior Playing, appropriate, at patient’s baseline Inappropriately sleepy or fussy but consolable Irritable or inconsolable Lethargic/confused or
reduced response to pain
Cardiovascular Pink or capillary refill <2 seconds Pale or capillary refill 3-4 seconds or mild tachycardia or single ventricle shunted (BTa shunt or Norwood/Sano) Gray/dusky or capillary refill 4-5 seconds or moderate tachycardia Gray/mottled or capillary refill >5 seconds or severe tachycardia or new onset bradycardia
Respiratory Within normal parameters, no retractions Mild tachypnea or
using accessory muscles or >30% FiO2 or >0.5 L/min/kg
Moderate tachypnea or retractions or >40% FiO2 or >1 L/min/kg Severe tachypnea or RRb < normal for age or >50% FiO2 or >1.5 L/min/kg

aBT: Blalock-Taussig.

bRR: respiratory rate.