Can RASS Be Used in Pediatric Patients?
No, the RASS was not designed for pediatric patients and major adult ICU guidelines explicitly exclude children, but recent high-quality validation studies demonstrate it is valid and reliable in critically ill children when properly implemented with education. 1, 2
Guideline Position on RASS in Pediatrics
The 2013 Critical Care Medicine PAD Guidelines, which established RASS and SAS as the most valid and reliable sedation assessment tools, were developed specifically for adult patients in the intensive care unit and do not address pediatric populations. 3
The 2016 ESPNIC (European Society of Paediatric and Neonatal Intensive Care) guidelines for critically ill infants and children recommend pediatric-specific tools instead:
- COMFORT Behavior Scale (ages 0-16 years, Grade A recommendation) 3
- State Behavioural Scale (ages 6 weeks-6 years, Grade B recommendation) 3
- These tools assess distress, alertness, respiratory response, physical movement, and muscle tone with established feasibility and utility at the bedside 3
Recent Validation Evidence Supporting RASS Use in Children
Despite the absence of guideline endorsement, two high-quality multicenter validation studies from 2021 and 2016 demonstrate RASS performs excellently in pediatric ICU patients:
2021 Multicenter Study (Highest Quality Evidence)
- Excellent inter-rater reliability: weighted kappa 0.946 (95% CI 0.93-0.96) across 28 observers from 14 PICUs 1
- Excellent construct validity: correlation with COMFORT-B scale rho = 0.935 and with numeric rating scale rho = 0.958 1
- Good agreement with COMFORT-B sedation categories: weighted kappa 0.827 for distinguishing over-sedation, optimal sedation, and under-sedation 1
- Responsive to changes: RASS scores changed significantly with variance in sedative doses 1
- Studied in 55 patients (139 episodes), median age 3.6 years (range 1 month to 18 years) 1
2016 Single-Center Validation Study
- Excellent inter-rater agreement: weighted kappa 0.825 between nurse and researcher assessments 2
- High criterion validity: Spearman correlation 0.810 with visual analog scale and weighted kappa 0.902 with University of Michigan Sedation Scale 2
- Valid in both mechanically ventilated (n=27) and spontaneously breathing children (n=73), ages 2 months to 21 years 2
Implementation Requirements
Education is critical for reliable RASS use in pediatrics. A 2018 quality improvement study demonstrated that without proper training, inter-rater reliability is only moderate (weighted kappa 0.56), but improves dramatically to 0.86 after a multi-modal educational intervention and maintains at 0.78 months later. 4
Special populations where RASS performs well after education:
- Infants less than 12 months of age (weighted kappa improved from 0.41 to 0.87) 4
- Children with developmental delay (weighted kappa improved from 0.49 to 0.84) 4
Clinical Decision Algorithm
For pediatric ICU sedation assessment, choose based on institutional resources:
If no validated pediatric sedation tool currently in use: Implement RASS with mandatory staff education program, as it shows excellent measurement properties and allows assessment of both agitation and sedation on a single scale 1, 2, 4
If COMFORT-B or State Behavioural Scale already established: Continue using these guideline-recommended pediatric tools, as they have Grade A evidence specifically for children 3
If transitioning from Ramsay Scale: Switch to RASS, as it demonstrates superior inter-rater reliability (weighted kappa 0.879 vs 0.449) and internal consistency (Cronbach α 0.989 vs 0.828) 5
Critical Pitfalls to Avoid
Do not assume RASS can be used in pediatrics without education. Baseline inter-rater reliability without training is inadequate (weighted kappa 0.56), requiring structured educational intervention to achieve acceptable performance 4
Do not use RASS in neonates or infants without specific validation in your unit. While studies included patients as young as 1-2 months, the youngest age groups require particular attention to ensure staff can reliably assess sedation levels 1, 2
Do not ignore guideline-recommended pediatric tools (COMFORT-B, State Behavioural Scale) if already successfully implemented. These have Grade A evidence specifically for children and established bedside utility 3
Do not apply adult sedation targets (RASS -2 to 0) universally to children. Pediatric patients, especially those under 6 years, often require deeper sedation levels to control behavior and allow safe completion of procedures 3