Sedation Assessment Scale for Pediatric Patients Under 8 Years
Use the COMFORT Behaviour Scale as your primary sedation assessment tool for children under 8 years of age, whether in critical care or procedural settings. 1
Primary Recommendation: COMFORT Behaviour Scale
The American Academy of Pediatrics provides a Grade A recommendation for the COMFORT Behaviour Scale as the primary sedation assessment tool for critically ill pediatric patients aged 0-16 years. 1 This scale has been extensively validated for the pediatric population and is specifically designed to assess sedation in children who cannot self-report. 2
How the COMFORT Behaviour Scale Works
The scale evaluates six behavioral parameters: 1
- Alertness
- Calmness/agitation
- Respiratory response or crying
- Physical movement
- Muscle tone
- Facial tension
Score Interpretation
The COMFORT Behaviour Scale produces scores ranging from 6-30 points: 1
- Score <11: Oversedation (risk of prolonged mechanical ventilation and increased healthcare costs)
- Score 11-22: Adequate sedation (target range)
- Score >22: Undersedation (risk of distress, self-extubation, and accidental line displacement)
Assessment Frequency
Document sedation scores every 4-8 hours alongside vital signs, with more frequent assessment during active sedative infusions or when symptoms are uncontrolled. 1 The American College of Critical Care Medicine emphasizes that accurate recording of sedation scores is mandatory. 1
For children showing signs of agitation, first confirm that ventilator settings are appropriately adjusted to the child's respiratory needs before increasing sedation. 2
Alternative Validated Scale
The State Behavioural Scale serves as an alternative option for children aged 6 weeks to 6 years, with a Grade B recommendation from the Society of Critical Care Medicine. 1 However, given the COMFORT Behaviour Scale's broader age range and Grade A recommendation, it remains the preferred choice for children under 8 years.
Critical Safety Considerations for This Age Group
Children under 6 years, particularly those under 6 months, face the highest risk of adverse events during sedation, including respiratory depression, airway obstruction, and loss of protective reflexes. 3 The majority of PICU patients are below 4 years of age and, due to their developmental stage, cannot understand their situation and may require greater sedative amounts to maintain lines and tubes. 2
Clinicians must be prepared to rescue patients from one level deeper sedation than intended, with continuous physiologic monitoring by personnel separate from those performing the procedure. 3
Common Pitfalls to Avoid
- Do not rely solely on clinical judgment without a validated tool – while clinical judgment is important, standardized assessment tools are essential for determining sedative efficacy and facilitating targeted sedation. 2
- Avoid infrequent assessment – sedation depth can change rapidly in young children, requiring regular monitoring at least once per shift and more frequently during active interventions. 2
- Do not overlook non-pain causes of distress – before increasing sedation for agitation, search for potential causes of non-pain-related distress such as ventilator maladjustment, environmental factors like noise, or physiological needs. 2
Research Context on Other Scales
While the University of Michigan Sedation Scale (UMSS) has been validated in research settings for children aged 4 months to 5 years, 4 and the Ramsay scale was recently validated for invasive procedures in children ≥6 months, 5 neither has achieved the Grade A guideline recommendation status of the COMFORT Behaviour Scale for this age group. The UMSS showed good validity and reliability but was primarily studied in procedural sedation contexts. 4, 6