RASS Use in Pediatric Patients
The RASS is not the recommended primary sedation assessment tool for pediatric patients; instead, use the COMFORT Behaviour Scale, which has Grade A evidence for children aged 0-16 years. 1
Guideline-Recommended Pediatric Sedation Scales
The European Society of Paediatric and Neonatal Intensive Care (ESPNIC) provides clear guidance on sedation assessment tools for critically ill children:
The COMFORT Behaviour Scale is the primary recommended tool with Grade A evidence for pediatric patients aged 0-16 years, assessing alertness, calmness/agitation, respiratory response, physical movement, muscle tone, and facial tension. 1
The State Behavioural Scale is an alternative with Grade B evidence for children aged 6 weeks to 6 years. 1
RASS is not included in the ESPNIC guideline recommendations for pediatric sedation assessment, despite being the gold standard for adults. 1
Why RASS Is Not First-Line in Pediatrics
The COMFORT Behaviour Scale was specifically designed and validated for the pediatric population, addressing unique developmental considerations:
Children under 4 years comprise the majority of PICU patients and cannot self-report or understand their clinical situation, requiring behavioral assessment tools tailored to their developmental stage. 1
The COMFORT Behaviour Scale has established feasibility and utility at the bedside with proven validity, reliability, and clinical utility across the entire pediatric age range. 1
RASS Performance in Pediatric Research
While RASS is not guideline-recommended for pediatrics, recent research has examined its properties in children:
RASS demonstrates excellent inter-rater reliability in pediatric patients (weighted kappa 0.946) across ages 1 month to 18 years in a multicenter PICU study. 2
RASS shows high correlation with the COMFORT-B scale (rho = 0.935) and can distinguish between sedation levels in children. 2
RASS validity has been confirmed in critically ill children ages 2 months to 21 years, with excellent agreement compared to visual analog scales (Spearman 0.810) and high inter-rater reliability (weighted kappa 0.825). 3
Educational interventions significantly improve RASS reliability in pediatrics, increasing weighted kappa from 0.56 to 0.86, including in infants under 1 year and children with developmental delay. 4
Clinical Implementation Guidance
If your institution uses RASS in pediatrics despite guideline recommendations:
Ensure comprehensive staff education before implementation, as this dramatically improves inter-rater reliability from moderate to excellent levels. 4
Assess sedation every 4-8 hours alongside vital signs, with more frequent monitoring during active sedation adjustments or clinical instability. 1
Always evaluate for underlying causes of agitation first (pain, ventilator maladjustment, environmental factors) before escalating sedatives. 1, 5
Critical Pitfalls to Avoid
Do not assume adult sedation tools automatically apply to children—pediatric-specific validated scales exist for good reason and carry higher-grade evidence. 1
Do not rely solely on clinical judgment without a validated assessment tool, as this leads to inconsistent sedation management and suboptimal outcomes. 1, 5
Do not overlook that 32% of pediatric observations show oversedation, which prolongs mechanical ventilation and increases healthcare costs. 1
Do not use RASS without proper training—untrained staff show only moderate reliability (kappa 0.56), which improves to excellent (kappa 0.86) after education. 4
Bottom Line for Practice
Use the COMFORT Behaviour Scale as your primary sedation assessment tool in pediatric ICU patients, as it carries Grade A recommendations from ESPNIC and was specifically designed for children. 1, 5 If your institution has already implemented RASS with comprehensive staff education and demonstrated excellent reliability, it may be used as an alternative, but this represents off-guideline practice. 2, 4, 3