Paediatric Early Warning Scoring Tool (PEWS)
Paediatric Early Warning Scoring Tool (PEWS)
This is a guide only and should not take priority over your clinical judgement or other clinical
pathways for specific conditions if a diagnosis has been reached.
This tool should be used in conjunction with the NICE Traffic Light System for identifying Risk of
Serious Illness and the NICE Summary of symptoms and signs suggestive of specific diseases.
Scoring will be calculated as follows red will score 3, grey will score 2, amber will score 1 and green
will score 0. The scores for each parameter will be added up and a total score will be documented at
the bottom of the chart. This total score will be used to decide which actions from the policy on the
reverse of the chart to follow. The maximum possible score is 12.
Respiratory Rate
Age
3
1
0
1
3
Under 4
Under 20
20-29
30-39
40-54
Over 54
months
4-months-2
Under 15
15-24
25-34
35-55
Over 55
years
2-5 years
Under 10
10-19
20-29
30-45
Over 45
5-12 years
Under 10
10-19
20-29
30-45
Over 45
Over 12 years Under 10
10-15
15-25
25-45
Over 45
Score:
Heart Rate
Age
Under 4 months 4-months-2 years 2-5 years 5-12 years Over 12 years
3
Under 80
Under 80
Under 60 Under 60 Below 60
1
80-109
80-99
60-79 60-69 60-69
0
110-159
100-149
80-119 70-119 70-99
1
160-190
150-180
120-150 120-150 100-150
3
Over 190
Over 180
Over 150 Over 150 Over 150
Score:
Capillary Refill Time
Age
0
All Ages Under 2
seconds
1
3-4 seconds
3
Over 4 seconds
Score:
Conscious level
Age All Ages
0
Alert
2
Responds to pain/voice
3
Unresponsive
Score:
GP Comments/Concerns:
Total PEWS Score:
Blood pressure will not score on PEWS; the parameters for normal blood pressure are:
Age ................
................
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