Paediatric · Severity
Paediatric Early Warning Score (PEWS)
Clinical bedside tool to identify deteriorating children early. Plus normal vital signs by age, AVPU, signs of shock and dehydration, and how parents can apply the same principles at home.
Last reviewed 31 May 2026
National PEWS (UK 2023)
Paediatric early-warning score
Respiratory rate (vs age)
Work of breathing
SpO2 in air
Heart rate (vs age)
Capillary refill / perfusion
AVPU level of consciousness
Temperature
Carer or nurse concern
Total 0 — routine monitoring
0
Continue routine observations per usual frequency. Reassess if any clinical change.
Educational tool only — not medical advice. RCPCH / NHS England National PEWS 2023 Implementation Guide. Local observation charts are the canonical document for cut-offs by exact age band. Decisions by paediatric team.
What does this mean?
The UK National PEWS rollout (NHS England / RCPCH 2023) replaced a patchwork of local PEWS variants with a unified chart and escalation protocol. It looks like MEOWS for paediatrics: vital signs + work of breathing + consciousness + perfusion + temperature scored 0–3, summed, with an absolute trigger if any single parameter scores 3. The biggest evidence-based addition: carer or staff concern as a stand-alone trigger — multiple studies showed that parental worry “something is wrong” out-predicted standardised scores in some serious deteriorations. The Cochrane 2024 review of PEWS use was mixed on mortality impact, but consistent on improvements in timeliness of recognition, communication, and family experience. A PEWS chart is a safety net, not a replacement for clinical judgement: trends matter more than single readings, and a falling PEWS does NOT mean “all clear” if the gestalt remains concerning.
What is PEWS?
Paediatric Early Warning Score — bedside tool to identify deteriorating children early. Multiple versions (Brighton, Melbourne, Cardiff, England National PEWS — NHS standard from 2023). Used on every paediatric ward / inpatient stay in UK NHS.
Five core components:
- Respiratory rate — by age.
- Work of breathing — recession, grunting, nasal flaring.
- Oxygen saturation — SpO2 < 92% concerning.
- Heart rate — tachycardia early sign; bradycardia very late.
- Capillary refill — > 2 sec concerning.
- AVPU — Alert / Voice / Pain / Unresponsive.
- Temperature — fever or hypothermia.
Score bands & action
- 0-1: routine observations.
- 2-3: increase frequency of observations; review.
- 4-5: senior review; consider escalation.
- 6+: urgent consultant review; consider PICU / outreach.
Single “red” parameter (apnoea, severe distress, prolonged cap refill, abnormal AVPU) can trigger escalation regardless of total score.
Normal vital signs by age
| Age | RR (breaths/min) | HR (bpm) |
|---|---|---|
| Newborn | 30-60 | 100-160 |
| 0-1y | 30-40 | 100-150 |
| 1-3y | 25-30 | 80-140 |
| 3-6y | 20-25 | 80-120 |
| 6-12y | 16-22 | 70-110 |
| Teen | 12-20 | 60-100 |
Normal SpO2 > 95%; temperature 36.5-37.5 °C.
What is AVPU?
- Alert — eyes open, responding normally.
- Voice — eyes open when you speak.
- Pain — only responds to painful stimulus.
- Unresponsive — no response.
Anything less than A in a previously well child is a red flag. Easier than Glasgow Coma Scale in young children.
How is PEWS different from adult NEWS?
- Age-adapted vital signs — thresholds vary by age.
- Children compensate longer — look relatively well until they collapse suddenly.
- Tachycardia, raised RR, work of breathing are earlier signs than in adults.
- Hypotension is LATE in children — children maintain BP until very unwell.
- Bradycardia is pre-arrest sign in children, not bradycardia is normal as in athletes.
When should I worry about my child's breathing?
Red flags:
- RR > 60 in under-1, > 50 in 1-5y, > 40 in 5-10y.
- Grunting (deep expiration).
- Chest indrawing (intercostal, subcostal recession).
- Nasal flaring.
- Head bobbing in young infants.
- Cyanosis (blue lips).
- SpO2 < 92% in air.
- Too breathless to feed / drink / talk in sentences.
- Tripod position (sitting forward to breathe).
Signs of dehydration
- Mild (3-5% loss): slightly thirsty, slightly dry mouth.
- Moderate (5-10%): sunken eyes, very dry mouth, fewer wet nappies, irritable, few tears, sunken fontanelle in babies.
- Severe (>10%): lethargic, cold extremities, weak pulses, cap refill > 3 sec, very few wet nappies, altered consciousness. EMERGENCY.
See /calculators/ors-rehydration.
What is shock?
Inadequate tissue perfusion. CHILDREN compensate longer than adults — meaning they may LOOK relatively well until they deteriorate rapidly.
- Early signs: tachycardia disproportionate to fever/pain; cool extremities; prolonged cap refill > 2 sec; mottled/pale skin; restlessness; reduced urine.
- Late signs: hypotension; altered consciousness; bradycardia (pre-arrest).
EMERGENCY — 999 / blue-light hospital.
When to A&E vs GP
999 / A&E IMMEDIATELY
- Blue lips / unconscious.
- Severe breathing difficulty.
- Severe bleeding.
- Suspected meningitis (non-blanching rash + unwell, neck stiffness, photophobia).
- Severe head injury.
- Severe burn.
- Seizure not stopping.
Same-day GP / 111
- Persistent fever.
- Mild-moderate breathing difficulty.
- Persistent vomiting.
- Suspected ear / chest infection.
- Rash with unwell child.
- Reduced feeding in baby.
- Concerning behaviour change.
Trust your instinct — parental concern is itself a strong predictor.
Different scenarios — using PEWS
Scenario 1: 6-month-old with bronchiolitis, RR 60, mild recession, SpO2 94%
Likely moderate PEWS. Hospital observation. Suctioning if needed, supplemental O2 if SpO2 < 92%. Monitor for feeding / fatigue.
Scenario 2: 2-year-old with gastroenteritis, sunken eyes, prolonged cap refill
Significant dehydration + moderate PEWS. ORS or IV fluids in hospital. Investigation for cause. See /calculators/ors-rehydration.
Scenario 3: 5-year-old with high fever 5 days, lethargic, refusing fluids
Possible Kawasaki disease, prolonged viral illness, or sepsis. Same-day paediatric review. Investigation for cause and PEWS monitoring.
Scenario 4: 8-week-old with fever 38.5 °C
NICE NG143: any fever under 3 months = same-day emergency. Septic-looking even with normal-looking observations. Septic workup, IV antibiotics, admission.
Scenario 5: Teenager post-surgery, tachycardia, cool extremities, anxious
Early shock signs. Urgent review. Possible bleeding, sepsis, fluid loss. Don’t wait for BP to drop — that’s late in children.
What parents can do at home
- Color — pale, mottled, blue.
- Breathing — rate, work, sounds.
- Circulation — cool extremities, slow refill.
- Consciousness / behaviour — alert, responsive, eye contact.
- Fluid intake — drinking, wet nappies.
“My child is not acting right” is a powerful clinical signal — clinicians take seriously.
Sources
- NHS England. National Paediatric Early Warning System (PEWS). 2023.
- Monaghan A. The Brighton Paediatric Early Warning Score.
- Akre M, et al. Sensitivity of the Pediatric Early Warning Score. Pediatrics 2010.
- RCPCH. Paediatric Early Warning System (PEWS).
- NICE NG143. Fever in under 5s.
Frequently asked questions
What is PEWS / National PEWS?
Paediatric Early Warning Score / Signs — bedside tool to identify deteriorating children early. Multiple versions: BRIGHTON PEWS, MELBOURNE PEWS, CARDIFF, ENGLAND National PEWS (NHS standard from 2023). Scores: respiratory rate, work of breathing, oxygen saturation, heart rate, capillary refill, AVPU (consciousness), temperature. Triggers escalation: nursing review → registrar → consultant → outreach team / PICU. Reduces in-hospital cardiac arrest / unrecognised deterioration. Used on every paediatric ward / inpatient stay in UK NHS.
What does a high PEWS score mean?
VARIES by system; rough thresholds: SCORE 0-1: routine observations. SCORE 2-3: increase frequency of observations; review. SCORE 4-5: senior review; consider escalation. SCORE 6+: urgent consultant review; consider PICU / paediatric outreach. SINGLE 'RED' parameter (e.g. ANY apnoea, severe respiratory distress, prolonged cap refill, abnormal AVPU) can trigger escalation regardless of total score. Each NHS trust has specific local thresholds.
How is PEWS different from adult NEWS?
Age-adapted. Children's vital signs vary by age (newborn HR 100-160; toddler 80-140; teen 60-100), so PEWS thresholds adjust. CHILDREN deteriorate differently from adults: more reserve, then collapse suddenly. Compensate for longer then decompensate rapidly. Earlier signs include: tachypnoea, tachycardia, work of breathing, prolonged cap refill, behavioural changes. ADULTS show fall in BP earlier; CHILDREN maintain BP until late. PEWS picks up children's earlier signs of deterioration.
What does each PEWS component mean?
RESPIRATORY RATE: by age — high RR is early sign of deterioration in children. WORK OF BREATHING: nasal flaring, head bobbing, recession (intercostal, subcostal, supraclavicular), grunting, tracheal tug. OXYGEN SATURATION: SpO2 < 92% in air is concerning in children. HEART RATE: by age — tachycardia early sign; bradycardia very late / pre-arrest sign. CAPILLARY REFILL: > 2 sec on central capillary bed concerning. AVPU: Alert / Voice / Pain / Unresponsive. TEMPERATURE: fever or hypothermia.
When should I worry about my child's breathing?
RED FLAGS: significantly faster breathing than usual (RR > 60 in under-1, > 50 in 1-5y, > 40 in 5-10y, > 30 in 10y+); grunting (deep expiration); chest indrawing (intercostal, subcostal recession); nasal flaring; head bobbing in young infants; cyanosis (blue lips); SpO2 < 92% in air; child too breathless to feed / drink / talk in sentences; tripod position (sitting forward to breathe). Call 999 if severe; same-day GP / A&E if any persistent.
How can I tell if my child is dehydrated?
MILD (3-5% body weight loss): slightly thirsty, slightly dry mouth, normal energy. MODERATE (5-10%): SUNKEN EYES, very dry mouth, REDUCED URINE (< 4 wet nappies/day in babies, < 4 pees/day in older children), thirst, irritable, FEW TEARS when crying, sunken fontanelle in babies. SEVERE (>10%): very lethargic, cold extremities, weak pulses, prolonged capillary refill > 3 sec, very few or no wet nappies, ALTERED CONSCIOUSNESS. Severe = same-day emergency / 999. See /calculators/ors-rehydration.
What is AVPU?
Consciousness assessment scale used in paediatric and adult emergency: A = ALERT (eyes open, responding normally); V = responds to VOICE (eyes open when you speak to them); P = responds to PAIN (only responds to a painful stimulus); U = UNRESPONSIVE (no response). Anything less than A (i.e. V, P, U) in a previously well child is a red flag warranting urgent assessment. Quicker / easier than Glasgow Coma Scale (GCS) in young children.
Normal vital signs by age?
RESPIRATORY RATE (breaths/min): newborn 30-60; 0-1y 30-40; 1-3y 25-30; 3-6y 20-25; 6-12y 16-22; teen 12-20. HEART RATE: newborn 100-160; 0-1y 100-150; 1-3y 80-140; 3-6y 80-120; 6-12y 70-110; teen 60-100. SBP > 70 mmHg (term newborn); > 70 + (2 × age) for children 1-10 years (rough rule). TEMPERATURE: 36.5-37.5°C normal range. SpO2: > 95% normal, < 92% concerning.
When should I take my child to A&E vs GP?
999 / A&E IMMEDIATELY for: blue lips / unconscious; severe breathing difficulty; severe bleeding; suspected meningitis (non-blanching rash + unwell, neck stiffness, photophobia); severe head injury; suspected fracture / dislocation; severe burn; seizure not stopping. SAME-DAY GP / 111 for: persistent fever; mild-moderate breathing difficulty; persistent vomiting; suspected ear / chest infection; rash with unwell child; reduced feeding in baby; concerning behaviour change. NORMAL surgery hours: routine concerns, planned reviews. TRUST YOUR INSTINCT — parental concern is itself a strong predictor.
What is shock and how to recognise?
SHOCK = inadequate tissue perfusion. CHILDREN compensate for shock longer than adults — meaning they may LOOK relatively well until they deteriorate rapidly. EARLY SIGNS: tachycardia disproportionate to fever / pain; cool extremities; prolonged cap refill > 2 sec; mottled or pale skin; restlessness; reduced urine output. LATE SIGNS: hypotension (drop in BP — adults show this earlier; children only when very unwell); altered consciousness; bradycardia (pre-arrest sign in children). EMERGENCY — same-day urgent care; usually 999 / blue-light hospital.
What is the 'septic-looking' baby?
Phrase clinicians use for a NEWBORN / SMALL INFANT looking unwell in non-specific ways. SIGNS: poor feeding (less than half normal intake); lethargy / floppy; pale / mottled / grey-tinged; cool to touch; subtle breathing changes; fewer wet nappies; abnormal behaviour for them. UNDER 3 MONTHS with any of these = same-day emergency. NICE NG143 explicit: ANY fever over 38°C in baby under 3 months = same-day emergency assessment. NEONATAL SEPSIS can present subtly and progress rapidly.
How does PEWS change with COVID / RSV / etc?
Same framework applies. Specific infections cause specific patterns: COVID in children — usually mild, but can cause MIS-C (multisystem inflammatory syndrome) 2-6 weeks after — fever + rash + mucositis + GI symptoms; RSV BRONCHIOLITIS — wheeze + raised RR + chest recession in <1y; INFLUENZA — high fever + body aches; CROUP — barking cough + stridor; SCARLET FEVER — sandpaper rash + strep throat + 'strawberry tongue'. PEWS picks up severity regardless of cause; specific diagnosis comes after.
What's the difference between PEWS and APLS?
PEWS = monitoring / screening tool for ward use to detect deterioration early. APLS (Advanced Paediatric Life Support) = course / framework for managing the deteriorating / critically ill child. Together: PEWS identifies → APLS-trained team manages. EVERY paediatric clinician in UK / EU should be APLS-trained. Includes airway management, fluid resuscitation, drug doses, defibrillation. UK / EU course typical 2-3 days.
Can parents do their own PEWS-like assessment?
Not formally but principles useful. PARENTS can assess: COLOR (pale, mottled, blue); BREATHING (rate, work, sounds); CIRCULATION (cool extremities, slow refill); CONSCIOUSNESS / BEHAVIOUR (alert, responsive, eye contact); FLUID INTAKE (drinking, wet nappies). 'My child is not acting right' is a powerful clinical signal — clinicians take seriously. If concerned, contact NHS 111 / GP / A&E. Many children's hospitals have parent education materials.
How accurate is PEWS at predicting deterioration?
Modest. CASE-CONTROL studies show PEWS detects deterioration 4-6 hours before cardiac arrest / PICU transfer; reduces unrecognised deterioration; sensitivity ~70-85% depending on system used. Like any score, NOT perfect — some deteriorations missed; some 'PEWS positive' children turn out fine. Best used as TRIGGER FOR REVIEW, not as definitive prediction. NHS National PEWS being standardised across UK to improve consistency.
How does this relate to other calculators on BumpBites?
Companion: /calculators/croup-westley for croup severity; /calculators/baby-fever for fever decision-making; /calculators/baby-cough for cough type; /calculators/ors-rehydration for dehydration; /calculators/pediatric-dose for paracetamol / ibuprofen / antibiotic dosing; /calculators/baby-percentile for growth tracking.