Withdrawal Assessment Tool (WAT-1) for Pediatric Withdrawal

WAT-1 Calculator

Loose / Watery Stools

Vomiting / Retching / Gagging

Temperature > 37.8°C

State Behavioral Distress (Previous 12h)

State Behavioral Distress (Current)

Tremor

Sweating

Uncoordinated / Repetitive Movement

Yawning or Sneezing

Startle to Touch

Increased Muscle Tone

Time to Gain Calm State (SBS ≤ 0)

Total WAT-1 Score: –

Score: 0

Default scoring assumes 0 for un-set fields.

Estimates severity of opioid and benzodiazepine withdrawal in children.

Why Use

Up to 94% of PICUs experience issues with iatrogenic sedative withdrawal symptoms in their patients, which can prolong length of stay.

When to Use

Pediatric patients (age 2 weeks to 18 years in the original study) at risk for opioid withdrawal (i.e., on sedation for ≥5 days). Note that the population in this study was limited to those intubated for respiratory conditions, which, while common, may limit applicability to children intubated and sedated for other reasons (e.g. status epilepticus or head trauma).

Formula

Addition of the selected points: Criteria Points Previous 12 hours Any loose or watery stools No 0 Yes 1 Any vomiting, retching, or gagging No 0 Yes 1 Temperature >100.0 °F (37.8°C) No 0 Yes 1 Observe 2 mins before stimulus (e.g. routine care) State Behavioral Scale (SBS)* ≤0 OR asleep or awake and calm 0 ≥1 OR awake and distressed 1 Tremor None or mild 0 Moderate to severe 1 Any sweating No 0 Yes 1 Uncoordinated and/or repetitive movement None or mild 0 Moderate to severe 1 Yawning or sneezing 0-1 time 0 ≥2 times 1 Observe during 1 min progressive stimulus Startle to touch None or mild 0 Moderate to severe 1 Muscle tone Normal 0 Increased 1 Post-stimulus recovery Time to gain calm state (SBS* ≤0) <2 min 0 2-5 min 1 >5 min 2 *State Behavioral Scale: Variable Points Unresponsive -3 Responsive to noxious stimuli -2 Responsive to gentle touch or voice -1 Awake and able to be calmed 0 Restless and difficult to calm +1 Agitated +2 From Curley 2006 .

Pearls / Pitfalls

Children on round-the-clock sedation for ≥5 days (e.g. when intubated and sedated in the PICU) are at higher risk for withdrawal than children sedated for ≤4 days. Additionally, administration of sedatives via continuous or intermittent dosing does not alter the likelihood of withdrawal. May be used to trend improvement or worsening in withdrawal symptoms over time. WAT-1 scores ≥3 were 87.2% sensitive and 88% specific for predicting severe withdrawal symptoms, and correlated with longer duration of intubation and opioid sedation, longer time needed to wean from all sedatives, and greater length of stay (both PICU stay and overall hospitalization). Withdrawal symptoms in neonates and infants may be subtler than in older children, and may include jitteriness, irritability, or inconsolability. Patients being weaned from continuous sedation using agents such as morphine, methadone, or lorazepam should be monitored closely for respiratory depression and oversedation.

Critical Actions

Consider addition of withdrawal-preventing medications in children on IV sedation for ≥5 days. Frequently reassess children who are weaning off sedation medications for respiratory depression and oversedation. Oversedation can occur even in patients who have had severe withdrawal symptoms, and may require rescue medications like naloxone.

Advice

The original study authors recommend scoring from the first day of weaning in patients who have received opioids and/or benzodiazepines for ≥5 days (by infusion or periodic dosing), and to continue twice daily scoring until 72 hours after the last dose. They also recommend completing along with the State Behavioral Scale (SBS) (see Evidence for details) at least once per 12 hour shift (e.g. at 8:00 and 20:00 ±2 hours). The progressive stimulus used in the SBS assessment provides a standard stimulus for observing signs of withdrawal. Scores ≥3 suggest severe withdrawal symptoms. Children on continuous sedation for ≥5 days are more likely to have WAT-1 scores ≥3. Up-trending scores suggest worsening withdrawal and may require addition of withdrawal-preventive medications (e.g. methadone or lorazepam), additional one-time doses, or adjustments in dose or dosing schedule.

More Information

Interpretation: WAT-1 Score Median duration of weaning ( IQR ) Opioids Benzodiazepines <3 (every time) 6 days (3-9) 6 days (3-11) ≥3 (at any time) 10 days (6-14) 10 days (5-14) From Franck 2012 .