This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
Children in intensive care cannot always say they are in pain or anxious, and sedatives that are too light or too heavy both cause harm. The COMFORT behavior scale (COMFORT-B) is a version of the original COMFORT scale without the physiological items (heart rate and blood pressure). It was validated by van Dijk and colleagues in the Netherlands for infants and children from birth to 18 years, ventilated or not.
How to score
Observe the child for about two minutes without disturbing them, then rate six behaviors from 1 to 5.
| Item | 1 | 5 |
|---|---|---|
| Alertness | deeply asleep | hyperalert |
| Calmness or agitation | calm | panicky |
| Respiratory response (ventilated) or crying (not ventilated) | no coughing, no spontaneous breathing / quiet breathing | fights the ventilator / screaming |
| Body movement | none | vigorous, including trunk and head |
| Facial tension | totally relaxed | contorted, grimacing |
| Muscle tone | totally relaxed | extreme rigidity |
For each item, the calculator lists the five descriptions. Choose the respiratory item for a ventilated child and the crying item for a child breathing on their own.
Example
A ventilated infant who is lightly asleep (2), calm (1), breathing spontaneously with little reaction to the ventilator (2), making occasional small movements (2), with normal facial tone (2) and normal muscle tone (3), scores 12: comfortable and adequately sedated.
Interpretation
| Score | Meaning |
|---|---|
| 6 to 10 | possible oversedation |
| 11 to 16 | comfortable, adequate sedation |
| 17 to 30 | distress or pain likely |
A score of 17 or more does not tell pain from anxiety or withdrawal. Many units add a nurse’s numeric rating of pain (the NISS or NRS) to decide whether to give more analgesia or more sedation, and use a withdrawal scale when sedatives are being weaned.
In practice
COMFORT-B is scored several times a day and after every change in medication, and it drives nurse-led sedation protocols in many pediatric intensive care units. Nurses should train together on video examples so that their scores agree.
Limits
Children with neurological impairment, paralysis or neuromuscular blockade may not express distress through behavior, so the scale can underestimate their discomfort. For a child on a regular ward, scales such as FLACC are more practical.