This review investigated whether there are any validated reliable tools to assess withdrawal symptoms in children in a paediatric intensive care unit and concluded that a sufficiently sensitive instrument for assessing withdrawal symptoms in paediatric intensive care unit patients needed to be developed. Due to methodological and reporting limitations the authors' conclusions may not be reliable.

To determine whether there are any validated, reliable tools to assess withdrawal symptoms in children in a paediatric intensive care unit in clinical practice.

PubMed, CINAHL and PsychINFO were searched between January 1980 and May 2006. Search terms were reported. Articles published in English or Dutch were included.

Studies of assessment tools appropriate for children that were aimed at identifying symptoms of benzodiazepine and/or opioid withdrawal were eligible for inclusion. The Sedation Withdrawal Score and Opioid and the Benzodiazepine Withdrawal Scale were used in the included studies. The studies used various withdrawal cutoff scores. The review did not include any diagnostic accuracy studies that compared the performance of the index test with a reference standard of diagnosis. Studies of children up to age 16 were eligible for inclusion. Preterm neonates (less than 37 weeks gestation) and neonates of addicted mothers were excluded. The participants in the included studies were six weeks to 28 months old where reported. Sensitivity, specificity and inter-rater reliability (IRR) were reported.

The authors stated neither how the papers were selected for review nor how many reviewers performed the selection.

The authors did not state that they assessed validity.

Outcome data were extracted as reported in the primary studies, where available. The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.

The studies were described narratively and grouped by type of assessment tool used. Study details were also reported in tables.

Two studies were included (total number of participants unclear): one prospective study (n=15) and a study of unknown study design (number of participants not reported).

The authors of the primary study that evaluated the Sedation Withdrawal Score reported that this score was clinically sensitive in detecting abstinence in a child of any age with signs of withdrawal from sedatives and/or opioids, however, no data were reported.

The predictive validity of the Opioid and Benzodiazepine Withdrawal Scale was assessed in one study that assessed children aged six weeks to 28 months (n=15). Sensitivity at score 8 or higher (indicating withdrawal) was 50 per cent, specificity was 87 per cent and the positive predictive value was 4.0 and the negative predictive value was 0.57. Inter-rater reliability was higher than 0.8 (the agreement procedure was not published).

A sufficiently sensitive instrument for assessing withdrawal symptoms in paediatric intensive care unit patients needed to be developed. The Opioid and Benzodiazepine Withdrawal Scale was the only available assessment tool with prospective validation, but its sensitivity was low.

The review question was broad and the inclusion criteria were clear with regard to participants and intervention, however, there were no criteria for outcomes and study design, which may have led to subjective decisions in study selection. The authors did not report any attempt to identify unpublished studies and only included studies published in English or Dutch, thus increasing the possibility of publication and language bias. The authors did not report whether any steps were taken to minimise bias and error in the review process and did not report that they assessed the methodological quality of the primary studies. Very few study details were presented and no reference standard was specified in either of the included studies. The conclusions were based on one small study. As there were a number of methodological and reporting limitations, the authors' conclusions may not be reliable.

Practice: The authors stated that nurses and physicians could give more priority to the observation and treatment of withdrawal symptoms in children in a paediatric intensive care unit.

Research: The authors stated that assessment tools should be tested in a multicentre study with a larger patient population and an extensive patient mix. The criterion validity can be tested using an independent experts' opinion as there was no gold standard for opioid and benzodiazepine withdrawal in children. Further assessments should be carried out before and after tapering off of opioids or benzodiazepines and at least the key confounders that mask withdrawal must be excluded. Quantification of withdrawal symptoms was needed and an adapted withdrawal tool based on this needed to be developed, and psychometric issues tested, before application to the paediatric intensive care unit population.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.