{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,10]],"date-time":"2026-03-10T16:23:45Z","timestamp":1773159825208,"version":"3.50.1"},"reference-count":32,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2022,6,13]],"date-time":"2022-06-13T00:00:00Z","timestamp":1655078400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec><jats:title>Objectives<\/jats:title><jats:p>Children's pain, undersedation, iatrogenic withdrawal syndrome and delirium often have overlapping symptoms, which makes it difficult to decide why a child in the PICU is not comfortable. Validated assessment tools for these conditions are available, but regular assessment with multiple instruments may be too time-consuming. Therefore, we aimed to develop a new holistic instrument\u2013the mosaIC checklist\u2013that incorporates the assessment of the four conditions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>We conducted a two-rounds international Delphi study among experts working in PICUs worldwide to find cues that in combination or separately are relevant for the four conditions.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>In the first Delphi round, 38 of the 48 enrolled participants (79%) completed a questionnaire; in the second round 32 of 48 (67%). Eventually, 46 cues in eight categories (e.g., facial, vocal\/verbal, body movements, sleep \/behavioral state, posture\/muscle tone, agitation, physiological and contextual) were found relevant. Thirty-three (72%) were considered relevant for pain, 24 for undersedation (52%), 35 for iatrogenic withdrawal syndrome (76%) and 28 (61%) for pediatric delirium. Thirteen cues (28%) were considered relevant for all four conditions; 11's (24%) for only one condition.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>This Delphi study is the first step in developing a 4-in-1 comprehensive checklist to assess pain, undersedation, iatrogenic withdrawal syndrome and delirium in a holistic manner. Further validation is needed before the checklist can be applied in practice. Application of the mosaIC checklist could help determine what condition is most likely to cause a child's discomfort\u2013and at the same time help reduce the PICU staff's registration burden.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fped.2022.887689","type":"journal-article","created":{"date-parts":[[2022,6,13]],"date-time":"2022-06-13T05:41:31Z","timestamp":1655098891000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":11,"title":["Four-in-One: A Comprehensive Checklist for the Assessment of Pain, Undersedation, Iatrogenic Withdrawal and Delirium in the PICU: A Delphi Study"],"prefix":"10.3389","volume":"10","author":[{"given":"Monique","family":"van Dijk","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erwin","family":"Ista","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2022,6,13]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"1186","DOI":"10.1001\/jamapediatrics.2019.3351","article-title":"Pain and sedation scales for neonatal and pediatric patients in a preverbal stage of development: a systematic review","volume":"173","author":"Giordano","year":"2019","journal-title":"JAMA Pediatr."},{"key":"B2","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1097\/j.pain.0000000000001377","article-title":"Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties","volume":"160","author":"Birnie","year":"2019","journal-title":"Pain."},{"key":"B3","article-title":"N-PASS: neonatal pain, agitation, and sedation scale - reliability and validity","author":"Hummel","year":"2003"},{"key":"B4","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1038\/sj.jp.7211861","article-title":"Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain","volume":"28","author":"Hummel","year":"2008","journal-title":"J Perinatol."},{"key":"B5","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1016\/S0304-3959(99)00239-0","article-title":"The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants","volume":"84","author":"van Dijk","year":"2000","journal-title":"Pain."},{"key":"B6","doi-asserted-by":"publisher","first-page":"58","DOI":"10.1097\/01.PCC.0000149318.40279.1A","article-title":"Assessment of sedation levels in pediatric intensive care patients can be improved by using the COMFORT \u201cbehavior\u201d scale","volume":"6","author":"Ista","year":"2005","journal-title":"Pediatr Crit Care Med."},{"key":"B7","doi-asserted-by":"publisher","first-page":"1524","DOI":"10.1007\/s00134-013-2971-3","article-title":"Optimal sedation in pediatric intensive care patients: a systematic review","volume":"39","author":"Vet","year":"2013","journal-title":"Intensive Care Med."},{"key":"B8","doi-asserted-by":"publisher","first-page":"573","DOI":"10.1097\/PCC.0b013e31818c8328","article-title":"The withdrawal assessment tool-1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients","volume":"9","author":"Franck","year":"2008","journal-title":"Pediatr Crit Care Med."},{"key":"B9","doi-asserted-by":"publisher","first-page":"142","DOI":"10.1016\/j.pain.2011.10.003","article-title":"Validity and generalizability of the withdrawal assessment tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients","volume":"153","author":"Franck","year":"2012","journal-title":"Pain."},{"key":"B10","doi-asserted-by":"publisher","first-page":"761","DOI":"10.1097\/PCC.0b013e31829f5be1","article-title":"Psychometric evaluation of the sophia observation withdrawal symptoms scale in critically ill children","volume":"14","author":"Ista","year":"2013","journal-title":"Pediatr Crit Care Med."},{"key":"B11","doi-asserted-by":"publisher","first-page":"1075","DOI":"10.1007\/s00134-009-1487-3","article-title":"Construction of the sophia observation withdrawal symptoms-scale (SOS) for critically ill children","volume":"35","author":"Ista","year":"2009","journal-title":"Intensive Care Med."},{"key":"B12","doi-asserted-by":"publisher","first-page":"175","DOI":"10.1097\/PCC.0000000000000306","article-title":"Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model","volume":"16","author":"Best","year":"2015","journal-title":"Pediatr Crit Care Med."},{"key":"B13","doi-asserted-by":"publisher","first-page":"e7","DOI":"10.1097\/CCM.0000000000001953","article-title":"Randomized evaluation of sedation titration for respiratory failure study I. 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