Behavioural status | Sleep | Quiet awake, alert, not active | Active awake, alert, movement of extremities | Vigorous activity, kicking, crying |
Muscular tone | Generalised hypotonia | Reduced muscular tone | Normal muscular tone | Increased muscular tone |
Motor response | No reaction | Spontaneous movements with pain | Spontaneous global movements | Continuos spontaneous movements restless |
Mimic | No reaction | Grimacing only with pain | Cries only when with pain, rapid return to rest | Cries, difficult to soothe |
Breathing | No spontaneous respiration | Spontaneous breathing, fully synchronised | Spontaneous breathing, not synchronous | Tachypnoea, fighting with the ventilator |
Aspiration | No reaction when aspired | Grimacing only, no movements of extremities and/or O2 desaturation <90% | Cries, little coughing, but soon returns to rest and/or O2 desaturation <80% | Strong opposition, intense coughing, cries difficult to soothe; and/or O2 desaturation <70% |