Central nervous system disturbances | High pitched cry | 2 | | | |
Continuous high pitched cry | 3 | | | |
Sleeps<1 hour after feeding | 3 | | | |
Sleeps<2 hours after feeding | 2 | | | |
Sleeps<3 hours after feeding | 1 | | | |
Mild tremors, disturbed | 1 | | | |
Mod-severe tremors, disturbed | 2 | | | |
Mild tremors, undisturbed | 3 | | | |
Mod-severe tremors, undisturbed | 4 | | | |
Increased muscle tone | 2 | | | |
Excoriation (specify area) | 1 | | | |
Myoclonic jerks | 3 | | | |
Generalised convulsions | 5 | | | |
Metabolic/ vasomotor/ respiratory disturbances | Fever (37.3–38.3°C) | 1 | | | |
Fever (38.4°C and higher) | 2 | | | |
Frequent yawning (3–4 times) | 1 | | | |
Nasal stuffiness | 1 | | | |
Sneezing (>3–4 times) | 1 | | | |
Nasal flaring | 2 | | | |
Respiratory rate>60/min | 1 | | | |
Respiratory rate>60/min with retractions | 2 | | | |
Gastrointestinal disturbances | Excessive sucking | 1 | | | |
Poor feeding | 2 | | | |
Regurgitation | 2 | | | |
Projectile vomiting | 3 | | | |
Loose stools | 23 | | | |
Watery stools | 3 | | | |
TOTAL SCORE | | | | |
SCORER’S INITIALS | | | | |