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WAT-1 Guidelines


Pediatric Assessment:

Withdrawal assessment, especially in preverbal or nonverbal children, can be challenging. The WAT-1 is used to identify iatrogenic withdrawal syndrome. The nurse should tailor their assessments to the child’s developmental level, medical status and temperament using the WAT-1.


Definition of Iatrogenic Withdrawal Syndrome:

Iatrogenic withdrawal syndrome is the term used for a characteristic pattern of unpleasant signs and symptoms that typically follows too rapid tapering or abrupt cessation of narcotics (opioids), benzodiazepines or other drugs with central nervous system depressant effects. Prominent manifestations include nervous system hyperirritability, autonomic system dysregulation, gastrointestinal dysfunction and motor abnormalities.


Definition of the Start of Weaning:

The date and time associated with a deliberate attempt to discontinue narcotics (opioids) and/or benzodiazepines


Assessment Frequency and Documentation:

Assess and document the patient’s WAT-1 in the designated column of the Patient Care Flowsheet.


Start WAT-1 scoring from the first day of weaning in patients who have received narcotics (opioids) +/or benzodiazepines by infusion or regular dosing for prolonged periods (e.g., 5 days). Continue twice daily scoring until 72 hours after the last dose.


The WAT-1 is completed and documented in the PICU with the SBS at least once per 12 hour shift at 08:00 and 20:00 ± 2 hours until 72 hours after the last PRN narcotic (opioid) and/or benzodiazepine dose.


If a patient is transferred to the floor prior to 72 hours after the last PRN narcotic (opioid) and/or benzodiazepine dose, WAT-1 scoring is completed and documented daily at 08:00 +/- 2 hours.


More frequent assessment may be necessary in patients who show symptoms of withdrawal from narcotics (opioids) and/or benzodiazepines. The increased frequency of the WAT-1 assessments in these patients should follow the assessment – intervention – reassessment cycle for treating patients' withdrawal.



The WAT-1 is an 11 item/12 point scale for monitoring narcotic (opioid) and/or benzodiazepine withdrawal symptoms in pediatric patients.


Assessment Method:

1.              Review the WAT-1, familiarizing yourself with the indicators and how they are scored.

2.              Review nursing documentation in the previous 12 hours.

3.              Complete a 2 minute observation period with the patient at rest.

4.              Assess patient during a progressive arousal then assess patient during an observation period following the stimulus. Use progressive stimuli to elicit the patient’s response; specifically, using a calm voice, call the patient’s name. If no response, call the patient’s name and gently touch the patient’s body. If no response, asses the patient’s response to a planned noxious procedure, e.g., endotracheal suctioning. If a noxious procedure is not planned then, using a pencil/pen, provide < 5 seconds of direct pressure to the patient’s nail bed.

5.              Complete a post-stimulus recovery observation period.


Scoring Method:

Presence and intensity of withdrawal symptoms consist of:

·         3 indicators obtained from the nursing documentation in the previous 12 hours are scored with one point:

1.              loose/watery stools that are not consistent with the patient’s age, medical condition or baseline stooling pattern.

2.              vomiting/wretching/gagging that cannot be attributed to other causes or interventions.

3.              temperature elevation that remains >37.8 more frequently than not during the previous 12 hours and not believed to be associated with an infection.

·         5 indicators assessed during a 2 minute observation of the patient at rest are scored with one point:

1.              state behavior based on observation (asleep/awake/calm = 0 or awake/distressed = 1) or based on the SBS score for sedation in mechanically ventilated patients (SBS ≤ 0 = 0 or SBS ≥ +1 = 1). See SBS guidelines for instructions on completing the SBS score.

2.              tremors that are moderate to severe and cannot be attributed to another clinical cause.

3.              sweating that is observed and not related to an appropriate temperature regulation response .

4.              uncoordinated/repetitive movements that are moderate to severe including head turning, leg or arm flailing or torso arching.

5.              yawning/sneezing that is observed more than once in the 2 minute observation period.

·         2 indicators assessed during a progressive arousal stimulus scored with one point:

1.              startle to touch that is severe

2.              muscle tone that is increased

·         1 indicator assessed during an observation period following the stimulus scored with up to two points:

1.              time to return to calm state that is greater than 5 minutes will receive 2 points. If the time to return to calm state is 2-5 minutes, it will receive 1 point.


The final WAT-1 score is the total sum of all indicators (0-12).



A higher WAT-1 score indicates more withdrawal symptoms while a lower score indicates fewer withdrawal symptoms. WAT-1 scores should be interpreted based on their trend over time.