Role of Full Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) in critically ill children to predict outcome: A prospective observational study

Saha, Bageshree; Halder, Sanjay; Samanta, Moumita; Mahato, Saikat; Sen, Sandipan; Sinhamahapatra, Tapan Kumar

doi:10.1590/1984-0462/2026/44/2025181

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Original Article • Rev. paul. pediatr. 44 • 2026 • https://doi.org/10.1590/1984-0462/2026/44/2025181 linkcopy

Role of Full Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) in critically ill children to predict outcome: A prospective observational study

Papel do Escore Full Outline of Unresponsiveness (FOUR) e da Escala de Coma de Glasgow (GCS) em crianças criticamente doentes para a predição de desfechos: um estudo observacional prospectivo

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: To evaluate the diagnostic value of the Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) to predict mortality in critically ill children with non-traumatic impaired consciousness.

Methods: In this single-center prospective observational study, children aged one month to 12 years admitted to the pediatric Intensive Care Unit (PICU) were included, and serial FOUR score and GCS at admission, 12^th, and 24^th hour were recorded. Children with PICU stay of <24 hours, with convulsion within the last hour, visual or motor impairment, or use of sedatives/ neuromuscular relaxants were excluded. Primary outcome: in-hospital mortality. Secondary outcome: requirement of intubation, and comparison of two scores for mortality.

Results: One hundred critically ill children were enrolled with a median (interquartile — IQR) age of 46.0 (10.0–84.0) months, and 53 children died during the hospital course. The GCS and FOUR scores were significantly higher among survivors (p<0.001). Both scores were independent predictors of mortality at admission and the 12^th hour, but only the FOUR score was a statistically significant predictor of mortality at the 24^th hour. The adjusted odds ratio (AOR) for mortality for FOUR24 was 0.505 (95% confidence interval — 95%CI 0.399–0.863) and for GCS24 score was 2.728 (95%CI 0.932–2.273). Sixty-three children needed intubation, with a median duration of 4.0 (1.0–7.0) days, and of these, 69.8% died.

Conclusions: GCS and FOUR scores have comparable efficacy in predicting mortality during initial assessment. However, the FOUR score is better than GCS at the 24^th hour and can hence be considered a prognostic tool.

Keywords:
Prognosis; Pediatric Intensive Care Units; Hospital mortality; Coma

		Total population	Survivors (n=47)	Non-survivors (n=53)	p-value
Ages (months)		46.0 (10.0–84.0)	30.0 (8.0–84.0)	53.0 (11.0–84.0)
	≤12 months	28 (28.0)	14 (29.7)	14 (26.4)	0.516
	1–5 years	32 (32.0)	16 (34.1)	16 (30.2)
	>5 years	40 (40.0)	17 (36.2)	23 (43.4)
Gender, Male		53 (53.0)	25 (53.2)	28 (52.8)	0.565
Diagnosis
Infectious causes
	AES	25 (25.0)	10 (21.3)	15 (28.3)
	Secondary encephalopathy*	20 (20.0)	16 (34.1)	4 (7.6)
	Meningitis	7 (7.0)	5 (10.5)	2 (3.8)
Non-infectious causes
	Metabolic disorders†	22 (22.0)	9 (19.1)	13 (24.5)
	ICH/SOL	15 (15.0)	1 (2.1)	14 (26.4)
	Acute stroke syndrome	4 (4.0)	2 (4.2)	2 (3.8)
	Post-operation	3 (3.0)	1 (2.1)	2 (5.7)
	Electrolyte abnormalities	2 (2.0)	2 (4.2)	0
	Epileptic disorders	2 (2.0)	1 (2.1)	1 (1.9)
Anthropometric indicators
	Weight for height (Z)	-0.63 (-3.1;0.3)	-0.46 (-2.2;0.41)	-1.56 (-3.5;0.2)	0.178
	Height for age (Z score)	-0.58(-1.8;0.3)	-0.57 (-1.7;0.2)	-0.89 (-1.9;0.6)	0.928
	BMI for age (Z score)	-1.02 (-3.3;0.8)	-0.44 (-2.9;1.2)	-1.29 (-3.6;0.7)	0.091
	PICU window (days)‡	4.0 (2.0;6.0)	4.0 (2.0;5.0)	4.0 (1.5;7.0)	0.464
	PICU stay (days)	7.0 (3.0;14.0)	12.0 (4.0;15.0)	5.0 (2.0;9.5)	<0.001
	pSOFA on admission	9.0 (4.0)	7.0 (5.5)	13.0 (4.0)	<0.001
	Intubated	63 (63)	19 (17.0)	44 (83.0)	<0.001
	IMV Duration (days)	4.0 (1.0-7.0)	5.0 (1.5-14.0)	3.0 (1.0-7.0)	0.249
Inotropes requirement
	No needed	20 (20.0)	20 (42.6)	0
	≤2 inotropes	29 (29.0)	20 (42.6)	9 (16.9)
	>2 inotropes	51 (51.0)	7 (14.9)	44 (83.0)

		Total children (n=100)	Survivors (n=47)	Non-survivors (n=53)	p-value	Correlation with ICU free days	p-values
Glasgow Coma Scale (hours)
	0	8.40±2.2	9.23±1.4	7.66±2.5	<0.001	0.325	0.001
	12	7.83±2.8	9.68±1.9	6.19±2.5	<0.001	0.608	<0.001
	24	7.75±3.6	10.70±2.3	5.13±2.2	<0.001	0.767	<0.001
Full Outline of Unresponsiveness score (hours)
	0	9.40±2.9	11.02±1.7	7.96±3.1	<0.001	0.463	<0.001
	12	8.79±3.8	11.47±2.1	6.42±3.4	<0.001	0.608	<0.001
	24	8.30±4.7	12.13±2.6	4.91±3.2	<0.001	0.231	0.231

	AUC	95%CI	p-value	Cut-of	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)
GCS 0	0.719	0.616–0.822	<0.001	8.5	76.59	69.81	69.23	77
GCS 12	0.847	0.768–0.925	<0.001	8.5	80.85	79.24	77.55	82.35
GCS 24	0.941	0.896–0.986	<0.001	8.5	85.1	90.56	88.88	87.27
FOUR 0	0.804	0.713–0.895	<0.001	9.5	78.72	75.47	74	80
FOUR 12	0.874	0.799–0.948	<0.001	8.5	93.6	75.47	77.19	93
FOUR 24	0.927	0.872–0.983	<0.001	9.5	85.1	90.56	88.88	87.27

		Adjusted OR	95%CI	p-value	Hosmer and Lemeshov Test	Nagelkerke R2
MODEL 1
	GCS 0	2.025	1.372–2.990	<0.001	χ²(8)=7.758, p=0.457	0.250
	FOUR 0	0.523	0.373–0.733	<0.001	χ²(8)=7.758, p=0.457	0.250
Variables included in the model: GCS 0, FOUR 0
Elimination method: Enter method
Confounding factors: Age, Weight, PICU duration, Inotrope requirement
MODEL 2
	GCS 12	2.010	1.260–3.206	0.003	χ²(8)=12.013, p=0.151	0.290
	FOUR 12	0.491	0.328–0.734	0.001	χ²(8)=12.013, p=0.151	0.290
Variables included in the model: GCS 12, FOUR 12
Elimination method: Enter method
Confounding factors: Age, Weight, PICU duration, Inotrope requirement
MODEL 3
	GCS 24	2.728	0.932–2.273	0.099	χ²(8)=4.780, p=0.781	0.391
	FOUR 24	0.505	0.399–0.863	0.007	χ²(8)=4.780, p=0.781	0.391
Variables included in the model: GCS 24, FOUR 24
Elimination method: Enter method
Confounding factors: Age, Weight, PICU duration, Inotrope requirement

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[T1FN1] *This group includes secondary encephalopathy with a primary infective focus other than CNS. Among 20 children with secondary infective encephalopathy, 6 children had dengue encephalopathy, 4 had scrub encephalitis, 2 had severe malaria, and the remaining 8 children developed septic shock without any primary CNS infection; †Seven children with diabetic ketoacidosis (DKA), four with hepatic encephalopathy, 3 children suffering neurotoxic snakebite, 2 organophosphorus poisoning, and six having chronic kidney disease (CKD) with uremic encephalopathy were included in this metabolic encephalopathy group; ‡PICU window refers to the interval (in days) between onset of first symptom and PICU admission.

[T1FN2] AES: Acute encephalitic syndrome; ICH: Intracerebral hemorrhage; SOL: Space-occupying lesion; BMI: Body mass index; pSOFA: Pediatric sequential organ failure assessment; IMV: Invasive mechanical ventilation; PICU: Pediatric Intensive Care Unit.