T his editorial accompanies two papers (1,2) on the use of the Bispectral Index (BIS) as a sedation index in children. Before discussing the salient elements and findings of these papers, it is instructive to consider what processed electroencephalogram (EEG) monitors actually measure. As an analogy, consider the dark days before the introduction of pulse oximetry into clinical practice, when clinicians generally used something that might approximate to a four-point scale (pink/slightly blue/ dark blue/black) to assess oxygenation. The introduction of pulse oximetry gave a continuous measure of oxygen saturation as a percentage of saturated hemoglobin and quickly became the gold standard for measuring oxygenation, despite the lack of prospective randomized trial evidence of improved outcomes (3). Similarly, we have multiple discontinuous clinical scales for describing sedation levels in adults, including the Observer’s Assessment of Alertness and Sedation (OAAS) and the Ramsay scales. The purpose of processed EEG monitors is to provide a continuous measure that encompasses the full range of sedation levels measured by the discontinuous scales. Pulse oximetry measures a physiological parameter that most physicians can readily understand (oxygen saturation). In contrast, processed EEG monitors calculate a mathematical abstraction of the electroencephalogram, a concept less familiar and less accessible to the practicing clinician. BIS was derived by empirically estimating the EEG parameters that best predicted OAAS measurements in a large patient and volunteer database of subjects receiving hypnotics and opioids. As a continuous measure that correlates to OAAS measures obtained from subjects receiving hypnotic drugs, BIS may be described as a “probability of state” measure, reflecting the complex nature of consciousness (4). Being derived from the OAAS, BIS should be expected to correlate well with the OAAS. The correlation would probably be less strong with other rating scales, such as the Ramsay scale, the modified maintenance of wakefulness test (MMWT) scale used in pediatrics, or the University of Michigan sedation scale (UMSS). These latter scales were not part of the database used to develop the BIS monitor, and the original database was entirely constructed from adult EEG data. Normal pediatric EEG differs markedly from adult EEG, displaying more variation than adult EEG (5,6). This may make processed EEG parameters less reliable in children. In general, the electrical activity of the brain changes during growth and development, warranting age-specific considerations and cautious interpretation of EEG data in the pediatric population. Despite such theoretical concerns, studies suggest that the performance of BIS in pediatric patients older than 6 months of age may be similar to that of adults (7–9). In younger infants, brain maturation and development may render processed EEG measures unreliable. However, McDermott et al. (8) still found a significant correlation between BIS and the UMSS in patients younger than 6 months of age in a small group of patients. In this issue of Anesthesia & Analgesia, Malviya et al. (1) report on the observed relationship between BIS and two observational measures, the UMSS and MMWT, in children 1 month to 17 years conceptual age. In lieu of clinical guidelines that call for delineation of sedation states, the investigators were particularly interested in the ability of different measures to discriminate conscious from deep sedation. Data from 39 patients were included, comprising repeated measurements (about 8 per individual on average) of sedation indices after unspecified procedures that required sedation/analgesia or general anesthesia. The authors report good correlation between UMSS and BIS ( 0.73), indicating reasonable concordance between these discontinuous and continuous scales. This supports the validity of BIS as a pediatric sedation monitor and complements similar reports by this group (10) and others (8). MMWT scores, by contrast, correlated weakly (0.36) with BIS, in contrast to earlier Dr. Peter S. Sebel is a paid consultant to Aspect Medical Systems. Accepted for publication November 16, 2005. Address correspondence and reprint requests to Peter S. Sebel, MB BS, PhD, MBA, Department of Anesthesiology, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, SE, Atlanta, GA 30303. Address e-mail to peter_sebel@emoryhealthcare.org.