Management of Suspected Sepsis in Children and Young People (Under 16)

This briefing document provides clinical guidance for emergency medicine professionals on the recognition, diagnosis, and early management of suspected sepsis in patients under the age of 16 who are not currently or recently pregnant. It reflects the updated NICE guideline NG254 (2025).

Executive Summary

The primary mission in the Emergency Department (ED) is the rapid identification of life-threatening organ dysfunction. Clinicians must maintain a high index of suspicion, asking "Could this be sepsis?" for any patient presenting with signs of infection.

• Critical Window: For patients meeting any High Risk criteria, a senior clinical decision maker (ST4+) must assess the patient, and broad-spectrum antibiotics must be administered within one hour.
• Risk Stratification: Risk is graded as High, Moderate-to-High, or Low based on age-specific criteria across behavior, respiration, circulation, and skin appearance.
• Key Interventions: Initial management focuses on the "Sepsis Six" principles: high-flow oxygen (if SpO2 <92% or shocked), blood cultures and investigations, intravenous (IV) antibiotics, and weight-based fluid resuscitation.
• Safety Netting: Patients not meeting high-risk criteria must still be reviewed by a clinician within 1–3 hours depending on the number of moderate-to-high risk markers.

Definition and Classification

• Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection [1].
• Suspected Sepsis: Individuals presenting with signs or symptoms indicating possible infection who require face-to-face assessment and potential urgent intervention [1].

Epidemiology and Aetiology

Incidence and Risk Factors

Specific UK incidence data is noted as a research priority, but the following populations are identified as most vulnerable to developing sepsis or facing delays in identification:

• Age: Infants under 1 year old are at the highest risk.
• Comorbidities: People with frailty (chronic illness, disabilities, complex care needs), impaired immune function (illness or medication), or those who have undergone surgery/invasive procedures in the past 6 weeks.
• Social Factors: Being from an ethnic minority background, living in deprived areas, or facing communication challenges (learning disabilities, autism, or language barriers) [1].
• Medical Devices: Presence of indwelling catheters or breaches in skin integrity.

Aetiology and Pathology

Sepsis results from an infection. While the macroscopic and microscopic pathology of specific pathogens is not detailed in the source, the clinical focus is on identifying the source (e.g., meningococcal disease, urinary tract infection, or pneumonia) and the resulting physiological "track and trigger" abnormalities [1].

Risk Stratification and Prognosis

Risk level is the primary driver of the management timeline. Prognosis is linked to the speed of intervention, particularly for those with high-risk criteria such as lactate >4 mmol/L, mottled appearance, or non-blanching rash.

Clinically Relevant Anatomy

Assessment should focus on systems prone to rapid deterioration in pediatric sepsis:

• Neurological: Level of consciousness (AVPU/GCS) and social responsiveness.
• Respiratory: Efficiency of gas exchange (SpO2) and work of breathing (grunting, nasal flaring).
• Circulatory: Peripheral perfusion (capillary refill time, skin color/mottling) and end-organ perfusion (urine output).
• Integumentary: Identification of non-blanching rashes or portals of entry (surgical sites, burns).

Clinical Assessment (ABCDE Structure)

Clinicians must perform a structured face-to-face assessment. Note that fever or hypothermia alone should not be used to rule sepsis in or out [1].

Airway and Breathing

• Signs: Grunting, apnoea, nasal flaring, and tachypnoea.
• High Risk Criteria:
  • Under 5s: RR ≥60 (under 1yr); ≥50 (1–2yrs); ≥40 (3–4yrs).
  • 5–11s: RR ≥29 (5yrs); ≥27 (6–7yrs); ≥25 (8–11s).
  • 12–15s: RR ≥25.
  • All ages: SpO2 <90% in air or new oxygen requirement.

Circulation

• Signs: Tachycardia, bradycardia (<60 bpm), prolonged capillary refill time (CRT ≥3s), and reduced urine output.
• Hypotension (High Risk 12–15s): Systolic BP ≤90 mmHg or >40 mmHg below normal.
• Fluid Status: Ask parents about frequency of urination in the last 18 hours. Reduced output is <1 ml/kg/hr in catheterized children (<0.5 ml/kg/hr for ages 12–15).

Disability (Neurological)

• High Risk Signs: No response to social cues, appearing "ill" to a professional, inability to stay awake if roused, or a weak/high-pitched/continuous cry in infants.
• Altered Mental State: Treat any change from baseline as significant. Use AVPU or GCS.

Exposure and Environment

• Skin: Look for mottled/ashen appearance, cyanosis (lips/tongue), and non-blanching rashes.
• Temperature: Tympanic temperature <36°C is a high-risk or moderate-to-high risk marker depending on age. Temperature ≥38°C is a high-risk marker for infants under 3 months.
• Source Search: Check for leg pain, cold hands/feet, and surgical sites.

Likelihood and History

New Clinical Pearl: Always ask if the patient has recently presented (to a GP or hospital) with these symptoms. Multiple presentations significantly increase the likelihood of sepsis [1].

Key Investigations and Interpretation

For any patient with ≥1 High Risk criterion or ≥2 Moderate-to-High Risk criteria:

Investigation	Rationale/Interpretation
Venous Blood Gas	Measure Lactate (High risk if >4 mmol/L; Moderate-to-high risk if 2–4 mmol/L) and Glucose.
Blood Cultures	Must be taken before antibiotics are administered [1].
FBC / CRP	Look for leucopenia or leucocytosis. (WBC <5 or >15 x10⁹/L in infants 1–3 months is a trigger for parenteral antibiotics).
U&Es / Creatinine	Assess for Acute Kidney Injury (AKI), especially in 12–15 year olds.
Clotting Screen	Check for disseminated intravascular coagulation or sepsis-induced coagulopathy.
Imaging	CXR or abdominal/pelvic imaging if the source is unclear [1].

Treatment and Management

Antibiotic Therapy

The choice of antimicrobial depends on age and setting:

• Community Acquired (General): Ceftriaxone 80 mg/kg (max 4 g) once daily.
• Under 3 Months: Add an agent for Listeria (e.g., Amoxicillin/Ampicillin).
• Neonates (<28 days):
  • Hospital-onset (<72hrs): Benzylpenicillin + Gentamicin.
  • Community-acquired: Ceftriaxone 50 mg/kg (unless <40 weeks corrected or receiving IV calcium, then use Cefotaxime).
• Neutropenic Sepsis: Treat immediately according to the NICE guideline on neutropenic sepsis [1].

Fluid Resuscitation

• Type: Use glucose-free crystalloids (Sodium 130–154 mmol/L).
• Bolus Dose: 10 ml/kg (max 250 ml bolus) delivered over <10 minutes. (10–20 ml/kg for neonates).
• Administration: Use a pump or syringe for children under 12 [1].

Oxygen

• Target SpO2 >92%. Give oxygen if shocked or SpO2 <92% in air. Note: Be cautious with pulse oximetry in patients with dark skin, as it may overestimate saturation [1].

Complications and Escalation

Immediate Complications

• Fluid Refractory Shock: If there is no improvement after two boluses, a consultant must attend in person.
• Organ Failure: Rising lactate, dropping GCS, or persistent hypotension.
• Management: Involve the Critical Care Specialist or Team (paediatric intensivist or outreach) for central access and inotropes/vasopressors if lactate remains >4 mmol/L [1].

Monitoring

• High Risk: Continuous monitoring or minimum every 30 minutes.
• Moderate Risk: Repeat structured assessment at least hourly [1].

Summary of Changes from Previous NICE Sepsis Guidance (NG51)

1. Multiple Presentations: Added a requirement to specifically ask if the patient has presented previously for the same illness; this is now a key risk-identification step.
2. Discharge Guidance: Removed specific discharge criteria for moderate/low risk in the early management phase; focus shifted to safety netting at the point of actual discharge.
3. Source Control: Expanded source control recommendations beyond intra-abdominal/pelvic sites to include any site requiring surgical or radiological intervention (e.g., abscess drainage).
4. Terminology: Updated "learning difficulties" to "learning disabilities" [1].

Learning Aids: The "Could This Be Sepsis?" Checklist

• Altered behavior?
• Breathing fast/grunting?
• Capillary refill >3 seconds?
• Discolored skin (mottled/ashen)?
• Extra presentations (multiple visits)?

References

1. National Institute for Health and Care Excellence (NICE). Suspected sepsis in under 16s: recognition, diagnosis and early management [NG254]. London: NICE; 2025. Available from: www.nice.org.uk/guidance/ng254

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Example EPIC EHR Documentation Structure

Suspected Sepsis Assessment (Under 16)

Risk Stratification (Tick all that apply):

• [ ] HIGH RISK:
  • [ ] Objective altered mental state / No response to social cues
  • [ ] RR: (Age-specific high)
  • [ ] SpO2 < 90% or new O2 requirement
  • [ ] HR: (Age-specific high) / Bradycardia (<60 bpm)
  • [ ] Mottled / Ashen / Cyanotic appearance
  • [ ] Non-blanching rash
  • [ ] Lactate > 4 mmol/L
  • [ ] SBP ≤ 90 mmHg (Ages 12-15 only)
• [ ] MODERATE-TO-HIGH RISK:
  • [ ] Parent/Carer concern regarding behavior change
  • [ ] RR: (Age-specific moderate)
  • [ ] SpO2 < 92%
  • [ ] HR: (Age-specific moderate)
  • [ ] CRT ≥ 3 seconds
  • [ ] Reduced urine output (<18 hours)
  • [ ] Temperature ≥ 38°C (if <3 months) or <36°C

Medical Decision Making (MDM):

• Multiple Presentations? [Yes/No]
• Source of Infection: [Suspected Site/Unknown]
• Vulnerability Factors: [Immunosuppression/Surgery <6wks/Indwelling line/Learning Disability]
• Consultant Review: [Name of Senior Decision Maker ST4+]
• Management Plan:
  • [ ] Blood cultures obtained prior to Abx
  • [ ] IV Antibiotics administered within 1 hour (if High Risk)
  • [ ] IV Fluid Bolus (10ml/kg) - [ ] First bolus [ ] Second bolus
  • [ ] Oxygen initiated (Target >92%)
  • [ ] Critical Care notified (if Lactate >4 or Fluid Refractory)

Discharge / Safety Netting:

• [ ] Sepsis warning signs explained (verbal and written)
• [ ] When to return/seek urgent help instructions provided
• [ ] GP discharge notification includes "Sepsis" diagnosis

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