Under 16s: evaluating risk and managing suspected sepsis

1.5 Evaluating risk level

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.5.2

Recognise that people under 16 with suspected sepsis are at high risk of severe illness or death from sepsis if they meet any of the high risk criteria:

  • For children under 5, see high risk criteria in table 1.

  • For children aged 5 to 11, see high risk criteria in table 2.

  • For children and young people aged 12 to 15, see high risk criteria in table 3. [2016]

1.5.3

Recognise that people under 16 with suspected sepsis are at moderate to high risk of severe illness or death from sepsis if they meet any of the moderate to high risk criteria:

  • For children under 5, see moderate to high risk criteria in table 1.

  • For children aged 5 to 11, see moderate to high risk criteria in table 2.

  • For children and young people aged 12 to 15, see moderate to high risk criteria in table 3. [2016]

1.5.4

If children under 16 with suspected sepsis do not meet any high or moderate to high risk criteria, see them as being at low risk of severe illness or death from sepsis. [2016]

Criteria for stratification of risk from sepsis in under 5s

Table 1: Criteria for stratification of risk of severe illness or death from sepsis in children under 5
Category Age High risk criteria Moderate to high risk criteria

Behaviour

Any

No response to social cues

Appears ill to a healthcare professional

Does not wake, or if roused does not stay awake

Weak high-pitched or continuous cry

Not responding normally to social cues

No smile

Wakes only with prolonged stimulation

Decreased activity

Parent or carer concern that child is behaving differently from usual

Respiratory

Any

Grunting

Apnoea

Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline

See recommendation 1.4.10 for safety warnings about the use of pulse oximeters

Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline

Nasal flaring

See recommendation 1.4.10 for safety warnings about the use of pulse oximeters

Respiratory

Under 1 year

Raised respiratory rate: 60 breaths per minute or more

Raised respiratory rate: 50 to 59 breaths per minute

Respiratory

1 to 2 years

Raised respiratory rate: 50 breaths per minute or more

Raised respiratory rate: 40 to 49 breaths per minute

Respiratory

3 to 4 years

Raised respiratory rate: 40 breaths per minute or more

Raised respiratory rate: 35 to 39 breaths per minute

Circulation and hydration

Any

Bradycardia: heart rate less than 60 beats per minute

Capillary refill time of 3 seconds or more

Reduced urine output

For catheterised patients, passed less than 1 ml/kg of urine per hour

Circulation and hydration

Under 1 year

Rapid heart rate: 160 beats per minute or more

Rapid heart rate: 150 to 159 beats per minute

Circulation and hydration

1 to 2 years

Rapid heart rate: 150 beats per minute or more

Rapid heart rate: 140 to 149 beats per minute

Circulation and hydration

3 to 4 years

Rapid heart rate: 140 beats per minute or more

Rapid heart rate: 130 to 139 beats per minute

Skin

Any

Mottled or ashen appearance

Cyanosis of skin, lips or tongue

Non-blanching petechial or purpuric rash

For signs and symptoms of meningococcal disease, see the NICE guideline on bacterial meningitis and meningococcal disease.

Pallor of skin, lips or tongue

Temperature

Any

Less than 36ºC

-

Temperature

Under 3 months

38°C or more

-

Temperature

3 to 6 months

-

39°C or more

Other

Any

-

Leg pain

Cold hands or feet

Criteria for stratification of risk from sepsis in children aged 5 to 11

Table 2: Criteria for stratification of risk of severe illness or death from sepsis in children aged 5 to 11 years
Category Age High risk criteria Moderate to high risk criteria

Behaviour

Any

Objective evidence of altered behaviour or mental state

Appears ill to a healthcare professional

Does not wake or if roused does not stay awake

Not behaving normally

Decreased activity

Parent or carer concern that the child is behaving differently from usual

Respiratory

Any

Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline

See recommendation 1.4.10 for safety warnings about the use of pulse oximeters

Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline

See recommendation 1.4.10 for safety warnings about the use of pulse oximeters

Respiratory

Aged 5 years

Raised respiratory rate: 29 breaths per minute or more

Raised respiratory rate: 24 to 28 breaths per minute

Respiratory

Aged 6 to 7 years

Raised respiratory rate: 27 breaths per minute or more

Raised respiratory rate: 24 to 26 breaths per minute

Respiratory

Aged 8 to 11 years

Raised respiratory rate: 25 breaths per minute or more

Raised respiratory rate: 22 to 24 breaths per minute

Circulation and hydration

Any

Heart rate less than 60 beats per minute

Capillary refill time of 3 seconds or more

Reduced urine output

For catheterised patients, passed less than 1 ml/kg of urine per hour

Circulation and hydration

Aged 5 years

Raised heart rate: 130 beats per minute or more

Raised heart rate: 120 to 129 beats per minute

Circulation and hydration

Aged 6 to 7 years

Raised heart rate: 120 beats per minute or more

Raised heart rate: 110 to 119 beats per minute

Circulation and hydration

Aged 8 to 11 years

Raised heart rate: 115 beats per minute or more

Raised heart rate: 105 to 114 beats per minute

Temperature

Any

-

Tympanic temperature less than 36°C

Skin

Any

Mottled or ashen appearance

Cyanosis of skin, lips or tongue

Non-blanching petechial or purpuric rash

For signs and symptoms of meningococcal disease, see the NICE guideline on bacterial meningitis and meningococcal disease.

-

Other

Any

-

Leg pain

Cold hands or feet

Criteria for stratification of risk from sepsis in children aged 12 to 15, pregnant people, and people aged 16 or over in non-acute settings

Table 3: Criteria for stratification of risk of severe illness or death from sepsis in children (in any settings) aged 12 to 15, and in people aged 16 or above if they are in community or custodial settings or if they are in an acute setting and are or have recently been pregnant
Category High risk criteria Moderate to high risk criteria

History

Objective evidence of new altered mental state

History from patient, friend or relative of new onset of altered behaviour or mental state

History of acute deterioration of functional ability

Impaired immune system (illness or drugs including oral steroids)

Trauma, surgery or invasive procedures in the last 6 weeks

Respiratory

Raised respiratory rate: 25 breaths per minute or more

New need for oxygen (40% FiO2 or more) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)

See recommendation 1.4.10 for safety warnings about the use of pulse oximeters

Raised respiratory rate: 21 to 24 breaths per minute

Blood pressure

Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40mmHg below normal

Systolic blood pressure 91 to 100 mmHg

Circulation and hydration

Raised heart rate: more than 130 beats per minute

Not passed urine in previous 18 hours.

For catheterised patients, passed less than 0.5 ml/kg of urine per hour

Raised heart rate: 91 to 130 beats per minute (100 to 130 beats per minute in pregnancy) or new-onset arrhythmia

Not passed urine in the past 12 to 18 hours

For catheterised patients, passed 0.5 ml/kg to 1 ml/kg of urine per hour

Temperature

-

Tympanic temperature less than 36°C

Skin

Mottled or ashen appearance

Cyanosis of skin, lips or tongue

Non-blanching petechial or purpuric rash

For signs and symptoms of meningococcal disease, see the NICE guideline on bacterial meningitis and meningococcal disease.

Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound

1.6 Managing suspected sepsis outside acute hospital settings

When to transfer immediately to an acute hospital setting

1.6.1

Refer people under 16 with suspected sepsis for emergency medical care if:

  • they meet any high risk criteria (see tables 1, 2 and 3: criteria for stratification of risk from sepsis in children and young people under 16) or

  • their immunity is impaired by drugs or illness and they meet any moderate to high risk criteria.

    Use the most appropriate means of transport (usually 999 ambulance).

    Emergency care requires facilities for resuscitation to be available and, depending on local services, may be emergency department, medical admissions unit and paediatric ambulatory unit or paediatric medical admissions unit. [2016]

1.6.2

Pre-alert secondary care (through GP or ambulance service) when any high risk criteria are met in a person under 16 with suspected sepsis outside of an acute hospital, and transfer them immediately. [2016]

Managing the condition while awaiting transfer

1.6.3

In remote and rural locations where transfer time to emergency department is routinely more than 1 hour, ensure GPs have mechanisms in place to give antibiotics to people under 16 with high risk criteria in pre-hospital settings. For high risk criteria, see tables 1 to 3 on criteria for stratification of risk from sepsis. [2016, amended 2024]

1.6.4

In remote and rural locations where combined transfer and handover times to emergency department are greater than 1 hour:

If immediate transfer is not required

1.6.5

Assess people under 16 who are outside acute hospital settings with suspected sepsis and any moderate to high risk criteria to:

  • make a definitive diagnosis of their condition

  • decide whether their condition can be treated safely outside hospital.

    If a definitive diagnosis is not reached or the person's condition cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care. [2016]

1.7 Managing suspected sepsis in acute hospital settings

Initial investigations to find the source of infection

1 or more high risk criteria

Assessment, blood tests and antibiotics
1.7.2

For people under 16 who have suspected sepsis and meet 1 or more high risk criteria:

  • arrange for the senior clinical decision maker to urgently assess the person's condition and think about alternative diagnoses to sepsis

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • give a broad-spectrum antimicrobial at the maximum recommended dose, without delay (within 1 hour of identifying that they meet any high risk criteria), if antibiotics have not already been given for this episode of sepsis

  • discuss with a consultant.

    Also see the recommendations on finding and controlling the source of infection and choice of antibiotic therapy. [2016, amended 2024]

1.7.3

Ensure urgent assessment mechanisms are in place to deliver antibiotics when any high risk criteria are met in a person under 16 in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting). [2016]

1.7.4

Give parenteral antibiotics to children under 3 months as follows:

  • children younger than 1 month with fever

  • all children aged 1 to 3 months with fever who appear unwell

  • children aged 1 to 3 months with white blood cell count less than 5×109/litre or greater than 15×109/litre.

    [This recommendation is from NICE's guideline on fever in under 5s.] [2007, amended 2013]

Intravenous fluids
1.7.5

For children under 12 with suspected sepsis, any high risk criteria and lactate over 4 mmol/litre:

  • give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria), in line with recommendations on intravenous fluids for people with suspected sepsis and

  • refer to a critical care specialist or team for them to review the management of the person's condition, including their need for central venous access and initiation of inotropes or vasopressors.

    Referral may be a formal referral process or discussion with a specialist in intensive care or intensive care outreach team. [2016]

1.7.6

For children and young people aged 12 to 15 with suspected sepsis, any high risk criteria and either lactate over 4 mmol/litre or systolic blood pressure less than 90 mmHg:

  • give intravenous fluid bolus without delay (within 1 hour of identifying that they meet any high risk criteria), in line with recommendations on intravenous fluids for people with suspected sepsis and

  • refer to a critical care specialist or team for them to review the management of the person's condition, including their need for central venous access and initiation of inotropes or vasopressors.

    Referral may be a formal referral process or discussion with a specialist in intensive care or intensive care outreach team. [2016]

Monitoring and escalation
1.7.9

Monitor people under 16 with suspected sepsis who meet any high risk criteria continuously, or a minimum of once every 30 minutes depending on setting. Physiological track and trigger systems should be used to monitor all people. [2016]

1.7.10

Monitor the mental state of people under 16 with suspected sepsis. Consider using the Glasgow Coma Scale (GCS) or AVPU ('alert, voice, pain, unresponsive') scale. [2016]

1.7.11

Alert a consultant to attend in person if a person under 16 with suspected sepsis and any high risk criteria does not respond within 1 hour of any intervention. [2016, amended 2024]

2 or more moderate to high risk criteria

Children under 12
1.7.12

For children under 12 with suspected sepsis and 2 or more moderate to high risk criteria:

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • arrange for a clinician to review the child's condition and venous lactate results within 1 hour of meeting 2 or more moderate to high risk criteria.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.13

For children under 12 with suspected sepsis who meet 2 or more moderate to high risk criteria and have lactate over 2 mmol/litre, treat their condition as if it met one or more high risk criteria. [2016]

1.7.14

For children under 12 with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of 2 mmol/litre or lower, and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the child's condition and their need for antibiotics within 3 hours of meeting 2 or more moderate to high risk criteria. [2016]

Children and young people aged 12 to 15
1.7.15

For children and young people aged 12 to 15 with suspected sepsis and either 2 or more moderate to high risk criteria or systolic blood pressure 91 to 100 mmHg:

  • carry out a venous blood test, including for:

    • blood gas, including glucose and lactate measurement

    • blood culture

    • full blood count

    • C-reactive protein

    • urea and electrolytes

    • creatinine

    • liver function tests

    • a clotting screen

  • arrange for a clinician to review the person's condition and venous lactate results within 1 hour of meeting 2 or more moderate to high risk criteria.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.16

For children and young people aged 12 to 15 with suspected sepsis who meet 2 or more moderate to high risk criteria and have either lactate over 2 mmol/litre or evidence of acute kidney injury, treat their condition as if it met 1 or more high risk criteria. [2016]

For definition of acute kidney injury, see NICE's guideline on acute kidney injury. [2016]

1.7.17

For children and young people aged 12 to 15 with suspected sepsis who meet 2 or more moderate to high risk criteria, have lactate of 2 mmol/litre or lower, have no evidence of acute kidney injury, and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the person's condition and need for antibiotics within 3 hours of meeting 2 or more moderate to high risk criteria. [2016]

1 moderate to high risk criterion

1.7.18

For people under 16 with suspected sepsis who meet only 1 moderate to high risk criterion:

  • arrange for clinician review within 1 hour of meeting a moderate to high risk criterion and

  • perform blood tests if indicated.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016, amended 2024]

1.7.19

For children under 12 with suspected sepsis who meet only 1 moderate to high risk criterion and in whom a definitive condition cannot be identified:

  • repeat structured assessment at least hourly

  • ensure a senior clinical decision maker reviews the child's condition and need for antibiotics within 3 hours of meeting a moderate to high risk criterion. [2016]

1.7.20

For children and young people aged 12 to 15 with suspected sepsis who meet only 1 moderate to high risk criterion, have lactate of less than 2 mmol/litre and no evidence of acute kidney injury, and in whom a definitive condition cannot be identified:

No high risk or moderate to high risk criteria

1.7.21

For people under 16 who have suspected sepsis and meet no high risk or moderate to high risk criteria:

  • arrange for clinician review

  • use clinical judgement to manage their condition.

    A 'clinician' should be a medically qualified practitioner or equivalent who has antibiotic prescribing responsibilities. [2016]

Discharge

  • National Institute for Health and Care Excellence (NICE)