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.
In people under 16, grade risk of severe illness or death from sepsis using the person's:
history
physical examination results and
criteria based on age (see table 1: criteria for stratification of risk from sepsis in under 5s, table 2: criteria for stratification of risk from sepsis in children aged 5 to 11 and table 3: criteria for stratification of risk from sepsis in children and young people aged 12 to 15). [2016]
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:
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:
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]
| 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 |
| 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 |
| 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 |
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]
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]
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]
In remote and rural locations where combined transfer and handover times to emergency department are greater than 1 hour:
ambulance services should consider whether they need to put mechanisms in place to be able to give antibiotics to people with high risk criteria if antibiotics have not been given before by a GP (see recommendation 1.5.2 on evaluating risk level)
paramedics who are thinking about giving antibiotics should follow local guidelines or seek advice from more senior colleagues, if needed. [2016, amended 2024]
See also the recommendations on choice of antibiotic therapy for people with suspected sepsis.
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]
If a person under 16 with suspected sepsis does not meet any high risk or moderate to high risk criteria, provide them with information about:
symptoms to monitor and
how to access medical care if they are concerned.
Also see information at discharge for people assessed for suspected sepsis, but not diagnosed with sepsis. [2016]
For people in hospital who have suspected infections:
start looking for the source of infection (see the section on finding and controlling the source of infection)
take microbiological and blood samples before giving an antimicrobial.
See the UK standards for microbiology investigations. [2016, amended 2024]
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]
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]
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]
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]
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]
For children and young people under 16 with suspected sepsis, any high risk criteria and lactate between 2 and 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. [2016]
For people under 16 with suspected sepsis, any high risk criteria and lactate below 2 mmol/litre, consider giving an intravenous fluid bolus in line with recommendations on intravenous fluids for people with suspected sepsis. [2016, amended 2024]
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]
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]
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]
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]
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]
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]
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]
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]
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]
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]
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]
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:
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 moderate to high risk criterion.
For a definition of acute kidney injury, see NICE's guideline on acute kidney injury. [2016]
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]
Before discharging people who have been assessed for suspected sepsis, provide information on:
the management of their definitive condition (if identified) and
warning signs for sepsis (see information at discharge for people assessed for suspected sepsis). [2024]