Paediatric Sepsis

Sepsis in children differs from adults — normal vital signs vary by age, and children compensate well until they decompensate suddenly. NG254 (2025) is the paediatric guideline; NEWS2 and the adult NG253 thresholds do not apply here. Risk is…

NICE NG254 — suspected sepsis in under 16s

The pathway

1 · Age-appropriate vital signs

Use PEWS. Tachycardia is the earliest sign
HR >160 infant · >140 1–2yr · >130 2–5yr · >120 5–12yr
Hypotension is a late, pre-terminal sign in children

2 · Non-blanching rash

Non-blanching rash in a febrile child: IV/IO ceftriaxone 80mg/kg IMMEDIATELY — IM if no access. Do not wait for tests.

3 · Stratify the risk

Any HIGH risk criterion: senior decision maker urgently, full bloods, antibiotics within 1 hour, discuss with a consultant
2+ MODERATE-TO-HIGH: bloods with lactate, clinician review within 1 hour
Lactate >2 → treat as high risk
Lactate ≤2, no diagnosis → hourly reassessment, senior review within 3 hours
1 moderate-to-high: clinician review within 1 hour
12–15 years: also high risk if lactate >2 or AKI
Monitor every 30 minutes while high risk
No response within 1 hour of any intervention: consultant in person

4 · Fluid resuscitation — 10ml/kg, max 250ml

10ml/kg over <10 minutes, maximum 250ml whatever the child weighs
Glucose-free crystalloid, sodium 130–154 — 0.9% NaCl or Hartmann's
Smaller volumes in cardiac or kidney disease
Pump or syringe — a bag on a giving set will not achieve the rate
Reassess. No improvement → second bolus. Still none after the second → consultant in person

If you were taught 20ml/kg to 40–60ml/kg, that is not current NICE.

5 · IV antibiotics

Within 1 hour of any high risk criterion
28 days to 16 years, community-acquired: ceftriaxone 80mg/kg OD, max 4g
Under 3 months: add listeria cover — amoxicillin or ampicillin
Under 28 days: first 72h → benzylpenicillin + gentamicin. Community-acquired → ceftriaxone 50mg/kg only if >40 weeks corrected and not on IV calcium; otherwise cefotaxime 50mg/kg
Ceftriaxone with IV calcium can precipitate fatally in a neonate — check the fluid chart, including TPN
Inpatient or known resistant organism: local guidelines
Metronidazole if abdominal source
Narrow once the source or cultures are known

6 · Blood cultures + investigations

Blood cultures before antibiotics if possible — do not delay >15 min
Glucose, VBG, FBC, CRP, lactate, LFTs, coag

7 · PICU criteria

Fluid-refractory shock
Persistent hypotension
Requiring vasopressors
GCS <9
Respiratory failure

Drugs

Drug	Dose	Route	Notes
Ceftriaxone	80mg/kg once daily (max 4g)	IV/IM	Community-acquired, over 28 days. IM if no IV access and suspected meningococcal disease. NEONATES: check for calcium first. Ceftriaxone forms insoluble precipitates with calcium and this has been fatal in newborns. Contraindicated under 28 days if receiving IV calcium (including TPN), or at 40 weeks corrected gestation or below — use cefotaxime 50mg/kg 6–12 hourly instead.
0.9% NaCl or Hartmann's	10ml/kg, max 250ml	IV/IO bolus	Over <10 min by pump or syringe. Glucose-free. Reassess; second bolus if no improvement; consultant in person if still no improvement after the second. Smaller volumes in cardiac or kidney disease.
Piperacillin-tazobactam	90mg/kg (max 4.5g)	IV Q6h	Broader cover for unknown source or immunocompromised. Per local guidelines.

When to escalate

Non-blanching purpuric rash — IM/IV ceftriaxone before transfer,Fluid-refractory shock (no response after 40ml/kg) — PICU, start vasopressors,GCS falling or seizures — PICU, consider lumbar puncture safety,Immunocompromised child — discuss with oncology/immunology re: empirical cover,No improvement after the SECOND 10ml/kg bolus — consultant to attend in person (NG254 1.9.5),High risk with no response within 1 hour of any intervention — consultant to attend in person,Neonate needing a cephalosporin who is on IV calcium or TPN — cefotaxime, not ceftriaxone

Reference: NICE NG254 Suspected sepsis in under 16s (2025, replaced NG51 for this age group) / RCPCH Paediatric Sepsis Toolkit / APLS

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