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Paediatric sepsis
Children compensate brilliantly — until they suddenly don't. Spot sepsis from tachycardia, tachypnoea, prolonged CRT, mottling and altered behaviour, not from blood pressure. Then deliver the paediatric Sepsis Six within the hour and call PICU early. Built for revision, not live patient decisions.
Settle them, and check the basics
within the hourRed flags — what each should make you think
Low blood pressure in a child is a pre-arrest sign. Tachycardia, a long CRT, cool peripheries and a change in behaviour come first. Act on those. And always check the glucose: sick children quickly become hypoglycaemic.
The paediatric Sepsis Six
- O₂High-flow oxygen
- IVIV / IO access + bloods
- ℞IV / IO antibiotics
- flFluid bolus
- inoInotropes early
- ☎Seniors + PICU
Understand the child
recognise itHow sepsis shows in children
- Tachycardia and tachypnoea for age (use age-specific charts/PEWS)
- CRT of 3 seconds or more, mottled or cold peripheries
- Altered behaviour: not responding normally, floppy, irritable, weak or high-pitched cry
- Reduced urine output, poor feeding
- Fever or hypothermia (neonates often hypothermic)
- Parental concern that their child is "different" — take it seriously
High-risk groups
- Under 3 months (and especially neonates)
- Immunocompromised, indwelling lines, recent surgery
- Chronic disease, neurodisability
- Unimmunised
- Recent chickenpox or skin breach (iGAS)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Fever, non-blanching rash, cold peripheries, leg pain, shock.
Clinical.
Immediate IV ceftriaxone, fluids, PICU. See the child rash page.
Erythroderma, shock, recent chickenpox, burns or skin infection.
Clinical, cultures, swabs.
Sepsis six with clindamycin (toxin), source control, PICU.
Poor feeding, lethargy, temperature instability, apnoea, vesicles.
Full septic screen including LP.
Antibiotics per neonatal guideline; IV aciclovir if HSV possible.
First weeks of life, shock or cyanosis not responding to fluids, weak femoral pulses, hepatomegaly, murmur.
Four-limb BPs, pre/post-ductal SpO₂, echo.
Prostaglandin infusion (alprostadil) via neonatal/PICU/cardiology advice.
Deep breathing, dehydration, high glucose (DKA); hypoglycaemia, metabolic acidosis (inborn errors).
Glucose, ketones, gas.
Treat the specific cause (BSPED DKA guideline).
Investigate — what to order, when, and what it tells you
test with a question in mindBedside
Bloods
Source
How the plan comes together
disposition · handoverpaediatric ward
Responding to treatment, source identified, stable obs.
PICU / retrieval
Shock needing inotropes, ongoing fluid needs (over 40–60 mL/kg), respiratory failure, reduced GCS.
Hand over: weight, fluids given (mL/kg), antibiotics and time, lactate trend, glucose.
Look for tachycardia, a long CRT, mottling and a change in behaviour; don't wait for hypotension. Give the Sepsis Six in the first hour, reassess after every bolus, and call PICU early. Nicely done getting here.
Clerking template
copy or downloadPaediatric sepsis — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 12 knownFrequently asked questions
quick answersWhat are the red flags for paediatric sepsis?
- Mottled, ashen, cold extremities — think septic shock
- Not responding / hard to rouse — think severe illness
- Non-blanching rash — think meningococcal sepsis
- Hypotension — think late, pre-arrest sign
- Neonate with poor feeding, low temperature — think neonatal sepsis
- Shocked neonate not responding to fluids — think duct-dependent heart lesion
- Recent chickenpox / skin infection — think iGAS / toxic shock
What is the initial management of paediatric sepsis?
- High-flow oxygen — —
- IV / IO access + bloods — gas, lactate, glucose (treat hypoglycaemia), FBC, CRP, U&E, clotting, blood culture
- IV / IO antibiotics — within 1 hour — ceftriaxone; add amoxicillin under 3 months (Listeria); neonates per local regimen
- Fluid bolus — 10 mL/kg crystalloid over 5–10 min; reassess after each; caution with signs of overload
- Inotropes early — after about 40–60 mL/kg, or sooner; peripheral adrenaline can be started
- Seniors + PICU — early, with the retrieval team
Always alongside senior support and your local guideline.
What diagnoses must you not miss in paediatric sepsis?
- Meningococcal septicaemia — non-blanching rash
- Toxic shock / iGAS — rash + shock
- Neonatal sepsis / HSV — first weeks of life
- Duct-dependent heart lesion — shocked neonate
- DKA / metabolic (mimics) — Kussmaul breathing
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for paediatric sepsis?
- Bedside — Severity.
- Bloods — FBC, CRP, U&E, LFT, clotting, blood culture, meningococcal/pneumococcal PCR.
- Source — Clean catch / catheter.
Admit or discharge: how is the plan decided for paediatric sepsis?
- Paediatric ward — Responding to treatment, source identified, stable obs.
- Picu / retrieval — Shock needing inotropes, ongoing fluid needs (over 40–60 mL/kg), respiratory failure, reduced GCS.
Is there a clerking template for paediatric sepsis?
Yes — there is a free clerking template for paediatric sepsis on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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