Suspected sepsis in under 16s: recognition, diagnosis and early management (NG254)

What this guideline says

GMJ summary

This NICE guideline provides comprehensive recommendations for the recognition, diagnosis and early management of suspected sepsis in children and young people under 16 years (excluding pregnant or recently pregnant young people). It establishes age-specific risk stratification criteria, physiological parameters and care pathways for children under 5, aged 5–11, and aged 12–15.

The guideline stratifies risk into high, moderate-to-high, and low categories based on behaviour, respiratory, circulatory and skin signs. For children meeting high-risk criteria, it mandates immediate transfer to acute hospital settings, antibiotics within 1 hour, and senior clinical review. Outside hospital settings, pre-hospital antibiotics are recommended in remote locations where transfer time exceeds 1 hour. The guideline emphasises early source control, appropriate fluid resuscitation with crystalloids (10–20 ml/kg boluses), and antibiotic choices ranging from benzylpenicillin plus gentamicin for neonates to ceftriaxone 80 mg/kg (max 4 g) for community-acquired sepsis in older children.

Special attention is given to vulnerable groups including infants under 1 year, ethnic minorities, immunosuppressed children, and those with communication challenges. The guideline stresses the importance of listening to parental concerns about behavioural changes, providing clear discharge information, and ensuring all healthcare staff receive regular training in sepsis identification.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Risk stratification uses age-specific criteria: high-risk signs include altered consciousness, oxygen saturation <90%, bradycardia <60 bpm, non-blanching rash, or age-specific tachycardia and tachypnoea thresholds (e.g., respiratory rate ≥60 in infants <1 year, heart rate ≥160 in infants)
2. Children meeting any high-risk criterion require immediate transfer to emergency care via 999 ambulance with pre-alert, antibiotics within 1 hour, and consultant-level review
3. First-line antibiotics: benzylpenicillin plus gentamicin for neonates <28 days presenting in hospital; ceftriaxone 80 mg/kg once daily (max 4 g) for community-acquired sepsis in children (except neonates); add ampicillin/amoxicillin for listeria cover in infants <3 months
4. Intravenous fluid resuscitation: use glucose-free crystalloids with sodium 130–154 mmol/L; bolus 10–20 ml/kg over <10 minutes for neonates, 10 ml/kg (max 250 ml) for older children; give second bolus if no improvement, then alert consultant if still unresponsive
5. Children under 12 with 2+ moderate-to-high risk criteria and lactate >2 mmol/L should be treated as high-risk; young people aged 12–15 with systolic BP 91–100 mmHg or lactate >2 mmol/L also escalate to high-risk management
6. In remote locations where transfer time >1 hour, GPs should have mechanisms to give pre-hospital antibiotics; paramedics should consider antibiotics if combined transfer and handover times exceed 1 hour
7. Lumbar puncture is required for all babies <1 month with suspected sepsis, babies 1–3 months who appear unwell, or those with white cell count <5 or >15 × 10⁹/L (unless contraindicated)
8. Suspect neutropenic sepsis in children who are unwell and received anticancer or immunosuppressant treatment within 30 days; refer immediately for emergency care and treat per neutropenic sepsis guideline regardless of cause

Criteria for stratification of risk of severe illness or death from sepsis in children under 5

Table extracted from the guideline

Source: National Institute for Health and Care Excellence (UK), Suspected sepsis in under 16s: recognition, diagnosis and early management (NG254). Reproduced in summary form.

What changed in this edition

Versus the previous edition

• January 2026: amended recommendations to refer to 'learning disabilities' rather than 'learning difficulties'
• November 2025: split the original all-age sepsis guideline (NG51) into three separate guidelines for under 16s (NG254), over 16s, and pregnant/recently pregnant people
• 2024 updates: added recommendation to ask about recent presentations during initial assessment (1.3.9); expanded surgical source control recommendation beyond intra-abdominal infections (1.11.4); added discharge information recommendation (1.7.22); clarified neutropenic sepsis criteria to include immunosuppressant treatment beyond cancer (1.1.9, 1.1.11)

From the guideline

Verbatim

“For people under 16 who have suspected sepsis and meet 1 or more high risk criteria: give a broad-spectrum antimicrobial 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.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.