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Risk stratification tool for children aged under 5 years with suspected sepsis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Risk stratifification tool for children aged under 5 years with suspected sepsis

Category

Age

High Risk criteria

Moderate to high risk criteria

Low 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

Responds normally to social cues

Content or smiles

Stays awake or awakens quickly

Strong normal cry or not crying

Respiratory

Any

Grunting

Apnoea

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

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

Nasal flaring

No high risk or moderate to high risk criteria met

Under 1 year

Raised respiratory rate: 60 breaths per minute or more

Raised respiratory rate: 50-59 breaths per minute

No high risk or moderate to high risk criteria met

1-2 years

Raised respiratory rate: 50 breaths per minute or more

Raised respiratory rate: 40-49 breaths per minute

No high risk or moderate to high risk criteria met

3–4 years

Raised respiratory rate: 40 breaths per minute or more

Raised respiratory rate: 35-39 breaths per minute

No high risk or moderate to high risk criteria met

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

No high risk or moderate to high risk criteria met

Under 1 year

Rapid heart rate: 160 beats per minute or more

Rapid heart rate: 150-159 beats per minute

No high risk or moderate to high risk criteria met

1–2 years

Rapid heart rate: 150 beats per minute or more

Rapid heart rate: 140-149 beats per minute

No high risk or moderate to high risk criteria met

3-4 years

Rapid heart rate: 140 beats per minute or more

Rapid heart rate: 130-139 beats per minute

No high risk or moderate to high risk criteria met

Skin

Any

Mottled or ashen appearance

Cyanosis of skin, lips or tongue

Non-blanching rash of skin

Pallor of skin, lips or tongue

Normal colour

Temperature

Any

Less than 36ºC

Under 3 months

38°C or more

3-6 months

39°C or more

Other

Any

Leg pain Cold hands or feet

No high risk or moderate to high risk criteria met

The UK Sepsis Trust have produced a form for evaluation of possible sepsis for use in primary care (2):

 

Reference:


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