risk stratification tool for children aged under 5 years with suspected sepsis
Last edited 09/2019 and last reviewed 05/2023
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: