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: