Sepsis in children
A child with sepsis can look well until they suddenly collapse. Recognise it early, get access, give antibiotics within the hour, give fluid in 10 mL/kg steps with reassessment, and call senior help.
A 3-year-old girl has had fever and vomiting since this morning. She is now sleepy and floppy. Heart rate 178, RR 44, capillary refill 5 seconds, cold hands and feet, BP 78/40. A few purple spots on her legs do not fade under a glass. She weighs 14 kg.
What do you do in the next 15 minutes?
- High-flow oxygen15 L/min by non-rebreather mask.
- IV or intraosseous accessIO after 2 failed IV attempts or 90 seconds. Do not waste time.
- Antibiotics within 1 hourImmediately if non-blanching rash or shock.
- BloodsCultures, gas with lactate, sugar, CBC, CRP, electrolytes, clotting, group and save.
- Fluid bolus 10 mL/kgOver 5–10 minutes, then reassess after each.
- Check the sugarTreat low sugar.
- Senior, anaesthesia and PICUEarly.
- After 40–60 mL/kg and still shockedInotropes (adrenaline), PICU.
- Mottled, ashen, cold hands and feet
- Not responding or hard to wake
- Non-blanching rash
- Low BP
- Newborn with poor feeding or low temperature
- Needing more than 40 mL/kg of fluid
| Ceftriaxone | 80 mg/kg IV once daily (max 4 g). 100 mg/kg if meningitis |
| Under 3 months | Add amoxicillin 50 mg/kg every 6 hours (Listeria). Cefotaxime instead of ceftriaxone in newborns |
| Fluid bolus | 10 mL/kg over 5–10 minutes, reassess after each |
| Low sugar | Below 54 mg/dL (3 mmol/L): 10% dextrose 2 mL/kg |
| Fluid-refractory shock | Adrenaline infusion 0.05–0.3 micrograms/kg/min (PICU) |
Check every dose against a current drug reference and your hospital protocol.
On this page
Recognising the sick child
Children compensate very well. They keep a normal BP until they have lost a great deal, then collapse suddenly. Low BP is a late, pre-terminal sign in children.
- Appearance: floppy, drowsy, hard to wake, weak or high-pitched cry, not interested in surroundings.
- Breathing: fast, grunting, recession.
- Circulation: fast heart rate, capillary refill over 3 seconds, cold or mottled hands and feet, pale or ashen, little urine.
- Rash that does not blanch.
- Temperature: high, or low (especially in babies).
| Age | Normal heart rate | Normal RR |
|---|---|---|
| Under 1 year | 110–160 | 30–40 |
| 1–2 years | 100–150 | 25–35 |
| 2–5 years | 95–140 | 25–30 |
| 5–12 years | 80–120 | 20–25 |
Access
- Two attempts at IVOr 90 seconds, whichever comes first.
- Intraosseous (IO)Proximal tibia, 2–3 cm below the tibial tuberosity on the flat medial surface. Any drug or fluid can go through it.
- Bloods from the first accessCultures, gas, sugar, CBC, CRP, electrolytes, clotting, group and save.
Antibiotics
Fluids: careful steps
- Continue to monitor
- Further bolus only if signs of shock return
- Repeat 10 mL/kg
- Senior review after 20 mL/kg
- Prepare inotropes after 40 mL/kg
- Stop fluids
- Inotropes
- PICU
In settings without intensive care, the large FEAST trial in African children showed that fluid boluses in febrile children without low BP increased deaths. The children's Surviving Sepsis guidelines (2020) therefore advise:
- No low BP: maintenance fluids, no boluses.
- Low BP: boluses (up to 40 mL/kg in the first hour) with careful reassessment.
Discuss with your senior: the decision depends on what support is available.
Special situations
- Meningococcal disease: fever with a non-blanching rash. Ceftriaxone immediately. Prophylaxis for close contacts and notify public health.
- Newborns: sepsis may show only as poor feeding, low temperature, jaundice, apnoea or lethargy. Cefotaxime plus amoxicillin (and aciclovir if herpes is possible).
- Dengue shock: follow the dengue fluid protocol and check the haematocrit. See Dengue fever.
- Shocked baby under 4 weeks not responding to fluids: think duct-dependent congenital heart disease. Senior and cardiology urgently.
- DKA: do not give large boluses. See the paediatric DKA protocol.
Common mistakes
- Waiting for low BP before calling it shock.
- Five attempts at an IV in a shocked child instead of going to IO.
- Giving 20 mL/kg boluses repeatedly without reassessing the liver and chest.
- Forgetting the sugar.
- Missing a few non-blanching spots under the clothes.
- Sending home a child with fever and a fast heart rate that does not settle.
Frequently asked questions
What is the fluid bolus for children in septic shock?
10 mL/kg of crystalloid over 5–10 minutes, reassessing after each bolus. Senior review after 20 mL/kg and inotropes after 40–60 mL/kg if still shocked.
What antibiotic is used for sepsis in children?
Ceftriaxone 80 mg/kg IV once daily (max 4 g), with amoxicillin 50 mg/kg every 6 hours added for babies under 3 months. Cefotaxime replaces ceftriaxone in newborns.
When is intraosseous access used in children?
After two failed IV attempts or 90 seconds in a seriously ill child.
What are the red flags for sepsis in children?
Mottled, ashen or blue skin, a child who is hard to wake or not responding, a weak or high-pitched cry, grunting or very fast breathing, a non-blanching rash, cold hands and feet with slow capillary refill, and low temperature in babies.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A child in septic shock has had two failed cannula attempts. What is the next step?
Answer: Intraosseous access. If IV access fails quickly in a shocked child, insert an intraosseous needle.
- Keep trying peripheral cannula for 30 minutes: Delay.
- IM fluids: Not possible.
- Central line by a junior: Not first.
- Oral antibiotics: No.
2. A child in septic shock has had 40 mL/kg of fluid, remains shocked and the liver is now 4 cm below the costal margin. What next?
Answer: Stop boluses, start adrenaline. Hepatomegaly and crackles indicate fluid overload; move to inotropes.
- Furosemide and observe: Shock still needs support.
- Oral fluids: No.
- Steroids alone: Not alone.
- Another 20 mL/kg bolus: Signs of fluid overload.
3. A 3-week-old baby is grey and shocked and not improving with fluid. What else must be considered?
Answer: Duct-dependent heart disease. In the first weeks, closure of the ductus arteriosus in duct-dependent lesions causes shock. Prostaglandin and cardiology urgently.
- Simple viral illness: No.
- Teething: No.
- Pyloric stenosis: Different picture.
- Colic: No.
4. A 3-day-old baby is lethargic, feeding poorly, with temperature 35.5 °C and grunting. Mother had prolonged rupture of membranes. What is the first-line empirical antibiotic regimen (WHO)?
Answer: Ampicillin + gentamicin. Possible serious bacterial infection in young infants (poor feeding, lethargy, convulsions, fast breathing ≥ 60, severe chest indrawing, temperature ≥ 37.5 or < 35.5 °C): early-onset sepsis (GBS, E. coli, Listeria) — risk factors include PROM > 18 h, maternal fever, chorioamnionitis, prematurity. WHO first-line: IV/IM ampicillin (or benzylpenicillin) + gentamicin; switch per culture/local resistance (rising resistance in South Asia). Blood culture, glucose; LP if stable.
- Oral amoxicillin alone: Severe illness needs IV antibiotics.
- Ceftriaxone + vancomycin: Ceftriaxone with vancomycin is not first-line in neonates.
- Metronidazole: Metronidazole gives the wrong cover.
5. A 4-year-old is drowsy with cold peripheries, CRT 5 s, HR 170 and a rapidly spreading non-blanching purpuric rash. What is the first step after IV access?
Answer: IV ceftriaxone + fluids. Meningococcal septicaemia: purpuric non-blanching rash, shock (tachycardia, prolonged CRT, cold peripheries, later hypotension), may lack meningism. Immediate IM/IV benzylpenicillin in the community or IV ceftriaxone in hospital, fluid boluses 10 mL/kg (repeated, then inotropes), PICU. Avoid LP in shock/coagulopathy. Chemoprophylaxis for close contacts (ciprofloxacin or rifampicin); notify public health.
- Lumbar puncture first: LP delays treatment and is unsafe in shock.
- Oral amoxicillin: Oral antibiotics are inadequate.
- Wait for blood culture: Waiting for culture delays treatment.
6. A girl with meningococcal septicaemia has fever, a spreading purpuric rash and becomes profoundly hypotensive. Autopsy shows bilateral adrenal haemorrhage. What is this?
Answer: Waterhouse–Friderichsen syndrome. Meningococcal endotoxin (lipo-oligosaccharide) causes septic shock and DIC with bilateral adrenal haemorrhage and acute adrenal failure. Treat urgently with IV antibiotics (benzylpenicillin or ceftriaxone), fluids and steroids if needed. Contacts receive prophylaxis (rifampicin or ciprofloxacin).
- Sheehan's syndrome: Pituitary necrosis after postpartum haemorrhage.
- Addison's disease from tuberculosis: Chronic, not acute septic.
- Conn's syndrome: Aldosterone excess.
- Cushing's syndrome: Cortisol excess.
7. Which organism is the most important cause of severe, rapidly fatal puerperal sepsis?
Answer: Streptococcus pyogenes. Group A streptococcus causes the most dangerous puerperal sepsis, with toxic shock and necrotising infection; it was the classic 'childbed fever' prevented by Semmelweis's handwashing. Other causes: E. coli, anaerobes, group B streptococcus and Staphylococcus aureus. Treat promptly with broad-spectrum IV antibiotics and source control.
- Staphylococcus epidermidis: Skin commensal; device infections.
- Lactobacillus species: Normal vaginal flora.
- Candida albicans: Not a typical cause.
- Listeria monocytogenes: Pregnancy infection with neonatal risk, not puerperal sepsis.
References and dose sources
- NICE NG51: Sepsis, recognition, diagnosis and early management
- Surviving Sepsis Campaign international guidelines for children (2020)
- FEAST trial: fluid boluses in African children with severe febrile illness
- NICE NG240
- NICE NG254 — suspected sepsis in under 16s
- NICE NG143 — fever in under 5s
- UK Sepsis Trust — paediatric tools
- Ceftriaxone dosing: Drugs.com: Ceftriaxone dosage (see also our ceftriaxone dose page)
- Amoxicillin dosing: Drugs.com: Amoxicillin dosage (see also our amoxicillin dose page)
- Clindamycin dosing: Drugs.com: Clindamycin dosage (see also our clindamycin dose page)
- Ringer's lactate (Hartmann's solution) dosing: Drugs.com: Lactated Ringer's dosage (see also our ringer's lactate (hartmann's solution) dose page)
- Dextrose (glucose) dosing: Drugs.com: Dextrose dosage (see also our dextrose (glucose) dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.