Pediatric SIRS, Sepsis, and Septic Shock

Why use it

Sepsis is a leading cause of mortality in pediatric ICUs worldwide. Early recognition using standardized, age-appropriate criteria enables timely resuscitation, antibiotic administration, and escalation of care. The IPSCC criteria provide the validated framework endorsed by the Surviving Sepsis Campaign and PICU guidelines for identifying and staging pediatric sepsis, guiding treatment escalation (fluids, vasopressors, empirical antibiotics, corticosteroids) and level-of-care decisions (ward vs. PICU admission).

About

The International Pediatric Sepsis Consensus Conference (IPSCC), convened in 2005 by Goldstein and colleagues, established age-specific definitions of systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock in children. Published in Pediatric Critical Care Medicine (2005), these definitions recognize that normal vital sign values vary substantially across pediatric age groups — making adult SIRS criteria inapplicable to children. Six age groups are defined with distinct thresholds for heart rate, respiratory rate, and white blood cell count: newborn (0–7 days), neonate (1 week–1 month), infant (1 month–1 year), toddler/preschool (2–5 years), school-age (6–12 years), and adolescent (13–<18 years). SIRS requires ≥2 criteria, at least one of which must be an abnormal temperature or leukocyte count. Sepsis = SIRS + suspected or confirmed infection. Severe sepsis = sepsis + cardiovascular organ dysfunction, ARDS, or ≥2 other organ dysfunctions. Septic shock = sepsis + cardiovascular dysfunction persisting despite ≥40 mL/kg isotonic fluid resuscitation in 1 hour. These definitions remain the foundational reference for pediatric sepsis research and clinical practice, though the Sepsis-3 framework has been proposed for adolescents approaching adult criteria.

When to use

• Any febrile or hypothermic child with suspected infection in the emergency department or inpatient setting
• Vital sign abnormalities in a child with known or suspected infection to determine sepsis stage
• Triage of critically ill children to determine PICU admission criteria
• Monitoring response to sepsis resuscitation — apply serially to assess clinical trajectory
• Research, quality improvement, and audit of pediatric sepsis outcomes
• Newborns and neonates with suspected early or late-onset sepsis

Formula

Pearls & pitfalls

• At least one of the two SIRS criteria met must be TEMPERATURE (<36°C or >38.5°C) or LEUKOCYTE COUNT — tachycardia + tachypnea alone does NOT satisfy SIRS by IPSCC criteria.
• Bradycardia is a SIRS criterion in children younger than 1 year (newborns and infants) — it is NOT a criterion in older children and may indicate decompensated shock.
• Hypotension is NOT required for pediatric septic shock — cardiovascular organ dysfunction includes vasopressor dependency, persistent metabolic acidosis, elevated lactate, or prolonged capillary refill even with normal BP.
• The Surviving Sepsis Campaign Pediatric Guidelines (2020) recommend "time-to-antibiotic" within 1 hour for septic shock and within 3 hours for sepsis without shock.
• Fever in neonates <28 days is a medical emergency regardless of SIRS count — they require full septic workup (blood cultures, CBC, CRP, LP, urinalysis) and empirical antibiotics.
• WBC reference ranges used here are for TOTAL leukocyte count — neonates and young infants normally have higher WBC counts than older children.
• Fluid resuscitation: in settings with limited PICU resources or suspected malaria, initial fluid bolus of 10–20 mL/kg is preferred; the FEAST trial (Africa, 2011) showed harm with aggressive 20 mL/kg boluses in some resource-limited settings.
• In 2016, Sepsis-3 defined sepsis as life-threatening organ dysfunction from infection using SOFA score — these adult definitions are not directly applicable to children; pediatric-adapted pSOFA has been developed.
• Bands (immature neutrophils) >10% as an isolated finding with normal temperature satisfies the leukocyte criterion for SIRS.
• Procalcitonin (PCT) and CRP are useful biomarkers in pediatric sepsis but do not replace clinical criteria — PCT >0.5 ng/mL supports bacterial infection; PCT >2–10 ng/mL supports severe bacterial sepsis.

Next steps

SIRS without infection: Investigate non-infectious causes (burns, trauma, post-surgical inflammation, autoimmune disease). SIRS + suspected infection (Sepsis): Start empirical broad-spectrum antibiotics within 1 hour of recognition. Obtain blood cultures before antibiotics. IV fluid bolus 20 mL/kg isotonic crystalloid; reassess after each bolus. Bedside monitoring and nursing escalation. Severe Sepsis: PICU admission or urgent PICU consultation. Obtain arterial access. Further IV fluid resuscitation (up to 40–60 mL/kg total) targeting perfusion. Vasopressor support if fluid-refractory. Organ-specific management (respiratory, renal, neurological). Hydrocortisone for absolute or relative adrenal insufficiency (fluid/vasopressor-refractory). Septic Shock: Immediate PICU transfer. Vasoactive agents (dopamine first-line; norepinephrine or epinephrine for fluid/dopamine-refractory). Target: CRT ≤2s, normal HR/BP for age, UO >1 mL/kg/h, normal sensorium, improving lactic acidosis.

Evidence

Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8. PMID:15636651. These definitions have been adopted by the Surviving Sepsis Campaign (2012, 2018, 2020 pediatric guidelines) and PICU standards worldwide. Weiss SL et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106. PMID:32032273.

References

1. Goldstein B et al. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8. — link
2. Weiss SL et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106. — link
3. Dellinger RP et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med. 2013;41(2):580-637. — link
4. Schlapbach LJ et al. Defining pediatric sepsis — towards clarity and global applicability. Lancet Child Adolesc Health. 2023;7(3):220-229. — link