NICE vs RCPCH: Management of Suspected Sepsis in Children (2025)

This guideline provides a comparative analysis of two key UK documents for the management of suspected sepsis in children: the National Institute for Health and Care Excellence (NG239, published 2024) and the Royal College of Paediatrics and Child Health (RCPCH) evidence-based guideline (published 2024). Both aim to standardise and improve the recognition and treatment of this life-threatening condition. This comparison is intended for clinicians to understand the nuances, similarities, and key differences to inform their practice.

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Diagnosis and Initial Assessment

The fundamental difference between the two guidelines lies in their approach to risk stratification and the tools they recommend for initial assessment.

NICE Guideline (NG239)

NICE employs a traffic-light system for categorising risk in children under 5 years, similar to its feverish illness guidance. It focuses on identifying specific symptoms and signs of illness severity.

• Approach: Uses a structured risk categorisation (high, intermediate, low) based on clinical findings.
• Key Tools: Relies on the Paediatric Early Warning Score (PEWS) or a local equivalent track-and-trigger system to identify deterioration.
• Focus: Emphasises identifying "red flag" symptoms and signs (e.g., altered mental status, mottled/ashen/blue skin, no urine output) that warrant immediate action.

RCPCH Guideline

The RCPCH guideline advocates for the use of a single, specific screening tool: the Paediatric Sepsis 6 (PS6) screening tool.

• Approach: A more streamlined process centred on answering the six questions of the PS6 tool to rapidly identify children at high risk.
• Key Tools: The Paediatric Sepsis 6 (PS6) screening tool is core to the assessment. This tool is designed to be quick and memorable for all clinical staff.
• Focus: On a rapid "yes/no" screening process to trigger the Sepsis 6 bundle within one hour if concerns are identified.

Key Difference: NICE promotes a broader risk assessment using PEWS, while RCPCH champions a dedicated, rapid sepsis-specific screening tool (PS6). The RCPCH approach is designed for speed and simplicity in the initial "screening" phase.

Treatment and Management Bundles

Both guidelines stress the importance of timely intervention, but the structure and naming of the treatment bundles differ.

NICE Guideline

NICE structures its recommendations around time-bound actions.

• Immediate Action (Within 15 minutes): For children with red flag symptoms, actions include giving oxygen, performing blood tests (including lactate), and starting IV fluids.
• Rapid Treatment (Within 1 hour): For children at high risk, treatment includes antibiotics, IV fluids, and senior review within one hour of identifying the high risk.
• Antibiotics: Recommends broad-spectrum antibiotics effective against the likely pathogens, with a strong emphasis on local antimicrobial guidelines.

RCPCH Guideline

RCPCH is more prescriptive with its well-established "Sepsis 6" bundle.

• The Sepsis 6 Bundle: This is a defined set of three diagnostic and three therapeutic actions to be completed within one hour of identifying a high-risk child:
  • Deliver high-flow oxygen.
  • Take blood cultures.
  • Give IV antibiotics.
  • Take blood for haemoglobin and lactate.
  • Start IV fluid resuscitation.
  • Commence accurate fluid measurement.
• Antibiotics: Similarly to NICE, it recommends broad-spectrum antibiotics but provides more specific examples (e.g., co-amoxiclav or ceftriaxone for community-acquired sepsis).

Key Difference: The RCPCH guideline operationalises the "hour-1 bundle" concept through the memorable and actionable Sepsis 6. NICE provides a more tiered approach based on the initial risk categorisation (immediate vs. within 1 hour). The clinical actions, however, are very similar.

Special Situations and Populations

Neonates (Under 28 Days)

• NICE: Highlights that neonates are at particularly high risk. Management should be guided by a neonatal specialist, and a lower threshold for treatment and admission is advised. The traffic-light system is not applicable.
• RCPCH: Also stresses the high risk and need for senior input. Recommends specific antibiotic regimens for this age group (e.g., including an antibiotic with cover for Listeria). Both guidelines are aligned on the need for extreme caution.

Children with Complex Health Needs or Immunocompromise

• Both guidelines acknowledge the challenge of diagnosing sepsis in these groups, as baseline observations may be abnormal.
• They recommend using a combination of trend in observations (compared to the child's baseline), clinical judgement, and a lower threshold for escalation and treatment.

Practical Clinical Flow: A Synthesis

For practical purposes, clinicians can synthesise the two guidelines into a cohesive workflow:

1. Triage/Presentation: Use either the RCPCH PS6 screening tool or the NICE risk assessment criteria (PEWS/red flags) to identify a child at high risk of sepsis. The goal is rapid identification.
2. Immediate Action: If the child has any "red flag" symptoms (per NICE) or a positive PS6 screen (per RCPCH), trigger the emergency response.
3. Hour-1 Bundle: Initiate the Sepsis 6 bundle (as per RCPCH) or the equivalent actions outlined by NICE (antibiotics, fluids, oxygen, bloods). The key is that these interventions happen within one hour of identifying the high-risk status.
4. Ongoing Management: Continuous monitoring with PEWS, senior review, and escalation as needed, in line with both guidelines.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow in my Trust?

Your local NHS Trust will have a specific paediatric sepsis policy. This policy will typically be an amalgamation of national guidance, including NICE and RCPCH. You must follow your local policy. This comparison is to help you understand the rationale behind your local protocol.

2. Is the Paediatric Sepsis 6 tool outdated compared to the NICE approach?

No. The RCPCH guideline (2024) has updated and reaffirmed the PS6 tool. The NICE approach is complementary. Many trusts integrate the PS6 as the initial screening tool within a broader framework that includes PEWS, as recommended by NICE.

3. Are the antibiotic recommendations different?

The principles are identical: use broad-spectrum antibiotics effective against common pathogens. The specific choice should be guided by local antimicrobial resistance patterns and guidelines. Both documents defer to local formularies for the final choice.

4. How do I manage a child who doesn't clearly fit the "high-risk" category but I am still concerned?

Both guidelines emphasise clinical judgement. If you are concerned about a child's clinical condition, even if they do not meet all the formal criteria for "high risk," you should escalate for a senior review and consider initiating observations and investigations. "Treat the child, not the checklist."

5. What is the single most important practical takeaway?

Time is tissue. The most critical consensus point is the need for rapid recognition and the delivery of key interventions (especially antibiotics and fluids) within one hour of identifying a child at high risk of sepsis. Whether you use the NICE red flags or the RCPCH PS6 to trigger this response, the urgency is the same.

Source Links

• NICE Guideline NG239 (2024): Suspected sepsis: recognition, diagnosis and early management
• RCPCH Guideline (2024): Sepsis in children: recognition, diagnosis and management (evidence-based guideline)