Which observed behaviours may reassure physicians that a child is not septic? An international Delphi study

Correspondence to Dr Shammi Ramlakhan, Emergency Department, Sheffield Children’s NHS Foundation Trust, Sheffield, S10 2TH, UK; [email protected]

What is already known on this topic?

• The drive to improve the diagnosis of sepsis in children has concentrated on recognising features that suggest the possibility or probability of sepsis.

• The clinical assessment of unwell children is a dual process, with the physician considering the possibility of sepsis and looking for features of wellness.

• Little is known about the features that clinicians use to decide that a child is well or the consensus about these features.

What this study adds?

• Physicians regularly rely on features of wellness to reassure them about the possibility of sepsis in febrile unwell children.

• Observed behaviours and activities such as being energetic, smiling, playing and age-appropriate verbalisation are the most reassuring features.

• Features such as consolability and fear of the physician were not felt to be adequately reassuring.

Introduction

The recent drive to improve the recognition of sepsis in children has led to an exponential increase in the number of sepsis guidelines and decision aids produced.^{1 2} None of these have yet achieved sufficiently high sensitivity and specificity³ to avoid the risk of significant overdiagnosis and overtreatment. These guidelines and decision aids mainly focus on quantifiable measures (eg, tachycardia) and subjective negative features (eg, subdued).

The exclusion of sepsis through features of wellness is rarely considered despite the usual practical approach to diagnosis being simultaneously ruling out and ruling in. Understanding what clinicians rely on to rule out sepsis is important in paediatrics, since features such as tachycardia are so common in benign infections that they have poor specificity for the recognition of sepsis.⁴

How do clinicians decide that a child is septic or not?

The clinical features used to determine the likelihood of sepsis are generally negative; depending on signs, symptoms or test results being abnormal or concerning. Little weight is given to positive signs or symptoms,-those that are normal or reassuring in the context of an ill child.

Many physicians will already use wellness as part of their diagnostic reasoning in determining the likelihood of sepsis or serious illness in a child. However, little is known about the features which clinicians commonly rely on, or the weight given...