A sick child is recognised from colour, activity, breathing and circulation before any single number, and NICE turns that impression into a red, amber or green risk grade. According to NICE guideline NG143, last updated 26 November 2021, red features include mottled skin, no response to social cues, grunting and a respiratory rate above 60. At the CT1 anaesthetics interview the sick child is a scenario about early recognition, weight-based treatment and calling the right team.

Key takeaways

  • NICE NG143 grades a feverish child as green, amber or red, and any red feature makes that child high risk for serious illness
  • Red features include pale, mottled, ashen or blue skin, no response to social cues, grunting, a respiratory rate above 60 and moderate or severe chest indrawing
  • A child under 3 months with a temperature of 38C or higher is high risk; a child aged 3 to 6 months at 39C or higher is at least intermediate risk
  • NICE NG254, published 19 November 2025, asks for a broad-spectrum antimicrobial within 1 hour of a child meeting any high risk sepsis criterion
  • Fluid resuscitation in under 16s is 10 ml/kg of glucose-free crystalloid over less than 10 minutes, to a maximum bolus of 250 ml, reassessed after each bolus
  • The Royal College of Anaesthetists says in GPAS chapter 10 that paediatric early warning scores should be used and the local paediatric intensive care transport team contacted as soon as possible

How do you recognise a sick child at the bedside?

You recognise a sick child by looking at four things before you touch them: colour, activity, breathing and circulation. NICE NG143 builds its whole traffic light system from exactly those categories, plus temperature and age.

According to NG143, a child is in the high risk group with any of pale, mottled, ashen or blue skin, no response to social cues, appearing ill to a healthcare professional, not waking or not staying awake, a weak, high-pitched or continuous cry, grunting, a respiratory rate above 60, moderate or severe chest indrawing, reduced skin turgor or a bulging fontanelle.

In practice the phrase that wins marks on the sick child is appearing ill to a healthcare professional, because NICE lists your own impression as a red feature. Say it rather than apologising for it.

What does the NICE traffic light system add?

The traffic light system for the sick child adds a defensible grade and a matching action, so your plan stops being a feeling and becomes a rule. NG143 sets green as low risk, amber as intermediate and red as high risk.

  • Amber features include pallor reported by a parent, not responding normally to social cues, no smile, waking only with prolonged stimulation, decreased activity, nasal flaring, dry mucous membranes, poor feeding, reduced urine output and rigors
  • A capillary refill time of 3 seconds or longer is an amber sign
  • Green means normal colour, responding normally, content or smiling, waking quickly, normal skin and eyes, and moist mucous membranes
  • Any red feature short of immediately life-threatening illness needs face-to-face assessment within 2 hours, or urgent referral to a paediatric specialist
  • Amber with no diagnosis needs either a safety net or referral for specialist paediatric assessment

However, the traffic light table is for the feverish child. NG143 also says to ask 'could this be sepsis?' and move to the sepsis guideline the moment the signs point that way.

Which observations are abnormal at which age in a child?

Normal values in a sick child move with age, which is why an adult set of thresholds is unsafe. NICE NG143 prints the Advanced Paediatric Life Support criteria for tachycardia and attributes them to APLS.

  • Tachycardia, per the APLS criteria in NG143: more than 160 beats per minute under 12 months, more than 150 at 12 to 24 months, more than 140 at 2 to 5 years
  • Tachypnoea suggesting pneumonia: above 60 breaths per minute at 0 to 5 months, above 50 at 6 to 12 months, above 40 over 12 months
  • NICE NG254 treats a saturation below 90% in air as a high risk sepsis criterion and below 92% as moderate to high risk
  • In a child older than 6 months, NG143 says not to use the height of the temperature alone to identify serious illness

That said, NG143 is explicit that reported parental perception of fever should be considered valid and taken seriously. A parent saying their child is not themselves is data, and NG254 lists parent or carer concern as a moderate to high risk criterion.

How do you grade the risk of sepsis in a child?

You grade sepsis risk in a child from history, examination and age-banded criteria, and NICE NG254 provides three tables: under 5s, 5 to 11 years and 12 to 15 years. Any high risk criterion makes the child high risk.

According to NG254, published 19 November 2025, high risk criteria in the under 5s include no response to social cues, grunting, apnoea, saturations below 90% in air, a heart rate below 60, a capillary refill time of 3 seconds or more, a mottled or ashen appearance, cyanosis, a non-blanching rash and a temperature below 36C.

NG254 replaced NG51 for children on that date, alongside NG253 for those aged 16 and over. Naming the current guideline number for the sick child separates a candidate who reads guidelines from one who remembers a lecture.

What do you do in the first hour for a child with suspected sepsis?

In the first hour you get senior eyes on the child, take bloods, give an antimicrobial and give fluid if it is indicated. NICE NG254 puts a 1 hour clock on the antibiotic from the moment a high risk criterion is met.

  • Arrange urgent assessment by the senior clinical decision maker and think about alternative diagnoses
  • Venous bloods: a gas with glucose and lactate, blood culture, full blood count, C-reactive protein, urea and electrolytes, creatinine, liver function tests and clotting
  • Give a broad-spectrum antimicrobial without delay, within 1 hour of identifying that the child meets any high risk criterion
  • Discuss with a consultant
  • Give oxygen if there are signs of shock or saturations below 92% in air
  • For community-acquired sepsis in under 16s excluding newborn babies, NG254 gives ceftriaxone 80 mg/kg once a day to a maximum of 4 g daily at any age

For a child under 12 with a high risk criterion and a lactate above 4 mmol/L, NG254 asks for fluid without delay and referral to critical care to review central access and the need for inotropes.

How much fluid does a sick child get, and how fast?

A sick child gets 10 ml/kg of glucose-free crystalloid over less than 10 minutes, to a maximum bolus of 250 ml, then is reassessed. NICE NG254 carries that figure from the paediatric intravenous fluids guideline, with sodium in the range 130 to 154 mmol/L.

NG254 asks for a second bolus if there is no improvement after the first, and says that if there is still no improvement after the second bolus a consultant should be alerted to attend in person. For newborn babies under 28 days the bolus is 10 to 20 ml/kg over less than 10 minutes.

NICE NG143 gives the same figure for a feverish child with shock: an immediate bolus of 10 ml/kg, normally 0.9% sodium chloride. Smaller volumes may be needed in cardiac or kidney disease.

What is different about resuscitating a child for the anaesthetist?

For the anaesthetist the practical differences in a sick child are that everything is weight-based, the normal values move with age, and access is harder. NICE NG39 says to consider intra-osseous access as first-line in children if peripheral access is anticipated to be difficult.

The Royal College of Anaesthetists states in GPAS chapter 10, the 2025 edition, that paediatric early warning scores should be used to help identify the deteriorating or critically ill child, and that every emergency department receiving infants and children should hold neonatal and paediatric resuscitation equipment, anaesthetic drugs and fluids.

When do you call the paediatric retrieval team?

You call early, and for a sick child the trigger is the possibility of critical care rather than the certainty of it. GPAS chapter 10 says hospitals without a suitable paediatric or neonatal intensive care bed should obtain the advice of the local paediatric intensive care transport team as soon as possible.

Transfer of critically ill children to specialist centres is generally done by paediatric critical care transport teams. The College notes that a time-critical transfer may occasionally be done by the referring hospital, in which case the child is accompanied by an appropriate senior anaesthetist, with the transport team still advising.

In practice, saying you would ring the retrieval team for advice while the child is being stabilised, rather than afterwards, shows the forward planning this station scores. The call is advice first and transport second.

Which traps catch candidates on the sick child?

The traps on the sick child are the ones NICE wrote its recommendations to close, and each has a one-line answer.

  • Using adult heart and respiratory rate thresholds. The APLS criteria in NG143 band them by age
  • Waiting for a temperature to fall after antipyretics as a test of seriousness. NG143 says not to rely on that, though amber and red children should still be reassessed after 1 to 2 hours
  • Giving an adult-sized fluid bolus. NG254 caps the paediatric bolus at 250 ml
  • Quoting NG51 for a child. It was replaced for under 16s by NG254 on 19 November 2025
  • Treating a normal temperature as reassurance. Under 3 months at 38C or higher is high risk, and a temperature below 36C is a high risk sepsis criterion
  • Managing alone. NG254 asks for a consultant discussion for any child meeting a high risk criterion

How this comes up at the CT1 anaesthetics interview

The sick child arrives in the clinical judgement station as a scenario you are asked to take over: a feverish infant in the emergency department, or a child on a ward who has become quiet. The station is 15 minutes after 5 minutes of reading, marked on clinical judgement and decision making, reflective practice and working under pressure.

  • Clinical judgement and decision-making: grade the sick child red, amber or green out loud, name NG143 and NG254, and attach an action to each grade
  • Working under pressure: say what you do while help is coming, and what the contingency is if the first fluid bolus does not work
  • Reflective practice: one sentence on what you would document and report, and what you would want debriefed afterwards

Rehearse it aloud rather than reading it. anaestheticinterview carries 340 questions across both stations with AI-marked spoken practice, which is how you find out whether your sick child answer survives a new observation halfway through.