Evolving landscape of paediatric sepsis: progress, gaps and the next generation of tools

Paediatric sepsis remains a major cause of childhood mortality worldwide, despite substantial changes in its epidemiology, definitions and management over the past two decades. Progress has come from sharper criteria centred on organ dysfunction, prevention through vaccination and more nuanced bedside management. The Phoenix Sepsis Criteria have moved paediatric sepsis away from inflammation-based definitions towards life-threatening organ dysfunction, while conjugate vaccine programmes have reshaped the population of children presenting with invasive bacterial infection. Contemporary guidance also increasingly stratifies treatment by severity, reflecting a shift away from uniform bundles applied to all.Important gaps remain. Many paediatric sepsis deaths still occur within the first 24 hours of referral to intensive care, suggesting that outcomes are often determined before paediatric intensive care unit admission. Early recognition remains difficult: screening tools perform imperfectly in unselected febrile children, biomarkers remain adjuncts, and clinicians still rely on gestalt and parental concern. Sepsis is also heterogeneous, spanning children with different pathogens, host factors and immune responses.Future progress is likely to depend on risk stratification rather than universal screening. Machine learning may make early recognition more reproducible, while phenotype-informed approaches may support trials targeted to biologically meaningful subgroups. Both require prospective validation before routine use.