Pediatric Sepsis: A Medical-Legal Guide for Attorneys

Clinical Vignette

A previously healthy 3-year-old is brought to an emergency department with a 2-day history of fever, decreased oral intake, and increasing lethargy. The triage nurse records a heart rate of 165 beats per minute, a respiratory rate of 36 breaths per minute, and a temperature of 39.4°C (102.9°F). The child's capillary refill time is 4 seconds, and the skin appears mottled. The physician documents that the child "appears tired but is interactive" and diagnoses a viral illness. No blood work, blood cultures, or lactate measurement is obtained. No intravenous fluids are administered. The family is discharged with instructions to follow up with their pediatrician.

Six hours later, the child is brought back by ambulance in septic shock. Blood pressure is unobtainable. Blood cultures subsequently grow Neisseria meningitidis. Despite aggressive resuscitation in the pediatric intensive care unit, the child develops purpura fulminans, requiring bilateral below-knee amputations. Neuroimaging reveals watershed infarcts consistent with prolonged hypoperfusion.

At the initial emergency department visit, this child had multiple objective signs of sepsis — tachycardia, tachypnea, prolonged capillary refill, and mottled skin — in the setting of fever and lethargy. Under current evidence-based guidelines, these findings should have triggered a sepsis evaluation including blood cultures, lactate measurement, intravenous fluid resuscitation, and empiric antibiotics. The failure to recognize and act on these findings represents a potential deviation from the standard of care.

What Is Pediatric Sepsis?

Pediatric sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection in a child. This definition, adopted by the Society of Critical Care Medicine (SCCM) Pediatric Sepsis Definition Task Force in 2024, replaced the older criteria based on the systemic inflammatory response syndrome (SIRS), which had been in use since 2005 but were found to have poor specificity and limited ability to identify children at highest risk.

Under the current consensus, pediatric sepsis is identified using the Phoenix Sepsis Score — a data-driven scoring system validated across more than 3.6 million pediatric encounters in 10 health systems worldwide. The Phoenix Sepsis Score evaluates dysfunction in four organ systems:

• Cardiovascular — hypotension, elevated lactate (>5 mmol/L), or need for vasoactive medications.
• Respiratory — impaired oxygenation or need for mechanical ventilation.
• Neurological — altered mental status (assessed by Glasgow Coma Scale).
• Coagulation — abnormal platelet count, INR, D-dimer, or fibrinogen.

A Phoenix Sepsis Score of 2 or higher in a child with suspected or confirmed infection identifies sepsis. Septic shock — the most severe form — is defined as sepsis with cardiovascular dysfunction (at least 1 cardiovascular point on the Phoenix score).

For attorneys, the key concept is straightforward: sepsis is not simply an infection. It is an infection that has triggered organ dysfunction — meaning the child's organs are beginning to fail. Septic shock means the cardiovascular system is failing. Both carry high mortality rates: in higher-resource settings, children meeting Phoenix sepsis criteria have an in-hospital mortality of 7.1%, rising to 10.8% for septic shock.

Epidemiology

Pediatric sepsis is not rare. Recent national estimates using electronic health record data aligned with the Phoenix criteria found that sepsis was present in 1.3% of all pediatric hospitalizations in the United States and was identified in 18% of all pediatric hospitalizations that ended in death. This corresponds to more than 18,000 cases and approximately 1,800 deaths annually. Globally, an estimated 25 million children experience sepsis each year, resulting in more than 3 million deaths — with the highest burden in infants and young children.

Why Pediatric Sepsis Is Difficult to Recognize

The difficulty of recognizing sepsis in children is central to understanding both why errors occur and how the standard of care is defined. Several factors make pediatric sepsis uniquely challenging:

Nonspecific Presentation

Children with early sepsis often present with symptoms indistinguishable from common, benign childhood illnesses — fever, fussiness, poor feeding, lethargy, or vomiting. In the early stages, even experienced physicians may not be able to distinguish a child with a self-limited viral illness from one developing life-threatening sepsis. A prospective population-based study found that suboptimal care occurred in 34% of children with community-onset severe bacterial infections, and the most common errors were underestimation of severity by the physician and delayed antibiotic therapy. Children younger than 5 years and those evaluated by non-pediatric physicians were at highest risk.

Compensated Shock

This is one of the most important concepts for attorneys to understand. Unlike adults, children can maintain a normal blood pressure even while in shock. Children compensate for inadequate cardiac output by dramatically increasing their heart rate and constricting their blood vessels. This means a child can appear to have a "normal" blood pressure while their organs are already being damaged by inadequate perfusion.

By the time a child's blood pressure drops — a state called decompensated shock — the child is often in extremis and may be minutes from cardiac arrest. Waiting for hypotension to recognize shock in a child is a fundamental error. The signs of compensated shock — tachycardia, prolonged capillary refill, mottled or cool extremities, altered mental status, and decreased urine output — should prompt immediate evaluation and intervention.

Age-Related Physiologic Differences

Normal vital signs in children vary dramatically by age. A heart rate of 160 beats per minute is normal in a crying infant but profoundly abnormal in a 10-year-old. A respiratory rate of 40 is expected in a newborn but alarming in a teenager. Failure to interpret vital signs in the context of age-appropriate norms is a common source of error — and a common allegation in litigation.

Children also have important immunologic differences from adults. Their immune systems are less mature, particularly in infancy, making them more susceptible to rapid progression of infection. Their ability to localize infection is limited, meaning infections can disseminate quickly.

Rapid Deterioration

Children with sepsis can deteriorate from appearing relatively well to cardiovascular collapse within hours. This narrow window for intervention is what makes timely recognition so critical — and what makes delays so consequential.

Current Evidence-Based Standards of Care

The management of pediatric sepsis is guided primarily by the Surviving Sepsis Campaign (SSC) International Guidelines, published by the Society of Critical Care Medicine. The most recent pediatric guidelines were published in 2026, updating the 2020 edition. These guidelines provide the most authoritative and widely adopted framework for the recognition and treatment of pediatric sepsis worldwide.

The Sepsis Bundle

The SSC guidelines recommend an initial sepsis bundle — a set of time-sensitive interventions that should be initiated as soon as sepsis is suspected:

• Obtain blood cultures — before administering antibiotics, provided this does not substantially delay antibiotic administration.
• Measure blood lactate — the 2026 guidelines issue a strong recommendation to measure blood lactate as part of the initial evaluation of children with probable sepsis or suspected septic shock. Elevated lactate (≥2 mmol/L) is independently associated with increased mortality and is one of three criteria used to identify septic shock under the Phoenix criteria.
• Administer broad-spectrum antibiotics — within 1 hour for children with suspected septic shock (strong recommendation); as soon as possible, ideally within 3 hours, for children with suspected sepsis without shock.
• Initiate fluid resuscitation — up to 40–60 mL/kg in bolus fluid (10–20 mL/kg per bolus) over the first hour for children with septic shock in settings with intensive care availability, with reassessment after every bolus.
• Consider vasoactive medications — if shock persists despite fluid resuscitation.
• Reassess hemodynamic status — after every fluid bolus, guided by clinical markers including heart rate, blood pressure, capillary refill, level of consciousness, and urine output.

Antibiotic Timing

The timing of antibiotic administration is one of the most critical — and most litigated — elements of sepsis management. The evidence is clear:

• A prospective cohort study of 441 children with sepsis found that delayed antibiotic administration beyond 1 hour of recognition was associated with significantly higher mortality (29% vs. 20%; adjusted OR 1.83) and longer time to shock reversal.
• A large retrospective study across 51 U.S. children's hospitals (19,515 cases) found that sepsis-attributable mortality increased significantly when antibiotics were delayed beyond 330 minutes (5.5 hours) from emergency department arrival, with adjusted odds of 3-day mortality of 3.44 and 30-day mortality of 3.63 compared with earlier administration.
• In adults, each additional hour of delay in antibiotic administration has been associated with a 1.09 increased odds of in-hospital mortality, with the association strongest in patients with septic shock.

The SSC guidelines distinguish between septic shock (antibiotics within 1 hour — strong recommendation) and sepsis without shock (antibiotics as soon as possible, ideally within 3 hours — conditional recommendation). This distinction is important in litigation: the standard for antibiotic timing depends on the clinical presentation at the time of recognition.

Fluid Resuscitation

The SSC guidelines recommend up to 40–60 mL/kg of crystalloid fluid boluses over the first hour for children with septic shock in settings with intensive care availability. Balanced crystalloid solutions (such as lactated Ringer's) are suggested over 0.9% saline. Critically, hemodynamic status should be reassessed after every bolus, and fluid administration should be discontinued if signs of fluid overload develop.

An important nuance: in settings without intensive care availability and in the absence of hypotension, the guidelines recommend against fluid bolus therapy — a strong recommendation based on high-certainty evidence from a landmark randomized controlled trial in Africa (the FEAST trial) that demonstrated increased mortality with fluid boluses in resource-limited settings without ICU support.

Vasoactive Medications

When shock persists despite fluid resuscitation, vasoactive medications (such as epinephrine or norepinephrine) should be initiated. The SSC guidelines recommend epinephrine as a first-line agent for children with septic shock.

Source Control

Emergent source control — such as drainage of an abscess or removal of an infected device — should be implemented as soon as possible when an infection amenable to a source control procedure is identified.

Screening and Performance Improvement

The SSC guidelines recommend that hospitals implement performance improvement programs for pediatric sepsis, including systematic screening protocols. Multiple screening tools exist, though no single tool has both perfect sensitivity and specificity. The 2024 Phoenix criteria provide a standardized framework for identifying children with sepsis, and newer screening tools such as the quick Pediatric Septic Shock Screening Score (qPS4) have demonstrated improved sensitivity for detecting Phoenix-defined sepsis and septic shock compared with older tools.

Important Caveats

The SSC guidelines acknowledge that most of their recommendations are based on low or very low certainty of evidence. Of 61 statements in the 2026 guidelines, only 3 were based on high or moderate certainty of evidence. The guidelines themselves state that their recommendations should be interpreted in the context of clinical judgment and local resources. However, the core principles — early recognition, timely antibiotics, appropriate fluid resuscitation, and ongoing reassessment — are universally accepted as the standard of care.

Common Allegations in Medical Malpractice Litigation

Pediatric sepsis cases in litigation typically involve one or more of the following allegations:

• Delayed recognition of sepsis. The most common allegation. Abnormal vital signs — tachycardia, tachypnea, prolonged capillary refill, altered mental status — were documented but not recognized as signs of sepsis. The child was diagnosed with a benign illness and discharged or left without further evaluation.
• Delayed antibiotic administration. Even when sepsis was eventually recognized, antibiotics were not administered within the recommended timeframe. Every hour of delay is associated with increased mortality.
• Failure to recognize abnormal vital signs. Vital signs were not interpreted in the context of age-appropriate norms. Tachycardia was attributed to fever or crying. Tachypnea was attributed to anxiety. Hypotension — a late and ominous sign in children — was the only trigger for intervention.
• Inadequate reassessment. A child was evaluated once and not reassessed despite ongoing or worsening symptoms. Sepsis is a dynamic process, and clinical status can change rapidly. Failure to reassess vital signs, perfusion, and clinical appearance after initial interventions is a common allegation.
• Failure to escalate care. Signs of clinical deterioration were present, but the child was not transferred to a higher level of care, a pediatric intensivist was not consulted, or ICU admission was delayed.
• Communication failures. Abnormal findings were not communicated between nursing staff and physicians, between shifts, or between facilities during transfer. Nursing notes documented concerning findings that were not acted upon by the treating physician.
• Discharge despite concerning findings. A child with documented abnormal vital signs, altered mental status, or signs of poor perfusion was discharged from the emergency department without adequate evaluation or treatment.
• Documentation deficiencies. Vital signs were not recorded at appropriate intervals. Reassessments were not documented. The clinical reasoning for disposition decisions was not recorded. Discharge instructions did not include specific return precautions.
• Failure to obtain cultures or lactate. Blood cultures and lactate measurement are recommended as part of the initial sepsis evaluation. Failure to obtain these studies can delay diagnosis, prevent identification of the causative organism, and limit the ability to guide antibiotic therapy.

Medical Causation

Causation is often the most contested element in pediatric sepsis litigation. The central question is: Would earlier recognition and treatment have changed the outcome?

Timing and the Natural Progression of Disease

Sepsis is a time-sensitive emergency. The evidence consistently demonstrates that delays in antibiotic administration are associated with increased mortality. However, causation analysis must account for the natural progression of the disease. Some children with overwhelming sepsis — particularly those with fulminant meningococcal disease or purpura fulminans — may deteriorate and die despite timely and appropriate treatment. In these cases, the intrinsic virulence of the organism and the host's immune response may determine the outcome regardless of the quality of care.

A prospective population-based study found a paradoxical association in which children who died from severe bacterial infections were actually less likely to have received suboptimal care than those who survived with sequelae — suggesting that in the most fulminant cases, the disease itself, rather than the quality of care, determined the fatal outcome. This finding is important for both plaintiffs and defendants: it underscores that not every death from sepsis represents a failure of care, but also that suboptimal care is strongly associated with preventable morbidity among survivors.

Probability Versus Possibility

In most jurisdictions, medical causation requires proof to a reasonable degree of medical probability — meaning that it is more likely than not that the alleged deviation from the standard of care caused or contributed to the injury. This is distinct from mere possibility. Expert testimony must establish that earlier intervention would have, more probably than not, altered the outcome.

Neurologic Injury

Septic shock causes inadequate perfusion of the brain and other organs. Prolonged hypoperfusion can result in watershed infarcts, hypoxic-ischemic encephalopathy, and permanent neurological injury. If a delay in recognition or treatment allowed a period of inadequate cerebral perfusion that would not have occurred with timely intervention, a causal link between the delay and the neurological injury may be established.

Multi-Organ Failure

Sepsis can progress to multi-organ dysfunction syndrome (MODS), involving the cardiovascular, respiratory, renal, hepatic, neurological, and coagulation systems. The development and severity of organ dysfunction are directly related to the duration and severity of sepsis. Earlier intervention — particularly fluid resuscitation, antibiotics, and vasoactive support — can prevent or mitigate organ dysfunction.

Death

When a child dies from sepsis, causation analysis must determine whether earlier treatment would have, more probably than not, prevented the death. This requires consideration of the specific organism, the child's baseline health, the severity of illness at presentation, and the expected response to timely treatment. Population-level data showing that delayed antibiotics are associated with increased mortality provide important context, but causation must ultimately be assessed on the facts of the individual case.

Common Misconceptions

• "Normal blood pressure excludes shock." This is perhaps the most dangerous misconception in pediatric emergency care. Children maintain blood pressure through compensatory mechanisms — tachycardia and vasoconstriction — until those mechanisms are exhausted. By the time blood pressure drops, the child is in decompensated shock and may be near cardiac arrest. Tachycardia, prolonged capillary refill, mottled skin, and altered mental status are the early signs of shock in children — not hypotension.
• "Fever is required for sepsis." False. While fever is common, some children with sepsis present with hypothermia (abnormally low temperature), which is actually associated with worse outcomes. Others may have a normal temperature at the time of evaluation. The absence of fever does not exclude sepsis.
• "Well-appearing children cannot deteriorate rapidly." Children with early sepsis may initially appear relatively well — interactive, alert, and feeding. This can create a false sense of reassurance. The transition from compensated to decompensated shock can occur within hours or even minutes. Clinical appearance at a single point in time does not predict the trajectory of illness.
• "Normal laboratory values exclude serious infection." Initial laboratory studies — including white blood cell count, C-reactive protein, and procalcitonin — may be normal early in the course of sepsis. These markers take time to rise. A normal initial result does not exclude the possibility of a serious bacterial infection, particularly if the clinical presentation is concerning.
• "A positive viral test rules out bacterial infection." Viral and bacterial infections can coexist. Identification of a viral pathogen does not eliminate the need for bacterial evaluation when clinical signs of sepsis are present.

Long-Term Outcomes

The consequences of pediatric sepsis extend far beyond the acute hospitalization. Attorneys evaluating damages should be aware of the full spectrum of long-term morbidity:

Mortality Beyond Hospitalization

In-hospital mortality is only part of the picture. The Life After Pediatric Sepsis Evaluation (LAPSE) study — a landmark prospective study across 12 U.S. academic PICUs — found that among 389 children with community-acquired septic shock, in-hospital mortality was 9%, but by 12 months after PICU admission, 13% had died. This means that a significant proportion of deaths occur after hospital discharge.

Health-Related Quality of Life

Among survivors in the LAPSE study, 35% had not regained their baseline health-related quality of life at 1 year after hospitalization. At 3 months, 42% of survivors had been readmitted to the hospital, 47% had visited an emergency department, 51% had started a new class of medication, and 33% were using a new medical device.

Neurocognitive Impairment

Children surviving septic shock are at significant risk for cognitive deficits. Studies have documented impairments in pattern recognition memory, executive functioning, attention, visual processing speed, and vocabulary. These deficits can affect academic performance, with high rates of difficulties in attention and completion of school work. In a large population-based study in Australia and New Zealand, children who survived septic shock had higher rates of failure to meet minimal academic requirements at primary school age compared with other PICU survivors and matched peers.

Limb Loss and Orthopedic Sequelae

Purpura fulminans — a devastating complication of septic shock characterized by widespread microvascular thrombosis — can result in extensive tissue necrosis requiring amputation. In a long-term follow-up study of children who survived meningococcal septic shock, 8% required amputation of one or more extremities, and 48% had significant skin scarring. Among children with purpura fulminans specifically, amputation rates are substantially higher. A study of 48 children surviving meningococcal purpura fulminans found that the mean number of surgical procedures required was 4.4 per patient, with amputations ranging from a single toe to bilateral legs and one arm. Twenty-seven percent had developmental delay at follow-up.

Hearing Loss

Hearing loss is a well-documented complication of bacterial meningitis and sepsis, occurring in up to 5% of all invasive meningococcal disease survivors and at higher rates in those with meningitis.

Chronic Organ Dysfunction

Nineteen percent of pediatric sepsis survivors develop a new or progressive organ dysfunction — including respiratory failure, seizure disorder, nutritional dependence, or chronic kidney disease — within 6 months of hospital discharge.

Psychological Impact

Both children and their families are profoundly affected. Prolonged periods of moderate-to-high distress after discharge are common among caregivers. Parental post-traumatic stress disorder and other mental health conditions can negatively affect parents' ability to support their children through recovery.

Damages Categories

Damages in pediatric sepsis cases may include:

• Lifelong medical costs — including rehabilitation, prosthetics, neurology, audiology, and specialty follow-up.
• Prosthetic limbs and adaptive equipment — often requiring multiple replacements throughout childhood and adulthood.
• Neurodevelopmental and educational services — speech therapy, occupational therapy, physical therapy, special education, behavioral health.
• Reduced earning capacity — related to cognitive, sensory, motor, or physical impairments.
• Reduced life expectancy — particularly in cases with severe organ dysfunction.
• Pain and suffering — including the burden of repeated hospitalizations, surgeries, and chronic disability.
• Wrongful death — in cases where delayed treatment results in mortality.
• Loss of parental consortium — the impact on the parent-child relationship.
• Caregiver costs — the economic and emotional burden on families providing long-term care.

Medical Records That Matter

Thorough case evaluation in pediatric sepsis litigation depends on careful review of the following:

• Triage notes — the initial assessment, including chief complaint, vital signs, and triage acuity level. Triage is often the first opportunity to identify a child at risk for sepsis, and the assigned acuity level determines how quickly the child is seen.
• Nursing documentation — nurses often document vital signs, clinical observations, and changes in condition more frequently and in greater detail than physicians. Nursing notes may reveal concerning findings — such as mottled skin, prolonged capillary refill, or parental concern about the child's behavior — that were not reflected in the physician's assessment.
• Vital-sign trends — a single set of vital signs provides limited information. The trend over time — worsening tachycardia, rising respiratory rate, declining mental status — is often more informative than any individual measurement. Failure to obtain serial vital signs is itself a potential deviation from the standard of care.
• Reassessment documentation — was the child reassessed after initial interventions? Were vital signs rechecked after fluid boluses? Was clinical improvement or deterioration documented?
• Medication timing — the exact time antibiotics were ordered, prepared, and administered. The interval between recognition of sepsis and first dose of antibiotics is often a central element in causation analysis.
• Laboratory timing — when blood cultures, lactate, and other studies were ordered and resulted. Were results reviewed and acted upon in a timely manner?
• Blood and other culture results — identification of the causative organism, antibiotic sensitivities, and whether empiric antibiotic coverage was appropriate.
• Consultant notes — was a pediatric intensivist, infectious disease specialist, or surgeon consulted? When? What were their recommendations?
• ICU documentation — detailed records of resuscitation efforts, vasoactive medication doses, ventilator settings, fluid balance, and organ function assessments.
• Discharge instructions — were specific return precautions documented? Were they provided in writing and in the family's primary language? Did they include instructions to return for worsening fever, altered mental status, poor feeding, or rash?
• Transfer records — if the child was transferred between facilities, were vital signs and clinical status communicated accurately? Was there a delay in transfer?

The Role of Pediatric Expertise

Pediatric sepsis differs fundamentally from adult sepsis in its presentation, physiology, and management. Attorneys handling pediatric sepsis cases should understand why pediatric-specific expertise is essential:

• Age-specific vital sign interpretation. Normal heart rate, respiratory rate, and blood pressure vary dramatically by age in children. What constitutes tachycardia in a 2-year-old is different from tachycardia in a 12-year-old. Experts evaluating the standard of care must be familiar with pediatric-specific vital sign norms.
• Compensated shock recognition. The concept of compensated shock — maintaining blood pressure through tachycardia and vasoconstriction while organs are being damaged — is a pediatric-specific phenomenon that is less prominent in adults. Experts must understand this physiology to evaluate whether shock was recognized appropriately.
• Pediatric-specific guidelines. The Surviving Sepsis Campaign publishes separate guidelines for children and adults. The fluid resuscitation volumes, antibiotic timing recommendations, vasoactive medication choices, and monitoring parameters differ between the two populations. An expert applying adult sepsis standards to a pediatric case may reach incorrect conclusions.
• Developmental considerations. Assessing mental status in a preverbal infant is fundamentally different from assessing an adult. Recognizing subtle signs of illness in a child who cannot articulate symptoms requires pediatric training and experience.
• Causation analysis. Understanding the natural history of pediatric sepsis, the expected response to timely treatment, and the known outcomes of delayed diagnosis requires familiarity with the pediatric sepsis literature. An expert who primarily treats adults may not be equipped to provide accurate causation opinions in a pediatric case.

An experienced pediatric expert can assist attorneys by interpreting the medical record in the context of current evidence-based guidelines, identifying deviations from the standard of care, evaluating causation, and explaining complex medical concepts in language accessible to judges and juries.

Key Takeaways for Attorneys

1. Pediatric sepsis is common and deadly. More than 18,000 children are hospitalized with sepsis annually in the United States, with approximately 1,800 deaths. Sepsis is present in nearly 1 in 5 pediatric hospitalizations that end in death.
2. Sepsis is a time-sensitive emergency. Delays in antibiotic administration are directly associated with increased mortality. Current guidelines recommend antibiotics within 1 hour for septic shock and within 3 hours for sepsis without shock.
3. Normal blood pressure does not exclude shock in children. Children compensate for inadequate perfusion by increasing heart rate and constricting blood vessels. Tachycardia, prolonged capillary refill, mottled skin, and altered mental status are the early warning signs — not hypotension.
4. "The child looked well" is not a defense. Children with early sepsis often appear relatively well. The standard of care requires clinicians to act on objective findings — vital signs, perfusion markers, and clinical trajectory — not solely on subjective clinical appearance.
5. Suboptimal care is common and consequential. Studies show that 34% of children with severe bacterial infections receive suboptimal initial care, and suboptimal care is strongly associated with preventable sequelae including amputation, neurological impairment, and hearing loss.
6. The consequences of missed or delayed diagnosis can be catastrophic and lifelong. Thirty-five percent of children surviving septic shock have not regained their baseline quality of life at 1 year. Complications include limb amputation, cognitive impairment, hearing loss, chronic organ dysfunction, and death.
7. Current guidelines provide a clear framework for evaluating the standard of care. The Surviving Sepsis Campaign guidelines — most recently updated in 2026 — define evidence-based expectations for recognition, antibiotic timing, fluid resuscitation, and ongoing management. While they acknowledge the role of clinical judgment, the core principles are widely accepted.
8. Vital-sign trends matter more than single measurements. A single set of normal vital signs does not exclude sepsis. Serial assessment and reassessment — particularly after interventions — is a fundamental component of the standard of care.
9. Nursing documentation is often the most important part of the medical record. Nurses frequently document vital signs, clinical observations, and changes in condition in greater detail than physicians. Discrepancies between nursing observations and physician assessments are often central to litigation.
10. Pediatric expertise is essential. Pediatric sepsis differs from adult sepsis in presentation, physiology, and management. Evaluating the standard of care and causation in pediatric sepsis cases requires expertise in pediatric medicine, not simply emergency medicine or adult critical care.