Sepsis survival rates for kids improve in New York state

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Sepsis is a medical emergency in which your body overreacts to an infection. Today we'll learn about sepsis in children from Dr. Melissa Schafer. She is director of pediatric hospital medicine at Upstate Golisano Children's Hospital.

Welcome to "The Informed Patient," Dr. Schafer.

Melissa Schafer, MD: Thank you so much for having me.

Host Amber Smith: Now, how do you describe or define sepsis to patients' families?

Melissa Schafer, MD: Sepsis in children is the body's response to an infection. We see that in children, of course, very frequently. They get illnesses commonly, but sepsis is one level beyond that. So sepsis is when your body's response to the infection starts having compromise in the internal organs, things like kidneys having trouble keeping up with the blood flow that they need to fight the infection, liver, brain and then, ultimately, cardiovascular.

So complications from an infection that affect the rest of the body is more what sepsis is getting at, not just any infection that comes with a fever.

Host Amber Smith: I was going to ask you what kinds of infections. Could it be like a sore throat that goes out of control, or what kind of infections are we talking about?

Melissa Schafer, MD: It can actually be any infection. Most of the time when we're talking about pediatric sepsis, we're thinking complications of a bacterial infection, but it can be viral, fungal, parasitic, although that's unusual. It can be any infection.

Host Amber Smith: Now, does sepsis go by other names that people may have heard? I've heard people call it a blood infection or septicemia. Is that the same thing?

Melissa Schafer, MD: Those are the same thing. I think we're moving away from those terms a little bit, but yes, a blood infection or septicemia, those would be terms that we use, too.

In children, we don't always, well, in adults too, we don't always find the bacteria in the bloodstream that's causing the blood infection. But if we see that there is an infection, the body's responding to it in a way that's having organ compromise, that's what we call sepsis, whether we are able to narrow down which bacteria's in the bloodstream or if it's just response to a viral or fungal infection, which can happen, too.

Host Amber Smith: What age children does sepsis generally affect?

Melissa Schafer, MD: So it can be any age. Children that are less than 60 days old are more susceptible to infection. And you'll find when you take home a newborn baby that your pediatrician will tell you any fever in a child this age needs to be checked out right away.

And we still give that advice because they are more susceptible to infection when they're newborns, but children of any age can have a bad infection. School-age and teenagers also can have a more complex infection. And a lot of the work that's been done in New York state came from the advocacy of the family of Rory Staunton, who was a teenager who passed away from sepsis, unfortunately, in 2012, in New York City.

And so his family was huge advocates for pediatric sepsis awareness and protocols to treat sepsis in hospitals. So a lot of the work that Upstate has done and other hospitals across New York was as a result of his family's advocacy. And he was a teenager, so it can happen at any age. And he is a very well-known example. And you can find articles in The New York Times about his story and what his family has done. And it's really been very helpful to bring sepsis awareness more into the public eye.

Host Amber Smith: And sepsis can affect adults, too. Is it a different disease in an adult than in a child?

Melissa Schafer, MD: It's not. It can look a little bit different because adults have lived longer, and their organs have been through more days and more time, so the body's response is a little bit different, but any infection in any age can be a problem and turn into sepsis.

Our immune system is our first line of defense to fight off any infection. And so the young, robust immune system that children have helps it not turn into sepsis, more just a self-limited infection, when you're younger. And then, same as newborns and the very older age group, they have the same limitations of the immune system, just being much older and having more trouble dealing with infections.

Host Amber Smith: Can you tell us how sepsis typically develops? I know that the person or the child has an underlying infection to start with, but when does it become, or how does it become, sepsis?

Melissa Schafer, MD: It's actually fascinating. A little nerdy, but fascinating. So, when your immune system gets revved up to kick off fighting this infection, it creates something called cytokines, which are proteins that your body's making to try and identify and fight off the infection.

One of the things that the cytokines do is it makes your blood vessels a little bit leaky. It's actually called capillary leak syndrome, where the fluid that's in your bloodstream will go to the site of infection to try and fight it off.

You have an infection in your thumbnail, your thumb gets swollen. That's your body creating the cytokines, having a little bit of that capillary leak, where the immune response goes to the place where it's needed. When that response is very, very robust, and it goes throughout the whole body and becomes overwhelming, you have complications leading to the organ damage, like I was talking about and, ultimately, septic shock.

So septic shock is when the amount of fluid left in the bloodstream is not enough to support your organ function because of those cytokines being so robust and being a little bit leaky.

So as a parent and as a physician, the things that we're asking folks to look for is, are they peeing OK? Are they acting OK? Those are signs that those organs are having enough fluids to be able to sustain the fight against the infection. And you'll often hear the advice, it's OK to give Tylenol and try and get them to take as much fluids as they can. And again, that's trying to help the body fight off the infection and help the body have what it needs to be able to sustain itself while the immune system does its thing.

Host Amber Smith: And it is a medical emergency.

Melissa Schafer, MD: It is a medical emergency, yes, especially when you are seeing that if the child isn't acting right or if they're not peeing well, usually they'll say, once in 12 hours, if they're not creating a diaper in that long, that's a time to get checked out by the doctor.

Or if any fever in a child under 60 days, which is around eight weeks,is a time to be checked out by a doctor

Host Amber Smith: And fever over 100 (degrees), or what is a fever?

Melissa Schafer, MD: Yeah, this is a great question that we have whole debates about for hours. I shouldn't bore you with it, but we do tell newborn parents, over 100.4.

And anyone with immune compromise over 100.4, and those folks will usually have doctors who will be in close contact to say your immune system is compromised and what you need to do about that.

Healthier children can have a higher fever at home and be just fine. I'm sure everyone has experienced a child with the flu or strep throat fighting off a high fever. As long as they're peeing OK, acting OK, and with some Tylenol, they're doing OK, there is no specific degree of fever that becomes worrisome. You would think there would be, but there actually isn't. And again, we've had debates and conferences about this as pediatricians, of like, "But isn't a certain threshold a problem?"

There are some well-known viruses that are self-limited infections that cause a very high fever. And as long as the child is OK with Tylenol and taking fluids and acting OK, that is perfectly fine to manage at home. So yes and no.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with pediatric hospital medicine chief Dr. Melissa Schafer about sepsis in children.

So beyond the fever, are there other signs or symptoms? How would a parent know that their child might be developing sepsis?

Melissa Schafer, MD: We do ask them to look for duration. If it just started, that's something you've got to let the immune system start to do its thing. It's doing it appropriately.

Infections that go on for longer are a reason to call your doctor, to check in, to make sure, is the child's body keeping up with what it needs to do. And then, is their brain acting OK? And are their kidneys acting OK? Or something that you can tell as a parent, did they pee today? Did they pee in the last 12 hours? And is their behavior normal or at least normal for when they're sick? Giving them a Tylenol and having them bounce right back to being playful and happy is a reassuring sign.

And then having them just be wiped out on the couch is a more concerning sign; they're really working through that infection, and it's time to talk to the doctor about what's going on.

Host Amber Smith: So what does a doctor do to diagnose sepsis?

Melissa Schafer, MD: Several things, actually. And that's where a lot of my quality improvement work has been focused.

Recognizing sepsis early is key, because then we're getting antibiotics and fluids into the kids who need them in a timely manner, and that's been the thing that's been shown to save lives most effectively. Identification is the biggest thing. And the ED (emergency department), the peds ED (pediatric emergency department), at Upstate has been wonderful working on how we can tell, based on lab values, vital signs and physical exam if a child is having sepsis or developing sepsis, or if this is something that they're just fighting off, and they're going to be OK without too much more medical support.

We use even more medical tools to sort of answer those questions of, is their fluid status OK? Are their organs keeping up with the need to fight the infection?

So we look at blood work. Your white blood cell count tells you about how revved up the immune system is. And if they obviously are fighting an infection, but their white blood cell count is low, that's actually a concerning sign. And there's some people out there who have other reasons to have white blood cell count being low, like they're on chemotherapy. Those ones are very susceptible to infection. And they actually need help fighting it off.

So being able to identify, is the immune system fighting appropriately? Does it need help? We use the labs and the exam and the vital signs and blood cultures to be able to tell what's going on and if they need help or if their body's doing it appropriately.

Host Amber Smith: You said the pediatric "ED"; that's the emergency department at the hospital.

Melissa Schafer, MD: The emergency department, yes.

Host Amber Smith: Gotcha. Now, are you able to predict which patients are at greater risk for sepsis?

Melissa Schafer, MD: The ones whose immune systems are not as robust and healthy. So the younger age group, under 60 days, and then children on chemotherapy or have other reasons to have immune suppression, organ transplant patients. And we actually have, even in Central New York, a community of people who have congenital immune system problems that are managed by our infectious disease team. They're not on chemotherapy, but they're always going to have trouble fighting an infection. And they've got to be in really close contact with their doctor when they're having any sign that their body's needing help with that.

Host Amber Smith: We've talked about how there's an underlying infection or illness before sepsis develops. Could this be from an infection, from a cut?

Melissa Schafer, MD: The case I mentioned, Rory Staunton, and his family was big advocates, it's been reported that his source of infection was a scrape on his arm that allowed bacteria to enter his bloodstream.

So yes, and very famously, his family advocated that we recognize that more clearly when it does happen. So yes, any scrape can be a portal of entry for bacteria into the body.

Host Amber Smith: We're told that it's important to clean cuts and scrapes after they happen, or to get the antiseptic and clean it very well. So is that why? Because we don't want this to be an infection that rages out of control?

Melissa Schafer, MD: Yeah. Intact skin is actually one of our best immune barriers and an underappreciated one. So yeah, keeping any scrape, cut or burn clean, and keep an eye on it as it heals to look for any signs of developing infection is important. Also, an under-recognized one is other rashes, like eczema, can create very small open wounds that, again, you need to be able to keep an eye on very closely and keep them clean as best you can.

Host Amber Smith: Can you walk us through what treatment for sepsis may involve in the hospital?

Melissa Schafer, MD: Yeah, absolutely. So this is one of the things that Rory's family advocated for, that hospitals across the state be able to deliver: Recognize, first of all, sepsis, as it's developing and deliver very timely antibiotics, fluids, and then check blood cultures to look for a bacterial bloodstream infection. That's the mainstay of the treatment.

And initially we thought being able to get that all in in the first hour was the thing that saved lives.

The first hour's really hard. There's a lot going on when you're first arriving to an emergency room or any health care setting. And further studies have shown that being able to recognize and act on it very quickly is the most important part, and that we probably have a looser time frame than the first hour.

And that even the first three hours, as long as we're assessing it, on top of it, is beneficial to survival and to your organ function.

Being quite so aggressive may actually not be quite as necessary, but having eyes on the patient and being able to assess what we're doing quickly is the key, and the treatment is fluids, antibiotics and finding out where the infection is.

Host Amber Smith: Are the patients generally alert when this is happening, or are they not?

Melissa Schafer, MD: Children actually are pretty well. Sometimes they'll be fussy, irritable, but being totally out of it? They're usually not. They're usually, actually, with it and able to participate in their care, which makes it hard because a lot of the things I just mentioned are delivered by IV (intravenously: through a needle in the arm).

So that means we have to put in an IV, and they're awake for that. But when it's necessary to support your organs and get you through your infection, we do it.

Host Amber Smith: Are there long-term problems to look out for after a child survives sepsis?

Melissa Schafer, MD: Absolutely. Depending on how long you're in the hospital ... It's hard to be in the hospital is basically what it comes down to. So people with severe sepsis, especially sepsis that needs to be treated in the ICU (intensive care unit) or in the hospital more than five or seven days, your body's working so hard just to fight that infection that you actually get out of shape a little bit, and just returning to normal walking, eating, school, all those normal things, it can take time.

There is a role for rehab. Upstate has a very robust pediatric physical medicine and rehab program, so we actually treat all of our rehab patients right on site, which is wonderful. So patients that end up going through a really long bout of sepsis, we have options for them and can get them back on their feet, but that can be really difficult and can take a lot of time.

Otherwise healthy children actually do pretty well with sepsis. Especially when they don't need to be in the hospital for very long. They're only in the hospital for a day or two and can transition to oral antibiotics, and their organs are right back to normal functioning. They generally do pretty well.

But when it takes a long time, and you've had some organ compromise, that can take a while to recover.

Host Amber Smith: I know in your role as the division chief of pediatric hospital medicine, you focus on quality improvement. How are we doing with pediatric sepsis?

Melissa Schafer, MD: So I mentioned Rory Staunton's family's advocacy, and there was a state regulation for hospitals that went into effect in 2014. Since then, they found that hospitals that are able to deliver that first round of antibiotics, get the fluid support on board, find out where the infection's coming from, that initial bundle, hospitals that are able to deliver that, their patients do very well and have improved mortality.

And we've been tracking that across New York state ever since, ever since 2014.

So we're very proud to, and this is all actually publicly reported information. so we're proud to report that in the last round of information that New York state reported, which was 2021, there were no pediatric sepsis mortalities from Central New York, which we're very excited about because we've been working on making sure that our hospital's able to deliver those care items, recognition, antibiotics, fluids, in a timely manner.

And it seems that we're able to do that, which is great.

Host Amber Smith: How has the Children's Hospital Association helped improve pediatric sepsis outcomes?

Melissa Schafer, MD: For pediatric care, a lot of quality improvement and data tracking happens at the state level because a lot of pediatric care is paid for by Medicaid, which is a state-delivered service.

So being able to have national data and national initiatives is something that sometimes can be hard for pediatrics. And so Children's Hospital Association was able to come in and gather together hospitals that were interested in working on their sepsis care. And they had a group together between 2017 and 2023 that worked on this. And they were able to improve pediatric sepsis, mortality and length of hospital stay for the hospitals that were participating in that initiative. And again, it was based on recognizing pediatric sepsis when the child shows up, however they show up, and delivering those antibiotics, fluids and determining the source of infection in a timely manner. Same core principles, just on a wider scale across the country.

And so that was very exciting because previous to that, initiatives had been limited to more local, or ED only, sort of collaborations.

Host Amber Smith: Well, Dr. Schafer, I want to thank you for making time for this interview.

Melissa Schafer, MD: Thank you so much for having me.

Host Amber Smith: My guest has been pediatrician Melissa Schafer, who is the director of pediatric hospital medicine at Upstate Golisano Children's Hospital.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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