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Assessment of a child under 5 years with suspected sepsis

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Sepsis

About

What is covered

This pathway covers the identification, early assessment, risk stratification and management of sepsis for children and adults. It also covers the identification of the source of infection.
Sepsis is a clinical syndrome caused by the body's immune and coagulation systems being switched on by an infection. Sepsis with shock is a life-threatening condition that is characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure. Sepsis has recently been highlighted as being a leading cause of avoidable death that kills more people than breast, bowel and prostate cancer combined.
Sepsis is difficult to diagnose with certainty. The signs and symptoms of sepsis can be very non-specific and can be missed if clinicians do not think 'could this be sepsis?'.
To reduce avoidable deaths, people with sepsis need to be recognised early and treatment initiated. This guideline aims to ensure healthcare systems in all clinical settings consider sepsis as an immediate life-threatening condition that should be recognised and treated as an emergency. The guideline outlines the immediate actions needed for those with suspicion of sepsis and who are at highest risk of morbidity and mortality from sepsis. It provides a framework for risk assessment, treatment and follow-up or 'safety-netting' of people not needing immediate resuscitation. The intention of this guideline is to ensure that all people with sepsis due to any cause are recognised and initial treatment started before definitive treatment is put in place.

Updates

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on the recognition, diagnosis and early management of sepsis in an interactive flowchart.

What is covered

This pathway covers the identification, early assessment, risk stratification and management of sepsis for children and adults. It also covers the identification of the source of infection.
Sepsis is a clinical syndrome caused by the body's immune and coagulation systems being switched on by an infection. Sepsis with shock is a life-threatening condition that is characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure. Sepsis has recently been highlighted as being a leading cause of avoidable death that kills more people than breast, bowel and prostate cancer combined.
Sepsis is difficult to diagnose with certainty. The signs and symptoms of sepsis can be very non-specific and can be missed if clinicians do not think 'could this be sepsis?'.
To reduce avoidable deaths, people with sepsis need to be recognised early and treatment initiated. This guideline aims to ensure healthcare systems in all clinical settings consider sepsis as an immediate life-threatening condition that should be recognised and treated as an emergency. The guideline outlines the immediate actions needed for those with suspicion of sepsis and who are at highest risk of morbidity and mortality from sepsis. It provides a framework for risk assessment, treatment and follow-up or 'safety-netting' of people not needing immediate resuscitation. The intention of this guideline is to ensure that all people with sepsis due to any cause are recognised and initial treatment started before definitive treatment is put in place.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Signs and symptoms of sepsis by risk level for adults and young people aged 12 years and over

Category
High risk criteria
Moderate to high risk criteria
Low risk criteria
History
Objective evidence of new altered mental state
History from patient, friend or relative of new onset of altered behaviour or mental state
History of acute deterioration of functional ability
Impaired immune system (illness or drugs including oral steroids)
Trauma, surgery or invasive procedures in the last 6 weeks
Normal behaviour
Respiratory
Raised respiratory rate 25 breaths per minute or more
New need for oxygen (more than 40% FiO2) to maintain saturation more than 92% (or more than 88% in known chronic obstructive pulmonary disease)
Raised respiratory rate 21–24 breaths per minute
No high risk or moderate to high risk criteria met
Blood pressure
Systolic blood pressure 90 mmHg or less or systolic blood pressure more than 40 mmHg below normal
Systolic blood pressure 91–100 mmHg
No high risk or moderate to high risk criteria met
Circulation and hydration
Raised heart rate: more than 130 beats per minute
Not passed urine in previous 18 hours.
For catheterised patients, passed less than 0.5 ml/kg of urine per hour
Raised heart rate: 91–130 beats per minute (for pregnant women 100 -130 beats per minute) or new onset arrhythmia
Not passed urine in the past 12–18 hours
For catheterised patients, passed 0.5–1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Temperature
-
Tympanic temperature less than 36ºC
-
Skin
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Signs of potential infection, including redness, swelling or discharge at surgical site or breakdown of wound
No non-blanching rash

Information at discharge for people assessed for possible sepsis, but not diagnosed with sepsis

Give people who have been assessed for sepsis but have been discharged without a diagnosis of sepsis (and their family or carers, if appropriate) verbal and written information about:
  • what sepsis is, and why it was suspected
  • what tests and investigations have been done
  • instructions about which symptoms to monitor
  • when to get medical attention if their illness continues
  • how to get medical attention if they need to seek help urgently.
Confirm that people understand the information they have been given, and what actions they should take to get help if they need it.

Identify the source of infection

Carry out a thorough clinical examination to look for sources of infection, including sources that might need surgical drainage, as part of the initial assessment.
Tailor investigations of the sources of infection to the person's clinical history and findings on examination.
Consider urine analysis and chest X-ray to identify the source of infection in all people with suspected sepsis.
Consider imaging of the abdomen and pelvis if no likely source of infection is identified after clinical examination and initial tests.
Involve the adult or paediatric surgical and gynaecological teams early on if intra-abdominal or pelvic infection is suspected in case surgical treatment is needed.
Do not perform a lumbar puncture without consultant instruction if any of the following contraindications are present:
  • signs suggesting raised intracranial pressure or reduced or fluctuating level of consciousness (Glasgow Coma Scale score less than 9 or a drop of 3 points or more)
  • relative bradycardia and hypertension
  • focal neurological signs
  • abnormal posture or posturing
  • unequal, dilated or poorly responsive pupils
  • papilloedema
  • abnormal 'doll's eye' movements
  • shock
  • extensive or spreading purpura
  • after convulsions until stabilised
  • coagulation abnormalities or coagulation results outside the normal range or platelet count below 100x109/litre or receiving anticoagulant therapy
  • local superficial infection at the lumbar puncture site
  • respiratory insufficiency in children.
Perform lumbar puncture in the following children with suspected sepsis (unless contraindicated, please see contraindications in the above recommendation):
  • infants younger than 1 month
  • all infants aged 1–3 months who appear unwell
  • infants aged 1–3 months with a white blood cell count less than 5×109/litre or greater than 15×109/litre.
Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in adults and young people with acute illness if sepsis is likely or present. (For more information see children and young people with acute illness and adults with acute illness in the NICE pathway on acute kidney injury.)
Ensure urgent assessment mechanisms are in place to deliver antibiotics when high risk criteria are met in secondary care (within 1 hour of meeting a high risk criterion in an acute hospital setting).
Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in location where transfer time is more than 1 hour.
For patients in hospital who have suspected infections, take microbiological samples before prescribing an antimicrobial and review the prescription when the results are available. For people with suspected sepsis take blood cultures before antibiotics are given.
If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings.
For all people with suspected sepsis where the source of infection is clear use existing local antimicrobial guidance.
Investigate for acute kidney injury, by measuring serum creatinine and comparing with baseline, in children with acute illness if sepsis is likely or present. (For more information see children and young people with acute illness in the NICE pathway on acute kidney injury.)

Information and support for people with sepsis, their families and carers

Ensure a care team member is nominated to give information to families and carers, particularly in emergency situations such as in the emergency department. This should include:
  • an explanation that the person has sepsis, and what this means
  • an explanation of any investigations and the management plan
  • regular and timely updates on treatment, care and progress.
Ensure information is given without using medical jargon. Check regularly that people understand the information and explanations they are given.
Give people with sepsis and their family members and carers opportunities to ask questions about diagnosis, treatment options, prognosis and complications. Be willing to repeat any information as needed.
Give people with sepsis and their families and carers information about national charities and support groups that provide information about sepsis and the causes of sepsis.
For people aged up to 17 years (except neonates) with suspected community acquired sepsis of any cause give ceftriaxone 80 mg/kg once a day with a maximum dose of 4g daily at any age.
For people aged up to 17 years with suspected sepsis who are already in hospital, or who are known to have previously been infected with or colonised with ceftriaxone-resistant bacteria, consult local guidelines for choice of antibiotic.
Follow the recommendations in the NICE pathway on antimicrobial stewardship when prescribing and using antibiotics to treat people with suspected or confirmed sepsis.

Discharge information

Ensure people and their families and carers if appropriate have been informed that they have had sepsis.
Ensure discharge notifications to GPs include the diagnosis of sepsis.
Give people who have had sepsis (and their families and carers, when appropriate) opportunities to discuss their concerns. These may include:
  • why they developed sepsis
  • whether they are likely to develop sepsis again
  • if more investigations are necessary
  • details of any community care needed, for example, related to peripherally inserted central venous catheters (PICC) lines or other intravenous catheters
  • what they should expect during recovery
  • arrangements for follow-up including specific critical care follow-up if appropriate
  • possible short-term and long-term problems.
Give people who have had sepsis and their families and carers information about national charities and support groups that provide information about sepsis and causes of sepsis.
Advise carers they have a legal right to have a carer's assessment of their needs, and give them information on how they can get this.
See the NICE pathway on bacterial meningitis and meningococcal septicaemia for recommendations on the follow-up of people who have had meningococcal septicaemia.

Signs and symptoms of sepsis by risk level for children aged 5–11 years

Category
Age
High risk criteria
Moderate to high risk criteria
Low risk criteria
Behaviour
Any
Objective evidence of altered behaviour or mental state
Appears ill to a healthcare professional
Does not wake or if roused does not stay awake
Not behaving normally
Decreased activity
Parent or carer concern that the child is behaving differently from usual
Behaving normally
Respiratory
Any
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
No high risk or moderate to high risk criteria met
Aged 5 years
Raised respiratory rate: 29 breaths per minute or more
Raised respiratory rate: 24–28 breaths per minute
Aged 6–7 years
Raised respiratory rate: 27 breaths per minute or more
Raised respiratory rate: 24–26 breaths per minute
Aged 8–11 years
Raised respiratory rate: 25 breaths per minute or more
Raised respiratory rate: Aged 8–11 years, 22–24 breaths per minute
Circulation and hydration
Any
Heart rate less than 60 beats per minute
Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1ml/kg of urine per hour
Oxygen saturation of less than 92% in air or increased oxygen requirement over baseline
No high risk or moderate to high risk criteria met
Aged 5 years
Raised heart rate: 130 beats per minute or more
Raised heart rate: Aged 5 years, 120–129 beats per minute
Aged 6–7 years
Raised heart rate: 120 beats per minute or more
Raised heart rate: 110–119 beats per minute
Aged 8–11 years
Raised heart rate: 115 beats per minute or more
Raised heart rate: 105–114 beats per minute
Skin
Any
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Other
Any
Leg pain
Cold hands or feet
No high or moderate to high risk criteria met
There is currently insufficient evidence to recommend the routine adoption in the NHS of the LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay for rapidly identifying bloodstream bacteria and fungi. The tests show promise and further research to provide robust evidence is encouraged, particularly to demonstrate the value of using the test results in clinical decision-making (see sections 5.18 to 5.22 of NICE diagnostics guidance 20).
The following recommendation is from NICE diagnostics guidance on procalcitonin testing for diagnosing and monitoring sepsis.
The procalcitonin tests (ADVIA Centaur BRAHMS PCT assay, BRAHMS PCT Sensitive Kryptor assay, Elecsys BRAHMS PCT assay, LIAISON BRAHMS PCT assay and VIDAS BRAHMS PCT assay) show promise but there is currently insufficient evidence to recommend their routine adoption in the NHS. Further research on procalcitonin tests is recommended for guiding decisions to:
  • stop antibiotic treatment in people with confirmed or highly suspected sepsis in the intensive care unit or
  • start and stop antibiotic treatment in people with suspected bacterial infection presenting to the emergency department.
Centres currently using procalcitonin tests to guide these decisions are encouraged to participate in research and data collection (see section 6.25 of NICE diagnostics guidance 18).
See the NICE pathway on rehabilitation after critical illness in adults for recommendations on rehabilitation and follow-up after critical illness.
Pre-alert secondary care (through GP or ambulance service) when high risk criteria are met in a person with suspected sepsis outside of an acute hospital, and transfer them immediately.
Reassess the patient after completion of the intravenous fluid bolus, and if no improvement give a second bolus. If there is no improvement after a second bolus alert a consultant to attend.
Do not use starch based solutions or hydroxyethyl starches for fluid resuscitation for people with sepsis
Consider human albumin solution 4–5% for fluid resuscitation only in patients with sepsis and shock.

Manage the condition while awaiting transfer

Ensure GPs and ambulance services have mechanisms in place to give antibiotics for people with high risk criteria in pre-hospital settings in locations where transfer time is more than 1 hour.
If meningococcal disease is specifically suspected (fever and purpuric rash) give appropriate doses of parenteral benzyl penicillin in community settings and intravenous ceftriaxone in hospital settings.
Use a pump, or syringe if no pump is available, to deliver intravenous fluids for resuscitation to children under 12 years with suspected sepsis who need fluids in bolus form.
Assess all people with suspected sepsis outside acute hospital settings with any moderate to high risk criteria to:
  • make a definitive diagnosis of their condition
  • decide whether they can be treated safely outside hospital.
If a definitive diagnosis is not reached or the person cannot be treated safely outside an acute hospital setting, refer them urgently for emergency care.
If children and young people up to 16 years need intravenous fluid resuscitation, use glucose-free crystalloids that contain sodium in the range 130–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes. Take into account pre-existing conditions (for example, cardiac disease or kidney disease), because smaller fluid volumes may be needed.

Signs and symptoms of sepsis by risk level for children aged under 5 years

Category
Age
High risk criteria
Moderate to high risk criteria
Low risk criteria
Behaviour
Any
No response to social cues
Appears ill to a healthcare professional
Does not wake, or if roused does not stay awake
Weak high-pitched or continuous cry
Not responding normally to social cues
No smile
Wakes only with prolonged stimulation
Decreased activity
Parent or carer concern that child is behaving differently from usual
Responds normally to social cues
Content or smiles
Stays awake or awakens quickly
Strong normal cry or not crying
Respiratory
Any
Grunting
Apnoea
Oxygen saturation of less than 90% in air or increased oxygen requirement over baseline
Oxygen saturation of less than 91% in air or increased oxygen requirement over baseline
Nasal flaring
No high risk or moderate to high risk criteria met
Under 1 year
Raised respiratory rate: 60 breaths per minute or more
Raised respiratory rate: 50–59 breaths per minute
1–2 years
Raised respiratory rate: 50 breaths per minute or more
Raised respiratory rate: 40–49 breaths per minute
3–4 years
Raised respiratory rate: 40 breaths per minute or more
Raised respiratory rate: 35–39 breaths per minute
Circulation and hydration
Any
Bradycardia: heart rate less than 60 beats per minute
Capillary refill time of 3 seconds or more
Reduced urine output
For catheterised patients, passed less than 1 ml/kg of urine per hour
No high risk or moderate to high risk criteria met
Under 1 year
Rapid heart rate: 160 beats per minute or more
Rapid heart rate: 150–159 beats per minute
1–2 years
Rapid heart rate: 150 beats per minute or more
Rapid heart rate: 140–149 beats per minute
3–4 years
Rapid heart rate: 140 beats per minute or more
Rapid heart rate: 130–139 beats per minute
Skin
Any
Mottled or ashen appearance
Cyanosis of skin, lips or tongue
Non-blanching rash of skin
Normal colour
Temperature
Any
Temperature less than 36ºC
Under 3 months
Temperature 38ºC or more
3–6 months
Temperature 39ºC or more
Other
Any
Leg pain
Cold hands or feet
No high risk or high to moderate risk criteria met
Provide people with suspected sepsis who do not have any high or moderate to high risk criteria information about symptoms to monitor and how to access medical care if they are concerned.
If sepsis is definitely excluded, see other NICE Pathways.
Oxygen should be given to children with suspected sepsis who have signs of shock or oxygen saturation (SpO2) of less than 92% when breathing air. Treatment with oxygen should also be considered for children with an SpO2 of greater than 92%, as clinically indicated.

Glossary

(for definition of acute kidney injury, see the NICE pathway on acute kidney injury)
a medically qualified practitioner who has antibiotic prescribing responsibilities
An intensivist or intensive care outreach team, or specialist in intensive care or paediatric intensive care
emergency care requires facilities for resuscitation to be available and depending on local services may be emergency department, medical admissions unit and for children may be paediatric ambulatory unit or paediatric medical admissions unit
(a senior decision maker for people aged 18 years or over should be someone who is authorised to prescribe antibiotics, such as a doctor of grade CT3/ST3 or above or equivalent, such as an advanced nurse practitioner with antibiotic prescribing responsibilities, depending on local arrangements; a senior clinical decision maker for people aged under 17 years is a paediatric or emergency care qualified doctor of grade ST4 or above or equivalent)
(a senior clinical decision maker for people aged under 17 years is a paediatric qualified doctor of grade ST4 or above or equivalent)
sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection – 'suspected sepsis' is used to indicate people who might have sepsis and require face to face assessment and consideration of urgent intervention –

Paths in this pathway

Pathway created: July 2016 Last updated: July 2016

© NICE 2017

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