When Fever Hides Fire: A Systematic Review of Clinical and Digital Approaches to Early Recognition of Pediatric Sepsis.

Early recognition of pediatric sepsis remains challenging because clinical presentation, sepsis definitions, and recognition approaches vary across healthcare settings. This systematic review evaluated clinical and digital strategies for the early recognition of pediatric sepsis, including structured screening tools, electronic alerts, prediction models, machine-learning approaches, clinical decision support, and recognition pathways. Diagnostic criteria were considered separately as reference frameworks for classifying established sepsis and interpreting the performance of recognition tools. PubMed and Scopus were systematically searched, eligible studies were independently screened, data were extracted, and methodological quality and risk of bias were assessed using design-appropriate tools. Because of substantial clinical and methodological heterogeneity, the evidence was synthesized narratively. A total of 13 studies were included. Several clinical and digital approaches generally performed well in ruling out sepsis among low-risk children; however, their ability to identify true cases and limit unnecessary alerts varied according to alert thresholds, clinical settings, and the sepsis definition or reference standard used. No single approach was consistently superior for early recognition. Automated screening appeared most useful when integrated with structured clinical assessment rather than used independently. Differences in pediatric sepsis definitions substantially influenced reported performance, and implementation studies more consistently demonstrated improvements in recognition and care processes than in patient outcomes. The available evidence was limited by heterogeneous methods, imperfect reference standards, insufficient external validation, and risk of bias. Clinical and digital recognition systems may support earlier identification of children with suspected infection who require further assessment; however, current evidence does not establish a universally superior approach. Further prospective multicenter studies are needed to determine which strategies provide meaningful clinical benefit across diverse healthcare settings.