75% of cases of meningitis are
believed to occur in those <15yrs of age. Three organisms (Streptococcus pneumoniae, Neisseria meningitides (mainly group B
in the UK) and Haemophilus influenzae
type b) account for 80% of the cases. H.
influenzae and meningococcal group C
have declined very significantly since the introduction of routine immunization
Three important practice points to
do not get classical symptoms of meningism with meningitis and there should be
an extremely low threshold for doing a lumbar puncture as part of the septic
screen in infants with unexplained fever or seizures.
septicaemia in 20–30% is often the treatment priority to prevent death.
forget possibility of tuberculous meningitis.
The sequence of pathology
and invasion of the nasopharyngeal epithelium.
of the blood stream.
to and invasion of the meninges.
of inflammation with leak of proteins leading to cerebral oedema.
in cerebral blood flow and metabolism.
In younger children symptoms may
be non-specific including fever, poor feeding, lethargy. Rash and seizures may
or may not be present. In older children, fever with headache and neck
stiffness. Other features include:
General: fever, vomiting, and anorexia.
Central: irritability, disorientation,
altered mental state.
Seizures: occur in 30%. Focal seizures
suggest localized infarction or subdural
collection. Do not assume ‘febrile convulsion’ in child under 1yr of age or
over 1yr of age with additional symptoms.
Neck stiffness: more common in older children.
Neurology: focal cranial nerve signs are more
common in children with tuberculous
or cryptococcal meningitis.
Eyes: papilloedema is a late sign and
not a reliable indicator of raised intracranial pressure. Retinal hemorrhages
may be present and may indicate sagittal venous thrombosis or coagulopathy.
However, these are rare and in the infant the possibility of non-accidental or
inflicted head injury should be considered.
Lumbar puncture is a useful
procedure to make the diagnosis of meningitis and identify the organism and it
is generally safe. However, patients with bacterial meningitis may have raised
ICP so if there is a clinical suspicion of this problem (low heart rate with
raised blood pressure, often first sign of which are transient changes seen on
cardiac monitors) then the procedure
should be deferred. (The cellular
and chemical changes of meningitis will remain in the CSF for several days).
The contraindications are:
or cardiovascular instability;
of raised intracranial pressure
·focal neurological signs or focal
of the skin at the lumbar puncture site (rare);
Suspected cases of meningococcal
meningitis in the community should receive IV benzylpenicillin (IM if no IV
access) as an initial single dose.
Children 10yrs, 1g.
Suspected cases in hospital should
receive 80mg/kg/od ceftriaxone (or cefotaxime 50mg/kg/tds). A management
algorithm for health profession-als based on the NICE clinical guideline 102 is
available at M www.nice. org.uk/CG102
·Do note use corticosteroids in
children younger than 3mths
is benefit from the use of dexamethasone and the dosing schedule is 0.15mg/kg
qds for 4 days to reduce the severity of neurological sequelae, particularly
deafness, after bacterial meningitis (M www.nice.org.uk/CG102).
dexamethasone was not given before the first dose of antibiotics, but was
indicated, try to give the first dose within 4hr of starting antibiotics, but
do not start dexamethasone more than 12 hours after starting antibiotics.
·Do not use the meningitic dosing
children with shock that is not responding to fluids and inotropes,
physiological replacement of hydrocortisone (25mg/m2 qds) should be
considered after discussion with the intensive care team.