Meningitis In Children

Meningitis is inflammation of the meninges, most importantly caused by bacterial infection in the acute paediatric setting. Bacterial meningitis is a medical emergency because neurological injury and death can occur rapidly.

Important organisms vary with age and immunization status. Beyond the neonatal period, Streptococcus pneumoniae and Neisseria meningitidis are major pathogens, while Haemophilus influenzae type b remains important in incompletely immunized populations.

Older children may present with:

• Fever
• Severe headache
• Neck stiffness
• Photophobia
• Vomiting
• Altered consciousness
• Seizures

Infants frequently present less specifically:

• Poor feeding
• Irritability
• Lethargy
• Bulging fontanelle
• Abnormal cry
• Hypotonia
• Fever or temperature instability
• Seizures
• Apnoea

Dangerous features include:

• Coma
• Recurrent or focal seizures
• Shock
• Purpuric rash
• Cranial nerve abnormalities
• Focal neurological deficits
• Signs of raised intracranial pressure

Absence of neck stiffness does not exclude meningitis in infants.

Perform lumbar puncture promptly when bacterial meningitis is suspected, unless immediate stabilization or a contraindication takes priority.

CSF assessment should include:

• Opening pressure where practical
• Cell count and differential
• Protein
• Glucose with simultaneous blood glucose
• Gram stain
• Culture
• Appropriate PCR where available

Typical bacterial meningitis shows:

• Neutrophilic pleocytosis
• Elevated CSF protein
• Low CSF glucose
• Low CSF to blood glucose ratio

Do not delay antibiotics for lumbar puncture or imaging.

Defer lumbar puncture when there is:

• Severe cardiorespiratory instability
• Evidence of impending cerebral herniation
• Significant focal neurological deterioration
• Infection over the puncture site
• Significant bleeding risk

Blood cultures should be obtained before antibiotics where this can be achieved without meaningful delay.

The presence of malaria does not exclude concurrent meningitis.

Stabilize airway, breathing and circulation.

Correct hypoglycaemia.

Treat shock and seizures.

Give empirical IV antibiotics immediately.

For children beyond the neonatal period:

Ceftriaxone 50 mg/kg IV every 12 hours, maximum 4 g/day

is an appropriate empirical regimen for suspected bacterial meningitis.

An alternative is:

Cefotaxime 50 mg/kg IV every 6 hours, according to age and local protocol.

Modify therapy once Gram stain, culture or PCR identifies the organism.

Typical treatment durations depend on pathogen:

• Meningococcal meningitis: approximately 5 to 7 days
• Haemophilus influenzae meningitis: approximately 7 to 10 days
• Pneumococcal meningitis: approximately 10 to 14 days
• Gram negative meningitis: longer courses, often at least 21 days

Manage raised intracranial pressure aggressively while maintaining adequate cerebral perfusion.

Treat seizures promptly.

Monitor:

• Conscious level
• Pupils
• Seizures
• Fluid balance
• Sodium
• Hearing and neurological function

Arrange formal hearing assessment after recovery because sensorineural hearing loss is an important sequela.

Persistent fever, recurrent seizures, focal deficits or failure to regain consciousness should prompt reassessment for complications such as subdural collection, ventriculitis, hydrocephalus, cerebral infarction or abscess.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Acute Convulsions In Children

An acute convulsion is a sudden episode of abnormal excessive neuronal activity producing involuntary motor activity, altered consciousness, or both. Most brief childhood seizures stop spontaneously. A convulsion continuing for 5 minutes or longer should be treated immediately because prolonged seizures become increasingly difficult to terminate and carry increasing risk of hypoxia, aspiration, metabolic derangement and neuronal injury.

Common causes include febrile seizures, epilepsy, meningitis, encephalitis, cerebral malaria, hypoglycaemia, electrolyte disturbances, head injury and poisoning.

Generalized convulsions typically cause loss of consciousness with tonic stiffening followed by rhythmic clonic movements.

Assess for features suggesting the underlying cause:

• Fever, meningism or rash
• Focal neurological signs
• Head trauma
• Persistent altered consciousness
• Hypoglycaemic symptoms
• Toxic exposure
• Known epilepsy or missed medication
• Recurrent focal seizures
• Signs of raised intracranial pressure

Diagnosis during an active generalized convulsion is clinical.

Immediately check:

• Bedside glucose
• Temperature
• Oxygen saturation
• Neurological state after seizure cessation

Further investigations depend on presentation and may include electrolytes, calcium, magnesium, FBC, malaria testing, renal function, toxicology, lumbar puncture and neuroimaging.

Persistent altered consciousness should not automatically be labelled postictal until hypoglycaemia, CNS infection, ongoing non convulsive status and intracranial pathology have been considered.

• Protect from injury. Do not restrain the child and do not place objects in the mouth.

• Position appropriately, maintain airway patency, suction visible secretions if required and give oxygen when clinically indicated.

• Check glucose immediately and correct hypoglycaemia.

For a seizure lasting at least 5 minutes:

• Diazepam 0.3 mg/kg IV slowly over approximately 1 minute, or 0.5 mg/kg rectally.

• Alternative: lorazepam 0.1 mg/kg IV, maximum 4 mg.

• Buccal or intranasal midazolam is appropriate when IV access is unavailable.

If seizure persists approximately 5 minutes after an adequate first dose, give a second benzodiazepine dose.

If seizures continue, move promptly to a second line anticonvulsant rather than repeatedly administering benzodiazepines.

Options include:

• Levetiracetam 40 to 60 mg/kg IV, commonly maximum 4.5 g depending on protocol.

• Phenytoin 20 mg/kg IV, maximum infusion rate 1 mg/kg/min, with ECG and blood pressure monitoring.

• Sodium valproate 20 to 40 mg/kg IV, avoiding use where significant hepatic disease or a mitochondrial disorder is suspected.

• Phenobarbital 15 to 20 mg/kg IV or IM, with close respiratory monitoring.

Persistent seizure activity despite appropriate second line therapy requires urgent anaesthetic and intensive care involvement.

Meningitis In Children

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management