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ADC Fetal and Neonatal Edition Letters and ADC Education and Practice Letters
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Bulging fontanelle in febrile infants: lumbar puncture is mandatory
- Sushil Beri, Dr Nahin Hussain (4 September 2009)
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Re: Bulging fontanelle in febrile infants: lumbar puncture is mandatory
- Shira Shacham (23 September 2009)
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Sushil Beri, Specialist Registrar, Paediatric Neurology Leicester Royal Infirmary, Leicester, Dr Nahin Hussain
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sushilberi{at}gmail.com Sushil Beri, et al.
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We read with interest the study by Shacham et al [1]. Out of 153 children with fever and bulging fontanelle, only one child had bacterial meningitis. However we disagree with their suggestion of withholding lumbar puncture in this group of children. In their cohort, 41 out of 153 children had aseptic meningitis but CSF viral cultures and PCR studies were only done in children who have received antibiotics and had an abnormal CSF chemistry. These cases would have been easily missed and not diagnosed without a lumbar puncture (LP). Exclusion of meningitis in infants is often very difficult even by the experienced physician as clinical signs are non specific. Bulging fontanelle in an infant can be a sign of raised intracranial pressure and exclusion of CNS infection in a child with fever is paramount. Though it can be due to minor non specific illnesses, but serious and potentially treatable causes must be excluded. The use of LP has declined over the years in UK [2]. In a study by Kneen et al [3], only 53% of children had lumbar puncture when it was clinically indicated. CSF findings helped in the management of 72% of these patients, either by identifying a causative organism or excluding meningitis. CSF leukocyte count, type of leukocytosis, culture positivity and the diagnosis of meningitis depends on several factors which include timing of LP, duration and type of antibiotics, antiviral medications and the epidemiology of acute meningitis in a specific geographical area. Although the authors acknowledge several limitations of their study, they fail to realise that the only way to exclude meningitis is by examining the CSF. CNS infections carry high mortality and morbidity especially in those who are untreated or partially treated. Køster- Rasmussen [4] found that delay in giving antibiotics was an independent risk factor to unfavourable outcome, with the odds increasing by up to 30% per hour of treatment delay in acute bacterial meningitis. Early LP in an infant with pyrexia and bulging fontanelle, when there are no contraindications is a more logical approach, not only for the diagnosis but also for appropriate management. The advantages of obtaining a microbiological diagnosis extend beyond individual patient management. Identifying an organism allows appropriate prophylaxis to be recommended for close contacts and public health service monitoring for disease outbreaks. Finally there is potential health and economic implication with reduced antibiotic and antiviral use, along with shorter hospital stay for children, in whom CNS infection has been completely excluded. No competing interest 1. Shacham S, Kozer E, H Bahat H, Mordish Y and Goldman M. Bulging fontanelle in febrile infants: is lumbar puncture mandatory? Arch Dis Child 2009;94:690-692. 2. Harper JR. Timing of lumbar puncture in severe childhood meningitis. British Medical Journal 1985; 291:651-652. 3. Kneen, R, Solomon T, Appleton RE. The role of lumbar puncture in children with suspected central nervous system infection. BMC Pediatrics 2002; 2:8. 4. Køster-Rasmussen R, Korshin A, Meyer CN. Antibiotic treatment delay and outcome in acute bacterial meningitis. Journal of Infection 2008; 57: 449-454. |
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Shira Shacham, pediatrician Assaf Harofeh Medical Center
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shirashacham1{at}gmail.com Shira Shacham
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Dear Editor, We thank doctors Beri and Hussain for their comments. They disagree with the suggestion of withholding a lumbar puncture in a specific subset of infants with fever and bulging fontanelle. One of the points they raised is that cases with aseptic meningitis will be missed. However, the purpose of performing a lumbar puncture in infants with fever and bulging fontanelle is not to diagnose aseptic meningitis but to exclude bacterial meningitis. Diagnosing aseptic meningitis does not influence the treatment or the course of disease and carries a good prognosis in most cases. Another point raised is that bacterial meningitis can cause high mortality and morbidity, especially in cases of delay in treatment. It is, of course, the primary purpose of every physician not to miss these cases. In our cohort, which is the largest cohort of febrile infants with bulging fontanelles published in the literature, only one case of bacterial meningitis was found, and this infant had clinical and laboratory characteristics that were substantially different from those of the other infants. None of the well appearing infants had bacterial meningitis. We cautiously suggest that in a well appearing infant, without signs, laboratory tests or imaging studies that suggest a bacterial etiology, it is reasonable to observe the infant and withhold a lumbar puncture. Prospective studies should be carried out in the future to confirm this approach. |
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