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Congratulations to the authors on a balanced article on the need for lumbar puncture.1
One point of possible confusion is the Glasgow Coma Score (GCS) quoted as a contraindication to LP. Kneen et al quote a GCS <13 as a contraindication to LP, which would exclude a very large number of childen with meningitis. Riordan and Cant2 in the same issue of your journal quote a GCS <8. Rennick et al3 also use a GCS <8 as their cut off figure in their hospital, as do we.4
There is little evidence to my knowledge. A retrospective Manchester study5 found that children with GCS <8 were more likely to die from coning than other children with meningitis (relative risk 4.6, 95% CI 1.06–35.8).
I would welcome comments from the authors and others as to whether they have better evidence for the GCS they quote, and if not, what we should advise in the absence of good evidence.
We thank Dr Isaacs for his helpful letter. He rightly points out that the published recommendations as to which Glasgow Coma Scale score serves as a contraindication to a lumbar puncture vary between <8 and <13, though we are not aware of any definitive evidence supporting either value. For the purposes of our overview commentary we chose the most conservative value (<13), which is also that recommended in the Advanced Paediatric Life Support Manual produced by the RCPCH advisory committee. Opinions will vary as to what level of consciousness is a contraindication to lumbar puncture (LP). In our clinical practice we do perform LPs on children with lower coma scores if there are no other contraindications to LP. These issues clearly deserve further consideration, but for this editorial our primary concern related to the observation that even many fully conscious children do not undergo LP for the spurious reasons outlined in our article.
In the editorial we refer to a survey of LP practice in Liverpool, which were unpublished observations at the time; these data have now also been published.1