This slideshow helps to better management of meningeal signs in children

1. Fariba shirvani MD
Management of meningeal signs in children

2. Definition:
• Signs and symptoms of meningitis in children
• The 3 classic symptoms (less likely in younger
children):
 Fever
 Headache
 Meningeal signs

3. What are meningeal signs

4. Meningeal signs
• Neck pain
• Meningeal irritation :Brudzinski sign ,
Kernig sign, tripod phenomenon, or
neck stiffness in children older than 1
year.
• In children 1 year or younger: bulging
fontanel

5. Clinical signs of meningeal irritation

6. Disorders accompanied with meningeal signs in
children:
Trauma
Paravertebral abscess
Retropharyngeal abscess
Muscle spasm
Right upper lobe pneumonia
Meningitis

7. Scoring for bacterial meningitis:
• Total Score =
[1 × Duration of Main Problem (1 Point for Each Day)] + [2 ×
Vomiting in History (Yes = 1; No = 0)] + [7.5 × Meningeal
Irritation (Yes = 1; No = 0)] + [6.5 × Cyanosis (Yes = 1; No =
0)] + [4 × Petechiae (Yes = 1; No = 0)] + [8 × Disturbed
Consciousness (Yes = 1; No = 0)] + [0.1 × Serum C-reactive
Protein (CRP) (per 10 mg/L)].
Oostenbrink RMoons KGMDonders ARTGrobbee DEMoll HA Prediction of
bacterial meningitis in children with meningeal signs: reduction of lumbar
punctures. Acta Paediatr. 2001;90611- 617

8. Scoring for bacterial meningitis:
• . In those with a risk score of less than 9.5 points
(approximately 35% of the patients), bacterial
meningitis seemed always to be absent. In the
remaining patients with(score, ≥9.5), the risk of
bacterial meningitis was 44%.
Oostenbrink RMoons KGMDonders ARTGrobbee DEMoll HA Prediction of
bacterial meningitis in children with meningeal signs: reduction of lumbar
punctures. Acta Paediatr. 2001;90611- 617

9. Bacterial meningitis score
• Components of the bacterial meningitis score are as
follows:
• Positive CSF Gram stain
• CSF absolute neutrophil count 1000/µL or higher
• CSF protein level 80 mg/dL or higher
• Peripheral blood absolute neutrophil count 10,000/µL
or higher
• History of seizure before or at the time of presentation
Meta-analysis of bacterial meningitis score validation studies.
Arch Dis Child. 2012; 97(9):799-805 (ISSN: 1468-2044)
Nigrovic LE; Malley R; Kuppermann N

10. What are the predictors of bacterial meningitis
• CSF indices:
• identified the absolute PMN cell count
• CSF–blood glucose ratio
– independent determinants of presence
of bacterial meningitis.

11. What are the predictors of bacterial meningitis
• patient characteristics:
• duration of the main problem,
vomiting, meningeal irritation,
cyanosis, petechiae, disturbed
consciousness, and serum CRP, can
discriminate well between the absence
or presence of bacterial meningitis

12. Contraindication of LP

13. (1) a short period of antibiotic therapy prior to LP does not
change cerebrospinal fluid (CSF) white blood cell count,
protein, or glucose; (2) the yield of CSF gram stain and
culture may be somewhat reduced by a short period of
antibiotic therapy, but these tests often remain positive;
and (3) adjunctive tests, including blood cultures and CSF
antigen tests, can often independently identify the
bacterial meningopathogen. The available evidence
suggests that if bacterial meningitis is suspected and LP
must be delayed, intravenous antibiotics are warranted
before CSF is obtained.

14. Treatment

15. • < 30 days, ampicillin and an aminoglycoside or a
cephalosporin
• 30-60 days, ampicillin and a cephalosporin;
because Streptococcus pneumoniae may occur in
this age range, consider vancomycin instead of
ampicillin
• In older children, a cephalosporin or ampicillin plus
chloramphenicol with vancomycin (needs to be
added secondary to the possibility of S pneumoniae)

16. Duration of Treatment

17. Neisseria meningitidis - 7 days
Haemophilus influenzae - 7 days
Streptococcus pneumoniae - 10-14
days
S agalactiae (GBS) - 14-21 days
Aerobic gram-negative bacilli - 21 days or 2
weeks beyond the first sterile culture (whichever
is longer)
Listeria monocytogenes - 21 days
or longer