History and exam
Key diagnostic factors
common
fever
Consider the possibility of bacterial meningitis when assessing any child or young person with acute febrile illness, particularly if they have associated risk factors.
Fever is the most common sign in children (reported in 92% to 93%).[3] It may be associated with chills/shivering.
However, fever is often absent in infants.[2][3] Do not be reassured by lack of fever in an unwell baby; more than 50% of neonates diagnosed with bacterial meningitis are afebrile on presentation.[3]
Practical tip
In children aged ≤5 years, do not routinely use measurements of oral and rectal temperature to determine body temperature.[27] Instead:
In infants aged <4 weeks, use an electronic thermometer in the axilla.[27]
In children aged 4 weeks to 5 years, use of one of the following:[27]
Electronic thermometer in the axilla.
Chemical dot thermometer in the axilla. However, use an alternative type of thermometer if multiple temperature measurements are required.
Infra-red tympanic thermometer.
Do not use forehead chemical thermometers because they are unreliable.[27]
vomiting/nausea
irritable/unsettled
A non-specific symptom. Irritability and lethargy are common in babies and young children. Older children may be agitated, aggressive, or subdued.[2]
headache
altered mental state
Includes altered level of consciousness or cognition, including confusion or delirium.[2] Can also be a feature of shock. Present in 13% to 56% of children with bacterial meningitis.[3][62][63][64]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale score of 9 or less or a progressive and sustained or rapid fall in level of consciousness) can be a sign of raised intracranial pressure.[2] [ Glasgow Coma Scale Opens in new window ]
Coma is a feature in 5% of infants <3 months with bacterial meningitis.[4]
neck stiffness
photophobia
May be caused by meningeal irritation.
seizures
Occur in:
9% to 34% of neonates with bacterial meningitis.[3] More common with group B streptococci than Escherichia coli.[3]
10% to 56% of children with bacterial meningitis.[3][60][62][63][64] More common with Streptococcus pneumoniae and Haemophilus influenzae type b than Neisseria meningitidis.[5]
Can be a feature of raised intracranial pressure.[2]
focal neurological deficit
Includes cranial nerve involvement, abnormal pupils, and paresis. May be caused by meningeal irritation and raised intracranial pressure and exudates encasing the nerve routes.
Can be a feature of raised intracranial pressure.[2]
rash
Examine the patient's skin very carefully for a rash. Always document its presence or absence.[2]
In practice, a petechial or purpuric rash is typically associated with meningococcal disease, but it may be present with any type of bacterial meningitis.
In the initial phases there may be only 1 or 2 petechiae.
Rashes can be hard to detect on brown, black, or tanned skin (look for petechiae in the conjunctiva)
Remember to check the nappy area.[2]
Children with petechiae confined to the skin above the nipple line (the distribution of the superior vena cava) may be less likely to have meningococcal disease than those with petechiae below the nipple line.[47]
shock
Signs of shock in children and young people include:[43][44][45]
Prolonged capillary refill time (e.g., more than 2-3 seconds)
Cold hands/feet
Weak, fast pulse
Pale/mottled/ashen/blue skin, lips, or tongue
Altered mental state/decreased conscious level
Practical tip
Have a low threshold for suspecting sepsis. Clinical presentation of sepsis in children is often subtle and non-specific and progression to organ failure and shock can be very rapid.
Think ‘ Could this be sepsis’ in any child with a suspected infection with signs of a systemic response, which may be indicated by a change in observations or a change in a child’s normal behaviour.[32][33] Always acknowledge parent or carer concern.[32]
Involve senior clinicians/specialists early.
If you suspect sepsis, use a standard ABC (airway, breathing, circulation) approach. Initiate treatment as soon as possible and always within the first hour following recognition of severe sepsis.[34][35]
Refer to local guidelines and use protocolised care bundles such as the Paediatric Sepsis Six initiative to guide management.
See Sepsis in children.
raised intracranial pressure
Signs of raised intracranial pressure include:[2][66][67]
Reduced or fluctuating level of consciousness (Glasgow Coma Scale of <9 or less or a progressive and sustained or rapid fall in level of consciousness). [ Glasgow Coma Scale Opens in new window ]
In children unable to give a verbal response (in practice, those under 2 years), use the Glasgow Coma Scale with modification for children. Glasgow Coma Scale: modification for children Opens in new window
New focal neurological signs, including seizures or posturing.
Abnormal pupillary reactions.
bulging fontanelle
May be a sign of meningitis; only relevant in children with an open fontanelle (typically aged under 2 years).
apnoea
Non-specific sign in babies.[2]
presence of risk factors
Risk factors for bacterial meningitis include:
Age <2 years
Incomplete immunisation
Infants who have not had their childhood vaccines are at high risk of contracting Haemophilus influenzae type b, pneumococcal, or meningococcal meningitis.[17]
Immunocompromising conditions
Immunodeficiency, which can be congenital (e.g., hypogammaglobulinaemia, complement deficiency, common variable immunodeficiency, sickle cell disease) or acquired (e.g., asplenia or hyposplenia, use of immunosuppressive medication, HIV infection, cancer) increases the risk of bacterial meningitis.[5][20][21][22]
Cranial structural defects
Congenital or acquired cranial structural defects may increase risk of bacterial meningitis.[5]
Medical Devices
Perinatal period
During the perinatal period, neonates are at increased risk of bacterial meningitis if:[24]
There is premature or prolonged (>18 hours) rupture of membranes
There is maternal colonisation with group B streptococcus
There is maternal chorioamnionitis
They are premature
They have low birth weight.
Exposure to pathogens
Exposure to infection within the household or close contact with another person who has meningitis increases the patient’s risk of bacterial meningitis.[5]
Contiguous infection
Infections such as sinusitis, pneumonia, mastoiditis, and otitis media increase the risk of meningitis.[5]
Crowding
Crowding (e.g., in a household or dormitory) provides an ideal environment for transmission of bacteria.[5]
Other diagnostic factors
common
uncommon
chills/shivering
Associated with fever.
unexplained body pain, including limb, back, or abdominal pain
A non-specific symptom.
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