Last updated:
April 1, 2026
Meningitis in Children
Meningitis is a life-threatening infection of the meninges.
Definition of terms
| Term | Definition |
|---|---|
| Acute bacterial meningitis | Rapid onset of symptoms. Can be identified using routine laboratory techniques. |
| Chronic meningitis | Ongoing symptoms of meningitis for ≥ 4 weeks without clinical improvement |
| Aseptic meningitis | The symptoms of meningitis are present without evidence of bacterial cause by usual laboratory testing methods. It includes viruses, Mycobacterium tuberculosis, Borrelia burdgoferi, and non-infectious causes. |
Common organisms
| Age | Common organisms |
|---|---|
| < 28 days | GBS, Escherichia Coli, Enterobacter, Listeria monocytogenes |
| 28 days – 3 months | Escherichia coli, GBS, S. pneumoniae, H. influenzae, N. meningitidis, Listeria monocytogenes |
| 3 months – 18 years | N. meningitidis, S. pneumoniae, H. influenzae |
- Risk factors in neonates
- Preterm
- Low birth weight
- Chorioamnionitis
- Endomeritis
- Maternal GBS colonization
- Prolonged duration of intrauterine monitoring ( > 12 hours)
- PROM
- Traumatic delivery
- Fetal hypoxia
- Galactosemia
- Urinary tract abnormalities
- Dermal sinus tract of the spine
- Risk factors in children
- Asplenia (functional or anatomic)
- Primary immunodeficiency
- HIV infection
- Sickle cell anemia (functional asplenia)
- Cochlear implant
- CSF leak
- Recent upper respiratory tract infection
- Day care attendance
- Lack of breastfeeding
- Exposure to a case of meningococcal or HiB meningitis
- Penetrating head trauma
- Dermal sinus tract of the spine
- Travel to an area with endemic meningococcal disease
- Lack of immunization
- Signs and symptoms in younger children (non-specific)
- Temperature instability (Fever OR Hypothermia)
- Lethargy OR Irritability (fussy, inconsolable cry, sleepy, weak, or jittery)
- Poor feeding
- Vomiting
- Apnea
- Convulsions (not always present)
- Bulging fontanelle
- Poor tone
- Signs and symptoms in older children
- Fever
- Headache
- Anorexia
- Nausea, Vomiting
- Photophobia
- Confusion
- Physical exam findings due to meningeal irritation (meningism)
- Neck stiffness
- Opisthotonus
- Positive Kernig
- Positive Brudzinski sign
- Focal neurological deficits
- Suggests localized infarction and subdural collection
- Cranial nerve palsies are commonly seen in tuberculous meningitis and cryptococcal meningitis
- Differentials for meningeal irritation (Meningism)
- Strep throat (URTI)
- Pneumonia
- Pyelonephritis
- Intracranial bleeding (Subarachnoid hemorrhage)
- Cerebral infarction
- Vasculitis
- Investigations
- Lumbar Puncture for CSF analysis: CSF should ideally be obtained before starting antibiotics. Pre-treatment with antibiotics might decrease the likelihood of positive CSF culture, but does not adversely affect CSF cell counts.
- WBC count
- Differential count
- Protein level
- Gram stain
- Culture
- Blood Culture
- Complete Blood Count
- C-reactive protein: elevated. Serial CRP to monitor clinical response and screen for complications
- Procalcitonin: elevated
- U/E/Cs
- Random Blood Sugar: to rule out hypoglycemia
- Urinalysis and Urine Culture
- PCR
- CT scan or MRI: if there are focal neurological deficits
- Cranial ultrasound: for neonates
- Lumbar Puncture for CSF analysis: CSF should ideally be obtained before starting antibiotics. Pre-treatment with antibiotics might decrease the likelihood of positive CSF culture, but does not adversely affect CSF cell counts.
- Supportive Treatment
- Treat dehydration and prevent overhydration
- SIADH may occur
- Manage blood sugar level
- Treat convulsions
- Treat fever and pain
- Monitor vital signs
- Measure head circumference daily for < 18 months (1.5 years)
- Treat dehydration and prevent overhydration
- Definitive Treatment
- Intravenous ceftriaxone
- 14 days for uncomplicated meningitis d/t GBS, L. monocytogenes, or S. pneumoniae
- 21 days for uncomplicated meningitis due to Gram-negative bacilli)
- Not recommended for jaundiced neonates or neonates ≤ 6 days
- Dexamethasone for HiB meningitis
- Infants and children < 6 weeks of age and older (considering possible risks vs potential benefits)
- Reduces the incidence of hearing loss
- Intravenous ceftriaxone
- Preventative Treatment
- Hib vaccine (integrated in Nov 2001)
- Pneumococcal Vaccine (integrated into KEPI 2010, PCV10)
- Meningococcal Vaccine (introduced 2019; Menactra, Nimerix): Turkana, Marsabit, Mandera, West Pokot, and Wajir
- Suppurative complications
- Subdural empyema
- Pleural empyema
- Arthritis
- Pericarditis
- Ventriculitis
- Brain abscess
- Neurological complications
- Hearing loss (20-30% w/ pneumococcal, 10% w/ meningococcal, 5% with HiB)
- Cognitive and developmental disability
- Hemiparesis
- Quadriparesis
- Cranial nerve palsies
- Epilepsy
- Cortical blindness
- Hydrocephalus
- Diabetes insipidus
- Hypothalamic dysfunction
- Prognosis
- A decreased level of consciousness at presentation is associated with an increased risk of death and neurological sequelae
- Development of seizures > 72 hours after starting antibiotics is associated with learning difficulties
- S. pneumoniae has a relatively poorer outcome compared to HiB or N. meningitidis
ETAT+
| Diagnosis | Features |
|---|---|
| Definite meningitis | Cloudy CSF tap AND/OR, WBC > 10 x 10^6/L; Gram-positive diplococci or Gram-negative cocco-bacilli |
| Probable Meningitis | Coma, Stiff neck, bulging fontanelle, Clear CSF |
| Possible meningitis | CSF WBC and Gram stain results not done, No coma/stiff neck/bulging fontanelle/clear CSF |
| Complicated meningitis | Subdural empyema, Ventriculitis, Brain abscess, Suppurative venous sinus thrombosis |
- When do we ABSOLUTELY need to perform LP (unless contraindications)
- Coma
- Inability to drink/feed
- AVPU = ‘P or U’
- Bulging fontanelle
- Convulsions if age < 6 months or > 6 years
- Evidence of partial seizures
- When do we need to perform LP (unless completely normal mental state after febrile convulsion)
- Agitation or Irritability
- Any convulsions
- Absolute contraindications to Lumbar Puncture (CT/MRI findings)
- Midline shift
- Posterior fossa mass (common in HIE)
- Loss of cisterns
- When to defer a Lumbar Puncture (relative contraindications)
- Shock or Cardiovascular instability
- Signs of raised ICP (Bradycardia, Hypertension, irregular respirations)
- Focal neurological deficits (Poor pupillary response to light, etc.)
- Focal seizures
- Infection of the skin at the LP site
- Evidence of coagulopathy (esp. in meningococcal septicemia)