Patient education: Meningitis in children (Beyond the Basics)

WHAT IS MENINGITIS? — 

The term "meningitis" refers to inflammation of the tissues that cover the brain and spinal cord (which are called the meninges).

Bacterial versus viral meningitis — There are two main types of meningitis:

●Bacterial meningitis (caused by bacteria), and

●Viral meningitis (causes by viruses); the term "aseptic meningitis" is also sometimes used for this category

The treatment and long-term complications of meningitis differ considerably between bacterial and viral meningitis. Bacterial meningitis is a severe infection that requires emergency evaluation and management, whereas viral meningitis is a milder illness that is usually self-limited. However, in most cases, it is not possible to know for certain whether a child has bacterial or viral meningitis based upon symptoms alone.

Meningitis versus encephalitis — Viral meningitis refers to a viral infection of the tissue around the brain (the meninges); it is usually a self-limited illness, as described above. Less commonly, the infection may involve not only the meninges, but also the brain tissue. This is called "meningoencephalitis" or simply "encephalitis." Viral encephalitis is a more severe illness, and children with this condition often have long-term disabilities after the acute illness.

The focus of this topic is on bacterial and viral meningitis. Encephalitis is discussed separately. (See "Patient education: Encephalitis (The Basics)".)

CAUSES OF MENINGITIS

Bacterial meningitis — The most common causes of bacterial meningitis in childhood vary somewhat depending upon the child's age, vaccination status, and current or past medical problems.

●Young infants – In newborns and young infants, the two most common causes of bacterial meningitis are group B streptococcus (referred to as "GBS") and Escherichia coli.

●Older infants, children, and adolescents – The two most common causes of bacterial meningitis in older infants and children are bacteria called Streptococcus pneumoniae (referred to as "pneumococcus") and Neisseria meningitidis, (referred to as "meningococcus").

Certain factors can increase a child's risk of developing bacterial meningitis, including recent exposure to someone with bacterial meningitis, recent infection (eg, ear or sinus infection), travel to areas where bacterial meningitis is common (eg, sub-Saharan Africa), serious head injury, problems with the immune system, cochlear implants, and certain anatomic abnormalities.

Viral meningitis — The most common cause of viral meningitis is a family of viruses called enterovirus. In temperate climates, enteroviral meningitis occurs most commonly in the summer through early fall. Enteroviruses are spread by direct contact with feces during activities such as diaper changing or indirectly through contaminated water, food, and surfaces.

Other viruses that cause meningitis or meningoencephalitis can be spread by airborne droplets, direct contact, during birth, or through the bite of an or insect (eg, mosquito, tick) or animal (eg, rabies).

Other causes — Less commonly, meningitis may be caused by other types of infections that are not detected with conventional bacterial tests. These infections are discussed separately:

●Lyme disease (see "Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)")

●Tuberculosis (see "Patient education: Tuberculosis (Beyond the Basics)")

SIGNS AND SYMPTOMS OF MENINGITIS — 

The signs and symptoms of bacterial and viral meningitis can be similar, although bacterial meningitis tends to be more severe. In most cases, it is not possible to know for certain whether a child has bacterial or viral meningitis based upon symptoms alone. The most common symptoms include:

●Newborns may develop a fever accompanied by nonspecific symptoms (eg, poor feeding, vomiting, diarrhea, rash). The infant may have a stiff neck or bulging fontanel (soft spot on the skull) and may be irritable, restless, or lethargic.

●Older infants and children may develop a sudden fever, irritability, confusion, headache, nausea, vomiting, or stiff neck and may complain that light bothers their eyes.

●The symptoms of viral meningitis can resemble those of the flu, including fever, muscle aches, runny nose, sore throat, and cough. Some of the viruses that cause viral meningitis can also cause other symptoms such as conjunctivitis, skin rashes, and sores in the mouth.

●One of the causes of bacterial meningitis (meningococcus) may be associated an unusual rash that appears as red to purplish spots on the skin that do not blanch with pressure (called with petechiae (picture 1) and purpura (picture 2)). Children with petechiae or purpura should be urgently evaluated.

●Meningitis can cause seizures and decreased level of awareness.

In some cases, symptoms worsen slowly over one to two days, while in other cases, the symptoms worsen rapidly over hours.

MENINGITIS DIAGNOSIS — 

Because bacterial meningitis is a medical emergency that must be treated promptly, it is important to determine the cause of the child's symptoms as quickly as possible. The following tests are generally recommended and are usually performed in a hospital emergency department:

●Blood culture – A sample of blood is cultured in the laboratory to determine if there are bacteria present (normally, no bacteria should be present in the blood). The results of a blood culture are generally available within 24 to 48 hours. If the blood culture is positive, additional testing can be done to find out which bacteria is causing the meningitis and which antibiotic is best.

●Lumbar puncture – During a lumbar puncture, also known as a spinal tap, a clinician uses a needle to remove a sample of spinal fluid from the area around the spinal cord in the lower back. Several tests are done on the fluid to determine if there are signs of infection:

•Cell count, protein, and glucose – The cell count (the number of infection-fighting cells) and the levels of protein and glucose in the spinal fluid can give clues about whether there is an infection and, if so, what type of infection (bacterial or viral). These initial results are available within an hour or two.

•Gram stain – In this test, a sample of spinal fluid is placed on a glass slide, special stains are applied, and the slide is then examined under a microscope to see if bacteria are present. Results are usually available within an hour or two. If bacteria are present, their shape and color provide clues as to which specific bacteria it is. A negative Gram stain does not mean the child doesn't have meningitis; "false negative" results can occur.

•Bacterial culture – The bacterial culture is the true test of whether a bacterial infection is present. This test usually takes 24 to 48 hours. In addition to finding out which bacteria is causing the infection, the bacterial culture determines which antibiotic treatment is best. If the test is negative, it generally means the child does not have bacterial meningitis. However, rarely, the result is a "false negative" and despite the negative culture result, other signs and laboratory tests strongly indicate that the child likely has bacterial meningitis. The most common cause of a false-negative bacterial culture result is that the child received antibiotics before the test was done.

•Polymerase chain reaction (PCR) tests – PCR tests are molecular tests that detect the DNA of viruses and bacteria. In many hospitals, PCR testing is performed with a "meningitis panel," which tests for several different viruses and bacteria all at the same time. There are also separate PCR tests that can be performed individually to detect specific viruses, such as enteroviruses, herpes simplex virus (HSV), and others. The results of PCR tests may be available quickly (even within a few hours), or they may take several days.

●CT scan – A computed tomography (CT) scan is a radiology test that is used to take images of the brain. Most children with suspected meningitis do not need to undergo a CT scan. However, in some cases, a CT scan is performed before the lumbar puncture. The purpose of this test is to help determine if it is safe to perform the lumbar puncture and to determine if another condition may be contributing to the child's symptoms (eg, bleeding or a mass in the brain).

MENINGITIS TREATMENT — 

The treatment for meningitis depends upon whether the meningitis is caused by a virus or bacterium. However, this distinction may not be clear until the culture and polymerase chain reaction (PCR) results are available. In many cases, children are treated as if they have bacterial meningitis until bacterial meningitis is definitively excluded. The reason for this is that there is a significant risk of serious illness or even death if the child has bacterial meningitis that isn't promptly treatment.

Bacterial meningitis — Bacterial meningitis is a life-threatening illness that requires hospitalization and treatment with intravenous antibiotics. The child will be monitored closely for signs of complications. Depending upon the severity of the illness, the child may also need supportive treatments to aid breathing, maintain blood pressure, prevent excessive bleeding, and stay hydrated.

Antibiotics — Antibiotic therapy is usually started immediately after the blood tests and lumbar puncture are performed. Treatment is administered intravenously (IV). Oral antibiotic therapy is not used to treat meningitis because it does not achieve a high enough concentration of antibiotic in the spinal fluid.

Length of treatment — The length of antibiotic treatment depends upon the results of the bacterial cultures:

●If the cultures and PCR testing are negative and the child has improved, antibiotics may be discontinued after 48 to 72 hours.

●If the cultures are positive, the length of treatment depends upon the bacteria that is identified and whether there are complications. The usual treatment course is 10 to 14 days. However, treatment may be as short as five days for certain bacteria and as long as four weeks for others.

Viral meningitis — Most cases of viral meningitis are cause by enteroviruses or similar viruses. These viruses typically cause a mild and self-limited illness. There is no effective antiviral therapy for these viruses. So, when PCR testing identifies one of these viruses as the cause of meningitis and the results of the bacterial culture confirm that there is no bacterial infection, antibiotic therapy is usually stopped since antibiotic therapy is not effective for treating viral infections.

Instead, treatment is supportive, meaning that care should be provided to support the child while they recover. This generally includes rest, encouraging the child to drink an adequate amount of fluid (when alert enough to do so), providing IV fluids (if unable to drink enough fluid), and medications to treat fever and/or headache (eg, acetaminophen or ibuprofen).

There are some rare exceptions when antiviral therapy is used to treat viral meningitis. For example, meningitis caused by herpes simplex virus (HSV) is treated with IV acyclovir. However, HSV meningitis in very uncommon in childhood except for in newborn infants and children with disorders of immune system.

PROGNOSIS AFTER MENINGITIS — 

A child's prognosis after an episode of meningitis depends upon the cause (type of bacterium or virus), the severity of the illness, and the age of the child.

Bacterial meningitis — Most children with bacterial meningitis recover completely with no long-term complications. The child should begin to improve within 24 to 36 hours after starting antibiotics. However, fever may persist for four to six days or longer.

However, even with proper treatment, meningitis can damage the brain and cause long-term complications. The most common complication is hearing loss, which occurs in approximately 5 to 10 percent of patients following bacterial meningitis. Other complications are less common and may include developmental delay or learning disabilities, behavioral and emotional problems, spastic or dysfunctional muscle coordination (eg, cerebral palsy), and seizures. Complications after bacterial meningitis are more common in children who live in low- and middle-income countries.

To determine if a child's hearing was affected by the illness, hearing testing is usually performed around the time of discharge from the hospital. Young children should also be monitored closely for signs of developmental delay (eg, not walking, talking, etc at the expected time).

Bacterial meningitis can be fatal. The risk of death is <5 percent in high-income countries and approximately 10 percent in low- and middle-income countries.

Viral meningitis — Most children with viral meningitis (caused by enteroviruses or similar viruses) recover with no long-term complications. Symptoms usually begin to improve within one week, although some children will have fatigue, irritability, decreased concentration, muscle weakness and spasm, and difficulty with coordination for several weeks or more. Death is uncommon in children with enteroviral meningitis.

The risk of death or long-term complications is considerably higher if the viral infection directly involves the brain tissue (encephalitis). However, viral encephalitis is far less common in childhood compared with viral meningitis. This is discussed separately. (See "Patient education: Encephalitis (The Basics)".)

MENINGITIS PREVENTION — 

Several measures can help to reduce the risk of developing bacterial and viral meningitis.

Vaccines — Several routine childhood vaccines reduce the risk of developing bacterial meningitis, including the pneumococcal, meningococcal, and Haemophilus influenzae type b (Hib) vaccines. These are discussed in detail separately. (See "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)" and "Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)".)

Vaccines are also available to prevent certain types of viral infections that may cause meningitis or other central nervous system infections, including polio, influenza, varicella-zoster (chickenpox), measles, and mumps. (See "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)" and "Patient education: Influenza symptoms and treatment (Beyond the Basics)".)

Preventive antibiotics — Preventive antibiotics are recommended for close contacts of anyone infected with meningococcal infection, even if the contact was previously vaccinated. Close contact is defined as a person who lives with the child or who spent ≥4 hours with the child for at least five of the seven days before the child developed symptoms.

Preventive antibiotics may also be necessary for close contacts of anyone infected with Hib bacterial infection. However, this only applies for those households in which there is a person with invasive Hib disease and at least one household member who is a child younger than 48 months of age and did not receive all of the vaccinations against Hib, or an individual who has a weakened immune system (even if that person was vaccinated against Hib).

Handwashing and other hygiene measures — Families of children with meningitis should take care to avoid becoming infected. This includes washing hands after touching the child or changing diapers and before eating or preparing food. Utensils and cups should not be shared, the child's mouth should be covered during a cough, and the child should not be kissed on the mouth. These measures should be continued until the child no longer has symptoms (eg, fever, diarrhea, rash).

WHEN TO SEEK HELP — 

Any parent/caregiver who suspects that their child could have meningitis should seek medical attention immediately.

Signs and symptoms of meningitis can include:

●Newborns may develop a fever accompanied by nonspecific symptoms (eg, poor feeding, vomiting, diarrhea, rash). The infant may have a stiff neck or bulging fontanel (soft spot on the skull) and may be irritable, restless, or lethargic.

●Older infants and children may develop a fever, irritability, headache, nausea, vomiting, or stiff neck and may complain that the light bothers their eyes. The child may be confused or difficult to awaken.

●Other signs can include red to purplish spots on the skin (petechiae (picture 1) and purpura (picture 2)), seizures, and a decreased level of awareness.

WHERE TO GET MORE INFORMATION — 

Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Meningitis in children (The Basics)
Patient education: Bacterial meningitis (The Basics)
Patient education: Viral meningitis (The Basics)
Patient education: Encephalitis (The Basics)
Patient education: Headaches in children (The Basics)
Patient education: Lumbar puncture (spinal tap) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)
Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)
Patient education: Influenza symptoms and treatment (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Bacterial meningitis in children older than one month: Clinical features and diagnosis
Bacterial meningitis in children older than one month: Treatment and prognosis
Bacterial meningitis in the neonate: Clinical features and diagnosis
Bacterial meningitis in the neonate: Treatment and outcome
Bacterial meningitis in children: Neurologic complications
Bacterial meningitis in the neonate: Neurologic complications
Bacterial meningitis in children: Role of dexamethasone
Lumbar puncture in children
Clinical manifestations of meningococcal infection
Meningococcal vaccination in children and adults
Viral meningitis in children: Epidemiology, pathogenesis, and etiology
Viral meningitis in children: Clinical features and diagnosis
Viral meningitis in children: Management, prognosis, and prevention
Acute viral encephalitis in children: Clinical manifestations and diagnosis
Acute viral encephalitis in children: Treatment and prevention

The following organizations also provide reliable health information:

●Centers for Disease Control and Prevention (CDC)

Toll-free – (800) 232-4636

(www.cdc.gov)

●United States National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●National Institute of Allergy and Infectious Diseases

(www.niaid.nih.gov)

●National Foundation for Infectious Diseases

Tel – (301) 656-0003

(www.nfid.org)

●Children's Hospital of Philadelphia Vaccine Education Center

(www.chop.edu/service/vaccine-education-center/home.html)

●KidsHealth, from Nemours

(http://kidshealth.org/parent/infections/lung/meningitis.html, also available in Spanish)

[1-5]