Meningitis in Children
Comprehensive Nursing Notes
Introduction
Meningitis is the inflammation of the meninges, the protective membranes covering the brain and spinal cord. In children, meningitis can be particularly dangerous as it can progress rapidly and lead to serious complications including brain damage, hearing loss, and even death if not promptly diagnosed and treated.
Key Concept
Children, especially infants and young children, have unique presentations of meningitis that may differ from adults. Understanding these differences is crucial for early recognition and intervention.
Meningitis Overview Mind Map
Pathophysiology
The pathophysiology of meningitis involves the following processes:
1. Entry of Pathogen
Pathogens can enter through multiple routes:
- Hematogenous spread (most common) – pathogens enter bloodstream and cross blood-brain barrier
- Direct spread from nearby infections (otitis media, sinusitis)
- Traumatic introduction (head trauma, neurosurgery)
- Congenital defects allowing pathogen entry
2. Inflammatory Response
Once pathogens reach the subarachnoid space:
- Inflammatory mediators are released
- Neutrophils migrate to the area
- Cytokines trigger further inflammatory cascade
- Increased permeability of the blood-brain barrier
3. Consequences of Inflammation
- Increased intracranial pressure (ICP)
- Cerebral edema
- Reduced cerebral blood flow
- Potential damage to cranial nerves
- Brain tissue injury from inflammation
Important: In infants, the pathophysiological changes present differently due to open fontanelles which can accommodate increased pressure, potentially masking early signs of increased ICP.
Etiology & Types
Meningitis can be classified based on the causative organism and the onset of disease:
| Type | Common Pathogens | Age Group Considerations | Clinical Features |
|---|---|---|---|
| Bacterial Meningitis |
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| Viral Meningitis |
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| Fungal Meningitis |
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| Tuberculous Meningitis |
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Mnemonic: “MENINGITIS” Causes
M – Meningococcus (Neisseria meningitidis)
E – Enteroviruses (leading cause of viral meningitis)
N – Neonatal pathogens (Group B Strep, E. coli, Listeria)
I – Immunocompromised pathogens (fungi, TB)
N – Neoplastic (rare cause of aseptic meningitis)
G – Group B Streptococcus (neonates)
I – Influenzae (Haemophilus influenzae)
T – Trauma/neurosurgery (predisposing factor)
I – Intracranial devices (shunts, drains)
S – Streptococcus pneumoniae
Important Consideration
The epidemiology of pediatric meningitis has changed significantly with the introduction of vaccines against Haemophilus influenzae type B (Hib), Streptococcus pneumoniae, and Neisseria meningitidis. However, vaccination status must be verified as part of the assessment.
Clinical Manifestations
The clinical presentation of meningitis in children varies significantly with age, type of pathogen, and disease progression:
Age-Specific Presentations
Neonates (0-28 days)
- Nonspecific symptoms – difficult to diagnose
- Temperature instability (hypothermia or fever)
- Poor feeding, irritability
- Lethargy or excessive sleepiness
- High-pitched cry
- Bulging fontanelle (late sign)
- Seizures
- Respiratory distress
- Note: Classic signs like neck stiffness often absent
Infants (1-12 months)
- Fever
- Irritability, inconsolable crying
- Vomiting and feeding difficulties
- Bulging fontanelle
- Lethargy or decreased responsiveness
- Seizures
Children (>1 year)
- High fever
- Severe headache
- Photophobia (light sensitivity)
- Phonophobia (sound sensitivity)
- Neck stiffness (nuchal rigidity)
- Vomiting
- Altered mental status
- Seizures
- Rash (particularly with meningococcal meningitis)
Brudzinski’s Sign
Flexion of the neck causes flexion of the hips and knees
Kernig’s Sign
Pain and resistance when trying to extend the knee while hip is flexed
Bulging Fontanelle
Raised, tense anterior fontanelle in infants – a late sign
Mnemonic: “FEVER PAIN” for Meningitis Symptoms
F – Fever (high)
E – Eye sensitivity (photophobia)
V – Vomiting
E – Encephalopathic (altered mental status)
R – Rash (especially in meningococcal)
P – Phonophobia (sound sensitivity)
A – Altered consciousness
I – Irritability (especially in infants)
N – Neck stiffness
Red Flags
The following signs require immediate medical attention:
- Purpuric or petechial rash (suggests meningococcal meningitis)
- Rapidly deteriorating mental status
- Focal neurological deficits
- Seizures
- Signs of increased intracranial pressure
- Shock or hemodynamic instability
Diagnostic Procedures
Prompt diagnosis of meningitis is critical for early intervention and improved outcomes. The gold standard for diagnosis is lumbar puncture (LP).
Lumbar Puncture (LP)
LP involves collection of cerebrospinal fluid (CSF) for analysis. Key aspects include:
Indications:
- Suspected meningitis
- Unexplained fever with neurological symptoms
- Unexplained altered mental status
- Evaluation of neonatal sepsis
Contraindications:
- Increased intracranial pressure (risk of herniation)
- Infection at LP site
- Coagulopathy or thrombocytopenia
- Cardiorespiratory instability
CSF Analysis:
| Parameter | Normal | Bacterial Meningitis | Viral Meningitis | Fungal Meningitis |
|---|---|---|---|---|
| Appearance | Clear, colorless | Cloudy, turbid | Clear to slightly cloudy | Clear to slightly cloudy |
| Opening pressure | 50-180 mmH2O | Elevated (>200 mmH2O) | Normal to slightly elevated | Elevated |
| WBC count | 0-5 cells/mm3 | 100-10,000 cells/mm3 (neutrophils) | 5-1000 cells/mm3 (lymphocytes) | 20-500 cells/mm3 (lymphocytes) |
| Protein | 15-45 mg/dL | Elevated (100-500 mg/dL) | Mildly elevated (50-100 mg/dL) | Elevated (>50 mg/dL) |
| Glucose | 50-80 mg/dL (2/3 of blood glucose) | Decreased (<40 mg/dL) | Normal | Decreased to normal |
| Gram stain | No organisms | May show organisms (60-90%) | No organisms | May show fungi with special stains |
Other Diagnostic Tests
Laboratory Tests:
- Complete blood count (CBC) – Elevated WBC suggests infection
- Blood cultures – To identify pathogen
- C-reactive protein (CRP) and procalcitonin – Elevated in bacterial infections
- CSF PCR for viral pathogens
- CSF culture and sensitivity
- Serum electrolytes – To assess for SIADH (syndrome of inappropriate antidiuretic hormone)
Imaging Studies:
- CT scan – Performed before LP if signs of increased ICP or focal neurological signs
- MRI – More sensitive than CT, may show meningeal enhancement, complications
- Ultrasound – For infants with open fontanelles to detect hydrocephalus or increased ICP
Mnemonic: “CSF PANG” for CSF Analysis
C – Cells (elevated WBCs)
S – Sugar (glucose decreased in bacterial)
F – Fluid appearance (cloudy in bacterial)
P – Protein (elevated)
A – Abnormal pressure (increased)
N – Neutrophils (predominant in bacterial)
G – Gram stain (may reveal organisms)
Important: When meningitis is strongly suspected, empiric antibiotics should be started before lumbar puncture if there will be a delay in performing the procedure, as diagnostic yield remains acceptable for 24-48 hours after antibiotic administration.
Treatment Approaches
Treatment of meningitis in children requires prompt intervention and is tailored to the suspected or confirmed pathogen.
Empiric Therapy
Initiated before pathogen identification based on age and presentation:
| Age Group | Common Pathogens | Empiric Antibiotic Regimen |
|---|---|---|
| Neonates (0-28 days) | Group B Streptococcus, E. coli, Listeria | Ampicillin + Gentamicin OR Ampicillin + Cefotaxime |
| Infants (1-3 months) | Group B Streptococcus, E. coli, Listeria, S. pneumoniae | Ampicillin + Cefotaxime/Ceftriaxone |
| Children (>3 months) | S. pneumoniae, N. meningitidis | Ceftriaxone/Cefotaxime + Vancomycin |
| Immunocompromised | Above plus Listeria, fungal pathogens | Vancomycin + Ceftriaxone/Cefotaxime + Ampicillin ± Antifungal |
Pathogen-Specific Therapy
Once the pathogen is identified, therapy is narrowed:
Bacterial Meningitis:
- S. pneumoniae: Ceftriaxone/Cefotaxime + Vancomycin (if penicillin-resistant)
- N. meningitidis: Ceftriaxone/Cefotaxime
- H. influenzae: Ceftriaxone/Cefotaxime
- Group B Streptococcus: Penicillin G or Ampicillin
- Listeria monocytogenes: Ampicillin + Gentamicin
- E. coli: Ceftriaxone/Cefotaxime
Viral Meningitis:
- Mainly supportive care
- Herpes simplex virus: Acyclovir
- Influenza: Oseltamivir if diagnosed early
Fungal Meningitis:
- Cryptococcus: Amphotericin B + Flucytosine
- Candida: Amphotericin B ± Fluconazole
Tuberculous Meningitis:
- Combination of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol
- Add corticosteroids (dexamethasone)
Adjunctive Therapies
Corticosteroids:
- Dexamethasone – reduces inflammatory response and may reduce complications
- Most beneficial in H. influenzae and pneumococcal meningitis
- Given before or with first dose of antibiotics
- Contraindicated in neonates
Supportive Care:
- Fluid management (careful monitoring for SIADH)
- Antipyretics for fever
- Anticonvulsants for seizures
- Monitoring and management of increased intracranial pressure
- Pain management
- Adequate nutrition
Treatment Considerations
- Duration of therapy varies:
- Bacterial meningitis: 7-21 days depending on pathogen
- Fungal meningitis: weeks to months
- TB meningitis: minimum 9-12 months
- Repeat LP may be necessary to ensure clearance of infection
- Pediatric dosing must be carefully calculated based on weight
- Monitor for adverse effects of antimicrobial therapy
Nursing Management
Comprehensive nursing management is essential for optimal outcomes in children with meningitis.
Mnemonic: “MENINGITIS Care” for Nursing Management
M – Monitor vital signs and neurological status
E – Ensure infection control practices
N – Neurological assessments frequently
I – Implement seizure precautions
N – Notification of reportable infections
G – Give medications as prescribed
I – Intake and output monitoring
T – Therapeutic positioning
I – Infection control and prevention
S – Support family and provide education
Assessment
- Frequent neurological assessment:
- Level of consciousness (using age-appropriate scales)
- Pupillary response
- Motor function and strength
- Fontanelle assessment in infants
- Cranial nerve assessment in older children
- Presence of meningeal signs
- Vital signs monitoring:
- Temperature (fever patterns)
- Heart rate (tachycardia may indicate sepsis)
- Respiratory rate and pattern
- Blood pressure (hypertension with bradycardia indicates increased ICP)
- Oxygen saturation
- Pain assessment:
- Use age-appropriate pain scales
- Assess for headache, neck pain, photophobia
- Intake and output monitoring:
- Risk for SIADH (decreased urine output, concentrated urine)
- Fluid balance
- Hydration status
Nursing Diagnoses
- Risk for ineffective cerebral tissue perfusion related to inflammation of meninges
- Hyperthermia related to infection and inflammatory process
- Acute pain related to inflammation of meninges and increased ICP
- Risk for injury related to seizure activity
- Deficient fluid volume related to fever, vomiting, poor intake
- Anxiety (patient/family) related to acute illness and hospitalization
- Disturbed sensory perception related to neurological effects of meningitis
- Risk for impaired skin integrity related to immobility and altered level of consciousness
Interventions
Neurological Management:
- Elevate head of bed 30° (unless contraindicated) to reduce ICP
- Implement seizure precautions:
- Padded side rails
- Suction equipment available
- Avoid restraints
- Emergency medications accessible
- Minimize environmental stimuli (dim lighting, reduce noise)
- Monitor for signs of increased ICP:
- Altered level of consciousness
- Pupillary changes
- Changes in vital signs (Cushing’s triad)
- Vomiting
- Bulging fontanelle in infants
Medication Administration:
- Administer antimicrobials as scheduled (timing is critical)
- Monitor therapeutic levels when applicable
- Assess for adverse reactions and drug interactions
- Administer antipyretics for fever management
- Provide analgesics for pain management
- Administer anticonvulsants if prescribed
Fluid and Nutrition Management:
- Maintain fluid balance as prescribed (may be restricted if SIADH present)
- Monitor electrolyte levels
- Provide age-appropriate nutrition
- Monitor weight daily
- Administer IV fluids as prescribed
Infection Control:
- Implement appropriate isolation precautions:
- Droplet isolation for meningococcal or H. influenzae meningitis for 24 hours after starting antibiotics
- Standard precautions for other types
- Educate family on importance of hand hygiene
- Notify appropriate authorities for reportable diseases
Comfort Measures:
- Position for comfort (neck pain common)
- Reduce environmental stimuli
- Provide quiet environment
- Administer pain medication as prescribed
- Apply cool compresses for fever
Supportive Care:
- Maintain skin integrity with frequent position changes
- Provide oral care
- Assist with activities of daily living as needed
- Implement safety measures for confused patients
Family-Centered Care
- Provide emotional support to child and family
- Educate family about:
- Disease process and expected course
- Treatment plan
- Signs of complications to report
- Importance of follow-up care
- Potential long-term sequelae
- Encourage family involvement in care when appropriate
- Provide developmentally appropriate activities and distractions
- Connect family with support resources if needed
- Assist with planning for discharge and home care needs
Evaluation & Outcomes
- Resolution of fever
- Improved neurological status
- Adequate pain control
- Absence of complications
- Adequate nutrition and hydration
- Family demonstrates understanding of:
- Medication administration
- Signs of complications
- Follow-up care requirements
- When to seek medical attention
- Return to age-appropriate activities
Complications and Prevention
Potential Complications
Acute Complications:
- Seizures
- Increased intracranial pressure
- Cerebral edema
- Hydrocephalus
- Subdural effusions
- Cerebral venous thrombosis
- Brain abscess
- Cranial nerve palsies
- Syndrome of inappropriate antidiuretic hormone (SIADH)
- Septic shock (especially with meningococcal meningitis)
- Disseminated intravascular coagulation (DIC)
Long-term Sequelae:
- Hearing loss (most common long-term complication)
- Developmental delays
- Cognitive impairment
- Learning disabilities
- Behavioral problems
- Seizure disorders
- Motor deficits
- Visual impairment
- Speech and language delays
| Type of Meningitis | Complication Rate | Common Sequelae |
|---|---|---|
| Bacterial (untreated) | 70-100% mortality | Death, severe neurological damage |
| Bacterial (treated) | 10-30% | Hearing loss, cognitive impairment, seizures |
| Viral | <5% | Usually self-limiting with full recovery |
| Fungal | 20-70% | Variable, depends on immune status and treatment timing |
| Tuberculous | 20-50% | Hydrocephalus, cranial nerve palsies, motor deficits |
Prevention Strategies
Immunization:
- Haemophilus influenzae type b (Hib) vaccine:
- Part of routine childhood immunization
- Primary series at 2, 4, 6 months with booster at 12-15 months
- Pneumococcal vaccines:
- PCV13 (pneumococcal conjugate vaccine) – routine at 2, 4, 6, 12-15 months
- PPSV23 (pneumococcal polysaccharide vaccine) – for high-risk children >2 years
- Meningococcal vaccines:
- MenACWY – recommended at 11-12 years with booster at 16 years
- MenB – may be given to adolescents 16-23 years
- Required for certain high-risk groups and during outbreaks
Chemoprophylaxis:
- For close contacts of cases of meningococcal meningitis
- For household contacts of Haemophilus influenzae type b meningitis if unvaccinated children in home
- Typically rifampin, ciprofloxacin, or ceftriaxone depending on situation
Other Preventive Measures:
- Good hand hygiene
- Avoiding close contact with individuals with respiratory infections
- Covering mouth and nose when coughing or sneezing
- Proper treatment of predisposing conditions (sinusitis, otitis media)
- Prompt treatment of infected individuals
- Infection control in healthcare settings
Nursing Role in Prevention
- Educate families about importance of vaccinations
- Ensure children receive vaccines according to recommended schedule
- Identify close contacts who may need prophylaxis
- Participate in community education about meningitis prevention
- Teach families about early recognition of symptoms
- Advocate for prompt medical attention for suspected cases
- Implement appropriate isolation precautions for hospitalized cases
Mnemonic: “PREVENT” for Meningitis Prevention
P – Prophylaxis for close contacts when indicated
R – Routine immunizations on schedule
E – Education about signs and symptoms
V – Vigilance for early symptoms
E – Environmental hygiene (handwashing)
N – Notification of public health authorities
T – Timely treatment of predisposing infections
Summary
Key Points to Remember
- Meningitis is inflammation of the meninges, which can be caused by bacterial, viral, or fungal pathogens
- Clinical presentation varies by age – infants and young children often present with nonspecific symptoms
- The gold standard for diagnosis is lumbar puncture with CSF analysis
- Prompt initiation of appropriate antimicrobial therapy is crucial for bacterial meningitis
- Nursing management includes neurological monitoring, medication administration, and family education
- Potential complications range from acute (seizures, increased ICP) to long-term (hearing loss, developmental delays)
- Prevention through vaccination is highly effective for specific pathogens
- Early recognition and treatment significantly improve outcomes
References and Further Reading
- American Academy of Pediatrics. (2021). Red Book: Report of the Committee on Infectious Diseases.
- Centers for Disease Control and Prevention. (2023). Meningitis. https://www.cdc.gov/meningitis/
- Hockenberry, M. J., & Wilson, D. (2022). Wong’s Nursing Care of Infants and Children.
- Thigpen, M. C., et al. (2011). Bacterial meningitis in the United States, 1998–2007. New England Journal of Medicine, 364(21), 2016-2025.
- World Health Organization. (2021). Meningitis. https://www.who.int/health-topics/meningitis