Clinical signs of meningitis

When examining a child for signs of meningitis it is crucial to remember that the younger a child the less likely it will be to have neck stiffness or photophobia (especially those <2 years of age). Be guided by the parents as to whether the child is drowsy or behaving inappropriately. Often parents are quick to recognise that the cry of a baby has changed or they are making poor eye contact.

• Babies with meningitis may have a full or bulging fontanelle reflecting the raised intracranial pressure.
  
  
• They may feel stiff or have jerky movements or they may be very floppy. Fits are common.
• Drowsiness or decreased conscious level (or fluctuating level) is a very important sign in children of all ages.
• Teenagers with meningitis often present in an aggressive and combative manner rather than becoming drowsy. Drug and alcohol intoxication may be suspected ²³.
• Rash: can be present, but more likely to be absent, atypical, scanty or petechial than in septicaemia.

(co-existing with symptoms of meningitis)

Clinical signs of raised intracranial pressure

Children with meningitis are at risk of developing RICP (see pathophysiology of RICP).

Signs of RICP are:

• Falling or depressed conscious level
• Abnormal posturing; decorticate or decerebrate
• Dilated pupils or unequal pupils
• Focal neurology
• Bradycardia and hypertension
• Abnormal breathing pattern
• Cushing's triad: slow pulse, raised blood pressure and abnormal breathing pattern - late sign of RICP
• Papilloedema is a late sign, its absence does not mean there cannot be any RICP
  
  Note: Health care workers are encouraged to wear masks when carrying out procedures which may result in exposure to infectious respiratory droplets, for example during resuscitation⁴⁶.
  
  

Patients with RICP may have prolonged capillary refill time and a mild metabolic acidosis. If these signs are present in a patient with a normal heart rate or bradycardia, and a normal or high blood pressure, then they are not due to shock.

The diagnosis of raised intracranial pressure is a clinical one:

• Routine CT scanning is not indicated in patients with meningitis as CT scans are not sensitive in picking up signs of RICP ^{31 32}. It is dangerous to put a child with fluctuating conscious level into the scanner without securing the airway first.
• Lumbar puncture is contraindicated in patients with signs of raised intracranial pressure as 'coning' can be precipitated 33 ³⁴.