Bulging Fontanelle Research Articles

Clinical Prognosis in Neonatal Bacterial Meningitis: The Role of Cerebrospinal Fluid Protein

Neonates are at high risk of meningitis and of resulting neurologic complications. Early recognition of neonates at risk of poor prognosis would be helpful in providing timely management. From January 2008 to June 2014, we enrolled 232 term neonates with bacterial meningitis admitted to 3 neonatology departments in Shanghai, China. The clinical status on the day of discharge from these hospitals or at a postnatal age of 2.5 to 3 months was evaluated using the Glasgow Outcome Scale (GOS). Patients were classified into two outcome groups: good (167 cases, 72.0%, GOS = 5) or poor (65 cases, 28.0%, GOS = 1–4). Neonates with good outcome had less frequent apnea, drowsiness, poor feeding, bulging fontanelle, irritability and more severe jaundice compared to neonates with poor outcome. The good outcome group also had less pneumonia than the poor outcome group. Besides, there were statistically significant differences in hemoglobin, mean platelet volume, platelet distribution width, C-reaction protein, procalcitonin, cerebrospinal fluid (CSF) glucose and CSF protein. Multivariate logistic regression analyses suggested that poor feeding, pneumonia and CSF protein were the predictors of poor outcome. CSF protein content was significantly higher in patients with poor outcome. The best cut-offs for predicting poor outcome were 1,880 mg/L in CSF protein concentration (sensitivity 70.8%, specificity 86.2%). After 2 weeks of treatment, CSF protein remained higher in the poor outcome group. High CSF protein concentration may prognosticate poor outcome in neonates with bacterial meningitis.

Feeding difficulties during the neonatal period

Feeding difficulties (FD) are a major issue in neonatology, as they could hamper the assessment of an adequate enteral nutrition, delay hospital discharge and lead to breastfeeding failure. Functional and anatomical maturation of the gastrointestinal tract is strictly related to gestational age (GA); hence, premature infants are more prone to develop FD. Feeding intolerance (FI) is very common among preterm infants; clinical symptoms of FI (e.g. abdominal distension, vomiting, bilious gastric residuals, occult or gross bloody stools) are observed in nearly 29% of such neonates [1]. FI could represent an early sign of necrotizing enterocolitis (NEC), which is the most feared gastrointestinal complication of prematurity. Hence, FI often brings clinicians to withhold, decrease or discontinue enteral feeds, thus hampering the establishment of an adequate enteral nutrition and leading to a prolonged duration of both parenteral nutrition (PN) and central lines, with increased risks of such complications as liver cholestasis or sepsis[2]. The coordination between sucking, swallowing and breathing is usually achieved at 34-36 weeks GA; hence, preterm infants are usually fed via an intragastric tube, through intermittent boluses or continuously. Poor sucking and sucking-swallowing incoordination are the major causes of FD and breastfeeding failure among late preterm infants (GA 34-366/7 weeks), with an increased risk of hypoglycemia, excessive weight loss, hyperbilirubinemia, dehydration[3]. Due to FD, up to 27% of all late preterm infants need to be initially supplemented with intravenous fluids[4]; moreover, tube feeding is frequently required for feeding administration in the first days of life. The abovementioned problems are infrequent in healthy term newborns. Term neonates developing FD such as poor sucking and/or vomiting need to be evaluated for pathological causes. Physical examination could aid to identify anatomical malformations possibly responsible for FD (e.g. cleft palate). FD and sleepiness can be due to hyperbilirubinemia, hypoglycemia or electrolyte disturbances[5], but could also subtend an underlying metabolic disease, such as hypothyroidism. FD, lethargy and/or other clinical neurological signs (e.g. seizures, focal neurological signs, hypo- or hypertonia, bulging fontanel, central apnoea) could address for central nervous system diseases (i.e. subarachnoid haemorrhage, ischaemic stroke, metabolic encephalopathy etc.). FD and lethargy could also represent a warning sign for invasive infections, especially if associated with respiratory distress, apnoea and bradycardia, temperature instability and increased capillary refill time[5]. Blood tests (including blood cells count, C-reactive protein, glucose, bilirubin, electrolytes, blood gas analysis) and cerebral ultrasound scan are useful tools to aid neonatologists in the differential diagnosis.

Clinical and ultrasonographic criteria for using ventriculoperitoneal shunts in newborns with myelomeningocele.

Objective Hydrocephalus is one of the main complications associated with myelomeningocele (MM). This study aimed to identify clinical and ultrasonographic criteria for using ventriculoperitoneal (VP) shunts in this group of patients.Method A retrospective cohort study, based on established protocol for VP shunt implant in hydrocephalic children with MM. Parameters used to guide the indication of VP shunts included measurement of head circumference (HC), evaluation of fontanels, and measurement of lateral ventricular atrium (LVA) width by transcranial ultrasonography.Results 43 children were included in the analysis, of which 74% had hydrocephalus and required a VP shunt. These children had LVA width ≥ 15 mm, showed increased HC, or had bulging fontanels.Conclusion VP shunt is required in children with increased HC (≥ 2 standard deviation regarding age group), bulging fontanels, or LVA width of ≥ 15 mm after the closure of MM.

Neonatal acute syphilitic meningitis: A case report

Although abnormal cerebrospinal fluid findings similar to aseptic meningitis are reported in up to 80% infants with congenital syphilis, overt symptomatic meningeal syphilis is quite a rare presentation, especially at an early age. We report a neonate who presented at 60 hours of life with irritability, poor activity, seizures and bulging fontanel. He was confirmed to have acute syphilitic meningitis.

Subdural hygroma associated with axillary cystic hygroma

We present a case of a 4-month-old girl with a history of a huge axillary cystic hygroma since birth, with elective surgical resection of the lesion and subsequent development of infection at the surgery site. During hospitalization for the infection, she developed seizures, a bulging fontanelle, increased head circumference, and widely separated cranial sutures. Brain imaging demonstrated new, large, bilateral subdural fluid collections with membrane enhancement around the left-sided collection. She was managed by subdural tap, bilateral craniotomy, broad-spectrum antibiotics, and subduroperitoneal shunt insertion. Ultimately, she had complete recovery without complications. This case adds to the spectrum of intracranial conditions that have been associated with cystic hygroma.

Characteristics of cerebrospinal fluid in neonatal purulent meningitis

Objective To analyze the changes of WBC classification, sugar and protein in cerebrospinal fluid(CSF) and pathogenic bacteria of neonatal purulent meningitis. Methods Thirty-one neonates with bacterial meningitis in our department of neonatology from June 2011 to June 2013 were enrolled, and the clinical features, pathogenic bacteria, laboratory examination of CSF were analyzed. Results Fever(90.3%), convulsions(67.7%) and changed consciousness(58.1%) were common clinical symptoms.The incidences of other nervous system abnormal signs such as gastrointestinal dysfunction(25.8%), abnormal breathing(16.1%), cervical resistance(16.1%), bulging fontanel(9.7%) were lower.The Gram-negative bacteria was more than Gram-positive in both blood and CSF culture.The escherichia coli was the most common bacteria, with positive rate of 38.1%(8/21)in blood culture and 55.5%(5/9)in CSF culture.The germiculture positive rate in CSF was lower than in blood culture (29.0% vs.67.7%). Polymorphonuclear leukocyte(PMN)[(79.61±12.06)%] was the most predominant cell of the leukocyte classification in CSF within 1 week in all cases, PMN was still predominant in 1 to 2 weeks in 7 cases, while only 2 cases in 2 to 3 weeks still dominated by PMN, PMN was not the predominant cell 3 weeks later. Conclusion In the typical neonatal purulent meningitis, PMN was the predominant cell in CSF within the first week, but the proportion of monocyte gradually increased and was dominant later.Escherichia coli was a common bacteria caused by this disease. Key words: Purulent meningitis; Neonate; bacteria; Cerebrospinal fluid; Polymorphonuclear leukocytes; Monocyte

The accuracy of a clinical parameters-based scoring system to predict spontaneous intracranial hemorrhage in children under one year old

Background Previous studies show that most children aged less than 1 year had intracranial hemorrhage without any history of trauma. The sign and symptoms of spontaneous intracranial hemorrhage (SIH) in children varies. To minimize morbidity and mortality, early detection and accurate diagnosis are required. Head CT scans area widely used for diagnosing SIH. Unfortunately, not all health facilities in Indonesia have CT scans.Objective To determine the accuracy of a clinical parameters-based scoring system in predicting spontaneous intracranial hemorrhage (SIH) in children under one year old.Methods This diagnostic study included children aged under one year who were admitted to Mohammad Hoesin Hospital, Palembang. Patients who showed any signs of increased intracranial pressure were recruited. Data were collected from medical records from January 2007 to September 2013. Through the use of logistic regression analysis, clinical parameters showing significant relationships with computerized tomography (CT)-scan confirmed SIH were selected as predictors. Each predictor was given a score based on an adjusted ratio. The cut-off point of the total scores from all patients was determined using a receiver operating curve (ROC) analysis. The accuracy of the total scores was calculated using a 2x2 validity test.Results Of the 186 children included in this study, 98 (52.7%) had SIH and 93 (94.8%) were under 3 month-old. The predictors for SIH used included age (>3 months: score 0; 1-3 months: score 3), gender (female: score 0; male: score 1), pallor (no: score 0; yes: score 1), bulging fontanel (no: score 0; yes: score 1), pupil (isocoria: score 0; anisocoria: score 2) and history of shaken baby (no: score 0; yes: score 3). The ROC analysis showed that the area under the curve (AUC) was 95.3% with a cut-off point of 4.5, had a sensitivity of 88.7% and a specificity of 93.1%Conclusion This scoring system based on clinical parameters had good accuracy for predicting SIH in children under 1 year of age who exhibited signs of increased intracranial pressure.

Does early neonatal vitamin A supplementation reduce infant mortality?

In this individually randomized, double-blind, placebocontrolled trial in Haryana, India, 44,984 neonates were randomly assigned to receive oral capsules containing vitamin A (retinol palmitate 50,000 IU plus vitamin E 9·5–12·6 IU; n=22,493) or placebo (vitamin E 9·5–12·6 IU; n=22 491) within 72 h of birth. The primary outcome was mortality between supplementation and 6 months of age. Between supplementation and 6 months of age, 656 infants died in the vitamin A group compared with 726 in the placebo group (29·2 per 1000 vs 32·3 per 1000; difference −3·1 per 1000, 95% CI −6·3 to 0·1; risk ratio 0·90, 95% CI 0·81 to 1·00). There was a small excess risk of transient bulging fontanelle (205 cases in the vitamin A group vs 80 cases in the placebo group; RR 2·56, 95% CI 1·98, 3·32).

Effect of early neonatal vitamin A supplementation on mortality during infancy in Ghana (Neovita): a randomised, double-blind, placebo-controlled trial

Results of randomised controlled trials of newborn (age 1-3 days) vitamin A supplementation have been inconclusive. The WHO is coordinating three large randomised trials in Ghana, India, and Tanzania (Neovita trials). We present the findings of the Neovita trial in Ghana. This study was a population-based, individually randomised, double-blind, placebo-controlled trial in the Brong Ahafo region of Ghana. The trial participants were infants aged at least 2 h, identified at home or facilities on the day of birth or in the next 2 days, able to feed orally, and likely to stay in the study area for at least 6 months. They were randomly assigned (ratio 1:1) to receive either one oral dose of vitamin A (50,000 IU) or placebo immediately after recruitment. The research team and parents of the infants were masked to treatment assignment. Follow-up home visits were undertaken every 4 weeks, when data were recorded for deaths, facility use, and care seeking. The primary outcome was post-supplementation mortality to 6 months of age. Analysis was by intention to treat. Potential adverse events were recorded at 1 and 3 days after supplementation. This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)CTRN12610000582055. We assessed 26,414 livebirths for eligibility between Aug 16, 2010, and Nov 7, 2011. We recruited 22,955 newborn infants, with 11,474 randomly assigned to receive vitamin A and 11,481 to receive placebo. Loss to follow-up was low with vital status at 6 months of age reported for 22,698 (98·9%) infants. We recorded 278 post-supplementation deaths to 6 months of age in the vitamin A group (mortality risk 24·5 in 1000 supplemented infants) and 248 deaths in the placebo group (mortality risk 21·8 per 1000 supplemented infants), relative risk (RR) 1·12 (95% CI 0·95-1·33; p=0·183) and risk difference (RD) 2·66 (95% CI -1·25 to 6·57; p=0·18). Adverse events within 3 days of supplementation did not differ by trial group. 122 infants died in the first 3 days after supplementation; 70 (0·6%) in the vitamin A and 52 (0·5%) in the placebo group (risk ratio [RR] 1·35, 95% CI 0·94-1·93, p=0·102). 53 infants were reported to have a bulging fontanelle; 32 (0·3%) in the vitamin A group and 21 (0·2%) in the placebo group (RR 1·53, 0·88-2·62, p=0·130). The results of this trial do not support inclusion of newborn vitamin A supplementation as a child survival strategy in Ghana. Bill & Melinda Gates Foundation grant to the WHO.

Efficacy of early neonatal supplementation with vitamin A to reduce mortality in infancy in Haryana, India (Neovita): a randomised, double-blind, placebo-controlled trial

Vitamin A supplementation in children aged 6 months to 5 years has been shown to reduce mortality. The efficacy of neonatal supplementation with vitamin A to reduce mortality in the first 6 months of life is plausible but not established. We aimed to assess the efficacy of neonatal oral supplementation with vitamin A to reduce mortality between supplementation and 6 months of age. We undertook an individually randomised, double-blind, placebo-controlled trial in Haryana, India. We identified pregnant women through a surveillance programme undertaken every 3 months of all female residents in two districts of Haryana, India, aged 15-49 years, and screened every identified livebirth. Eligible participants were neonates whose parents consented to participate, were likely to stay in the study area until at least 6 months of age, and were able to feed orally at the time of enrolment. Participants were randomly assigned to receive oral capsules containing vitamin A (retinol palmitate 50,000 IU plus vitamin E 9·5-12·6 IU) or placebo (vitamin E 9·5-12·6 IU) within 72 h of birth. Randomisation was in blocks of 20 according to a randomisation list prepared by a statistician not otherwise involved with the trial. Investigators, participants' families, and the data analysis team were masked to treatment allocation. The primary outcome was mortality between supplementation and 6 months of age. Analysis included all participants assigned to study groups. This trial is registered with ClinicalTrials.gov, number NCT01138449, and the Indian Council of Medical Research Clinical Trial Registry, number CTRI/2010/091/000220. Between June 24, 2010, and July 1, 2012 we screened 47,777 neonates and randomly assigned 44,984 to receive vitamin A (22,493) or placebo (22,491). Between supplementation and 6 months of age, 656 infants died in the vitamin A group compared with 726 in the placebo group (29·2 per 1000 vs 32·3 per 1000; difference -3·1 per 1000, 95% CI -6·3 to 0·1; risk ratio 0·90, 95% CI 0·81 to 1·00). We noted no significant interactions between the intervention effect and sex on mortality at 6 months (p=0·409). Supplementation with 50,000 IU vitamin A within the first 72 h of life was generally safe and well tolerated, with the exception of a small excess risk of transient bulging fontanelle (205 cases in the vitamin A group confirmed by physician vs 80 cases in the placebo group, risk ratio 2·56 [95% CI 1·98-3·32]). The findings of this study, done in a population in which vitamin A deficiency is a moderate public health problem, are consistent with a modest reduction in mortality between supplementation and 6 months of age. These findings must be viewed together with similar trials in other populations to enable determination of appropriate public health policy. Bill & Melinda Gates Foundation to WHO.

E-006 Familial Incidence of the Congenital Torcular Dural Arteriovenous Shunt

PurposeThere are several hereditary disorders that are well known to be associated with arteriovenous malformations (AVMs) involving the central nervous system including Sturge-Weber, Klippel-Trenaunay-Weber, and Parkes-Weber syndromes as well as...

Mechanistic studies in swine to evaluate newborn infant vitamin A dosing strategies (260.1)

Clinically, infant care is challenging especially in resource‐poor developing countries where small‐for‐gestational‐age is common and in any country when an infant is born prematurely. Several components comprise perinatal mortality of infants. Children suffering from vitamin A deficiency have a greater risk of irreversible blindness and dying from infectious diseases. Supplementation programs are an approach to address this issue. Studies have found little or no improvement in infant vitamin A status after supplementing with 25,000 IU vitamin A. Based on WHO’s recommendations, children ages 6 ‐ 11 mo receive 100,000 IU vitamin A and those 12 ‐ 59 mo receive 200,000 IU vitamin A every 4 to 6 mo. Multi‐centered and randomized trials of infant supplementation programs have shown inconsistent results. Infant supplementation itself has been debated due to the higher incidence of bulging fontanelle in vitamin A‐dosed infants. Therefore, a series of studies were performed in a swine model to evaluate infant dosing regimens. Newborn piglets from vitamin A‐depleted sows received a placebo, 25,000, 50,000, or 200,000 IU vitamin A supplements at birth. Tissues were collected and analyzed. The degree of vitamin A deficiency did not seem to affect the response to treatment. High doses may be quickly catabolized to maintain balance. Lung and spleen require chylomicron vitamin A to maintain concentrations, which was confirmed with a tracer study using α‐retinol. The tracer study also showed quick uptake in the adrenal gland. Low birth weight piglets took up less vitamin A. Food sources of vitamin A performed better than supplementation at improving vitamin A status of offspring.Grant Funding Source: Supported by the Nutrition Unit at the World Health Organization.

Surgical options for treatment of traumatic subdural hematomas in children younger than 2 years of age

Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center. In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker-Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study. One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days-23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%. The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.

Cranial Computed Tomography Utilization for Suspected Ventriculoperitoneal Shunt Malfunction in a Pediatric Emergency Department

BackgroundComputed tomography (CT) scan, the largest medical source of ionizing radiation in the United States, is used to test for failure of ventricular peritoneal shunts. Study ObjectivesTo quantify the exposure to cranial CT scans in pediatric patients presenting with symptoms of shunt malfunction, and to measure the association of signs and symptoms with clinical shunt malfunction and the need for neurosurgical intervention within 30 days of presentation. MethodThis was a quality improvement study evaluating a pathway used by providers in a tertiary care pediatric emergency department with 85,000 patient visits per year, by retrospective chart review of 223 patient visits for suspected shunt malfunction. We determined the median CT scan per patient per year and the association of signs and symptoms on the pathway with radiological signs of shunt failure and neurosurgical intervention within 30 days of scan. ResultsThe median exposure was 2.6 (interquartile range 1.44–4.63) scans per patient per year. Among 11 signs and symptoms, none was associated with radiologic shunt failure. Neurosurgical intervention within 30 days was positively associated with bulging fontanelle (adjusted odds ratio [AOR] 11.78; 95% confidence interval [CI] 1.67–83.0) and behavioral change (AOR 3.01; 95% CI 1.14–7.93), and negatively associated with seizure (AOR 0.13; 95% CI 0.02–0.79) and fever (AOR 0.15; 95% CI 0.04–0.55). ConclusionsPatients with ventricular peritoneal shunts underwent many cranial CT scans each year. None of the signs or symptoms included on the clinical pathway was predictive of changes on CT scan.

The Legacy of John Caffey: Shaken Baby or Pyloric Stenosis?

The American Academy of Pediatrics’ 1993 definition of Shaken Baby Syndrome (SBS) refers to John Caffey’s 1972 publication describing a syndrome including retinal hemorrhages, subdural and/or subarachnoid hemorrhages. In his 1974 follow-up paper emphasis is on possible predictive factors in the infant’s history. Particularly significant are bulging fontanels and “Forceful” vomiting. Bulging fontanels suggest excessive intra-cranial pressure, and forceful vomiting suggests pyloric stenosis. It is this invitation to consider the possible involvement of vascular hypertensive factors that is his legacy, the subject of this paper. The SBS hypothesis assumes that the brain “floats” in the skull tethered only by the bridging veins. Actually, the apparently vacant subarachnoid space is filled by a mesh of collagen reinforced fibres, called “trabeculae”. These are too fine to register on Ultrasound or MRI screens. Importantly, it is these trabeculae (not the bridging veins) that position the brain in the skull. They also locate and support the bridging veins. These trabeculae are not mentioned in the SBS literature, rendering the SBS hypothesis invalid in its present form. Forceful vomiting produces extreme venous hypertension which can induce Valsalva Retinopathy (bleeding in the eyes), and tearing (splitting) of the subdural compartment, leading to subdural hemorrhage. Pyloric stenosis occurs in 1 in 150 male infants, but only 1 in 750 females, a M/F ratio 5:1. Male preponderance is also found in convictions for “Shaken Baby Syndrome”, 62.6%. (M/F 2:1). Here, this is attributed to testosterone accelerated production of contractile proteins in pyloric smooth muscle cells, causing them to swell and block the lumen earlier than in females.

Neonatal Sepsis as a Major Cause of Morbidity in a Tertiary Center in Kathmandu

Neonatal sepsis causes high morbidity and mortality of newborns. The study aims to study the predictors and clinical, haematological and bacteriological factors of neonatal sepsis. A descriptive cross sectional study was conducted in a Neonatal Intensive Care Unit (NICU) of Paropakar Maternity and Women's Hospital in Kathmandu between October and December 2011. Demographic, obstetrics, clinical and microbiological data were studied for 300 neonates. The NICU prevalence rate of sepsis was 37.12%. Early onset neonatal sepsis was common (91.39%) (P=0.000). Cesarean section (OR 1.95, 95% CI 1.15-3.31), apgar score<4 at 1 min (P=0.00) and <7 at 5 min of birth (P=0.00) predicted sepsis. Neonates with sepsis were more likely to present with hypothermia (OR 1.180, 95% CI 0.080-17.214), pustules (OR 2.188, 95% CI 0.110-43.465), dehydration (OR 3.040, 95% CI 0.170-54.361), diminished movement (OR 3.082, 95% CI 0.433-21.950) and bulging fontanels (OR 16.464, 95% CI 0.007-41495.430). Coagulase negative Staphylococcus spp. (CoNS) (21, 41.17%) was most common pathogen of neonatal sepsis. Variable antibiotic resistance patterns of isolates with emergence of meropenem resistance in Pseudomonas spp. and methicillin resistance in CoNS and S. aurues were noted. Mortality due to sepsis was highest (15, 8.06%) among total mortalities (21, 11.29%). Delivery via cesarian section, apgar score<4 at 1 min, and <7 at 5 min predicted sepsis. Morbidity and mortality of neonatal sepsis was common in this setting and early maternal and neonatal interventions are required to address this issue.

Diagnostic and evolutionary aspects of intraventricular hemorrhage in preterm infants

Objectives. The aim of this study was to asses the risk factors, the grades of severity, and the complications associated with intraventricular hemorrhage. Methods. The retrospective study, conducted over a period of five years in the Neonatology Clinic Timisoara, included 514 preterm infants with specific sonographic signs of intraventricular hemorrhage (IV). Results. The incidence varied indirectly proportional to gestational age, being higher among preterm VLBW and ELBW. The main incriminated risk factors were: acidosis, respiratory distress syndrome, hypoxia and hypercarbia. The distribution of cases based on the degree of severity was as follows: grade I, 204 patients (39.68%), grade II, 142 patients (27.62%), grade III, 91 cases (17.70%) and grade IV, 77 cases (15%). Most cases were asymptomatic, being diagnosed based on routine ultrasound. 36% had saltatory evolution, with progressive deterioration of neurologic status, altered muscle tone and respiratory distress. 21% had catastrophic evolution with bulging fontanelle, projectile vomiting, seizures, decerebrate posturing, and apneic spells. Upon follow-up at 6 months, the outcome of the sonographic signs depended on the severity of the bleed, 28.9% cases presented complete resorption, 35% germinal matrix cyst and 25.87% ventriculomegaly. Conclusions. Transfontanellar ultrasound was the diagnostic method of choice. Most intraventricular bleedings were diagnosed among VLBW and ELBW infants, and were severe forms of disease. Mild and medium forms of disease had good outcome, with partial/ complete resolution of the ultrasonographic signs. Posthemorrhagic obstructive hydrocephalus was the most common complication.

Central Nervous System Involvement in Hemophagocytic Lymphohistiocytosis: A Single-Center Experience

BackgroundHemophagocytic lymphohistiocytosis is a rare multisystem disorder characterized by proliferation and diffuse infiltration multiple organs with histiocytes, including the central nervous system. PATIENTS and MethodsThirty children diagnosed with hemophagocytic lymphohistiocytosis between 1997 and 2010 were reviewed and analyzed. Central nervous system disease involvement was defined as the presence of neurological symptoms and signs or elevated values of cerebrospinal fluid cells and/or proteins. ResultsAmong the 30 patients, 17 (56%) had central nervous system involvement. Fourteen patients (46%) presented with neurological symptoms including seizures, irritability, bulging fontanelle, cranial nerve palsy, or disturbance of consciousness, whereas the remaining three patients developed central nervous system symptoms during the course of the disease. Seventeen patients (56%) had cerebrospinal fluid abnormalities. Neuroradiological studies were performed in nine patients. The most common findings were edema, atrophy, subcortical necrosis, and high signal intensity on T2-weighted magnetic resonance imaging. All patients were treated according to the Hemophagocytic Lymphohistiocytosis-94 and Hemophagocytic Lymphohistiocytosis-2004 protocols. Patients with central nervous system involvement had greater mortality. In prediction of the outcome, the cutoff value for cerebrospinal fluid protein was 470 mg/L. The most common neurological sequela was psychomotor delay. ConclusionCentral nervous system involvement in hemophagocytic lymphohistiocytosis is common and is associated with poor outcome.

Bacterial Meningitis in Children

To assess the clinical and laboratory features of suspected meningitis to assist in the accurate diagnosis of bacterial meningitis in young Indian children. Children <2 years of age with clinical suspicion of meningitis were enrolled. Clinical and laboratory information was collected, and cases were classified based on cerebrospinal fluid findings as clinical, aseptic, or probable and confirmed bacterial meningitis. A total of 2564 children with suspected meningitis were enrolled over 45 months; 156 cases of aseptic and 51 cases of bacterial meningitis were identified. Stiff neck and bulging fontanelle were more common in bacterial meningitis (P < .05), but were present in <15% of patients. The World Health Organization and American Academy of Pediatrics classifications for high suspicion of bacterial meningitis were met in 84% and 88% of cases of bacterial meningitis, respectively, but were also present in 54% and 74% cases of aseptic meningitis. Culture and gram stain were positive in 7 (14%) and 4 (8%) cases of bacterial meningitis. Signs of bacterial meningitis and proposed criteria for high suspicion of bacterial meningitis are non-specific in this population. Standard microbiological tests for bacteria are insensitive in this setting, necessitating highly sensitive methods to identify bacterial meningitis.

Utilité de la ponction lombaire lors de la première convulsion fébrile chez l’enfant de moins de 18 mois. Étude rétrospective de 157 cas

Because meningitis symptoms are not very specific under the age of 18 months, lumbar puncture (LP) was widely recommended in children presenting a febrile seizure (FS). Recent retrospective studies have challenged this age criterion. In 2011, the American Academy of Pediatrics updated its guidelines for the first episode of simple FS: LP is indicated if signs suggestive of meningitis are present and remains "an option" in case of prior antibiotic treatment or between the age of 6 and 12 months if the child is not properly vaccinated against Haemophilus and Streptococcus pneumoniae. Because the meningitis epidemiology and the vaccination coverage are different, the objective of this study was to evaluate whether these new guidelines were applicable in France. Between 2009 and 2010, we conducted a retrospective single-center study including 157 children aged less than 18 months admitted to the pediatric emergency department (Children's Hospital, Toulouse, France) for their first febrile seizure. The data collected were: type of seizure, knowledge of prior antibiotic treatment, neurological status, signs of central nervous system infection, and biological results (LP, blood cultures). Lumbar puncture was performed in 40% of cases (n=63). The diagnosis of meningitis/encephalitis was selected in eight cases: three cases of viral meningitis, three bacterial meningitis (Streptococcus pneumoniae), and two non-herpetic viral encephalitis. The incidence of bacterial meningitis in our study was 1.9%. The risk of serious infection, bacterial meningitis or encephalitis, was increased when there was a complex FS (14% versus 0% with a simple FS, P=0.06). The presence of other suggestive clinical symptoms was strongly associated with a risk of bacterial meningitis/encephalitis (36% in case of clinical orientation versus 0% in the absence of such signs, P<0.001). All severe clinical presentations were associated with complex FS (prolonged, focal, and/or repeated seizures) and the presence of other suggestive clinical signs (impaired consciousness lasting longer than 1h after the seizure, septic aspect, behavior disorders, hypotonia, bulging fontanel, neck stiffness, petechial purpura). The risk of bacterial meningitis or encephalitis associated with a simple FS and followed by a strictly normal clinical examination is extremely low. After a simple febrile seizure without any other suggestive signs of meningitis, systematic lumbar puncture is not necessary even in children younger than 18 months. LP remains absolutely indicated if clinical symptoms concentrate on central nervous system infection and should be discussed in case of complex seizures, prior antibiotic treatment, or incomplete vaccination.