How to… perform a lumbar puncture

Cite this article as:
Taryn Miller. How to… perform a lumbar puncture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31106

Performing a neonatal or paediatric lumbar puncture can be a daunting procedure but is an important part of the initial investigations of an unwell patient. However, it’s important to remember that a lumbar puncture should never delay administration of antibiotics that could be life-saving to a patient with suspected bacterial meningitis. 

Before the start of any procedure always ask, “Why are we doing this procedure? Are there any contraindications?”. 

The Royal Children’s hospital in Melbourne outline the indications and contraindications to performing a lumbar puncture as follows:

Indications

  • Suspected meningitis or encephalitis 
  • Suspected subarachnoid haemorrhage in the context of a normal CT scan 
  • To assist with the diagnosis of other CNS or neurometabolic conditions 

Contraindications

  • The febrile child with purpura where meningococcal infection is suspected 
  • Cardiovascular compromise/ shock 
  • Respiratory compromise 
  • Signs of raised intracranial pressure (diplopia, abnormal pupillary responses, abnormal motor posturing or papilledema) 
  • Coma: Absent or non-purposeful response to pain. 
  • Focal neurological signs or seizures 
  • Recent seizures 
  • Local infection around the area where the LP would be performed 
  • Coagulopathy/ thrombocytopenia 

The next important step is to gain verbal consent from the parents by explaining the procedure, risks and complications. 

Stop – As a parent, an initial septic workup of an unwell child can be an extremely stressful time. Try and explain the procedure with the risks and complications as concisely and clearly as you can without using medical jargon. It can be useful to think… if I were a parent what would I want to know?

It is useful to have your departments recommended lumbar puncture leaflet printed to give to the parents to read after the conversation. 

We would like to perform an investigation known as a lumbar puncture on your child. We do not perform this investigation unless it is absolutely necessary, and we think this is necessary to perform on your child today. 

This is a test that involves a small needle that is inserted into the back of your babies/ child’s spine to obtain a sample of the fluid that runs around the brain and the spinal cord. We usually do this test to identify whether your child has meningitis (infection of the lining of the brain). Sometimes we occasionally think your child is too ill to have a lumbar puncture and we will give antibiotics straight away to cover the most common types of bugs that cause meningitis. However, if possible, we like to perform a lumbar puncture that helps us identify: 1 ) if your child has meningitis by looking at the cells in the fluid, and 2) what type of bug is causing your child’s meningitis. This helps us choose the correct type of antibiotic and how long it is needed for. 

The procedure can be an uncomfortable procedure similar to performing a blood test. Most babies will be upset by being held in one position more than by the procedure itself. To minimise discomfort we will give pain relief such as sucrose or a pacifier to help. The procedure usually takes 30 minutes to perform. 

This can be a distressing procedure for parents to watch and we often offer parents not to be present while we perform the procedure. This can help increase the chance of success as it is a difficult procedure to perform. However, you are always more than welcome to be present. 

A lumbar puncture is a safe test and the risk of any serious complications such as bleeding, infection or damage to the nerves is extremely low. More common risks are that we are not able to get the sample we need or having to try more than once. Today we will only try twice and then stop if we are unsuccessful. 

Remember the parents may refuse a lumbar puncture and this should prompt us to think again and take some more time to re-discuss this with a senior and / or the parents. 

The procedure

Gather equipment and personnel 0:13  

Ensure that at least two people (the person performing the lumbar puncture and an assistant to hold) are present. It is often useful to have a third person to help as an assistant or with any other problems during the procedure. 

Equipment

  • Drapes or a sterile dressings pack 
  • Sterile gloves 
  • Sterile Gown 
  • Mask 
  • Spinal needle – 22G or 25G bevelled spinal needle with a stylet* 
  • Specimen pots x 2/3 
  • Chlorhexidine 0.5% in 70% alcohol solution with tint (chloraprep 3mls skin cleaning applicator) or your local alternative 
  • Local anaesthetic and/or sucrose 
  • Specimen pots x 2 
  • Labels 
  • Tegaderm for the site following removal of the needle 

For some more information on how to choose a correct spinal needle for the patient check this post from Henry.

Position 0:35

Position is everything for a paediatric lumbar puncture. A calm, cool and collected assistant who is confident in maintaining an adequate position is essential for improving the likelihood of success. 

You: Decide whether you are going to sit or stand for the procedure and set the bed height accordingly 

Patient: 

  • Position the patient in the left or right lateral position with their knees to their chest. Avoid over flexing the neck as this can cause respiratory compromise especially in younger neonatal patients. 
  • Position the patient so that the plane of their back is exactly perpendicular (90 degrees) to the bed. 
Lateral position for lumbar puncture

Landmarks: 

You are aiming for approximately the L3-L4 or L4-5 interspace. In neonates you can feel the ASIS and in older children you can feel the PSIS.  Invision a straight line between the top of the iliac crests intersecting your target area L3/4. 

Analgesia, anaesthesia, and sedation  1:15

  • All children should have a form of local anaesthetic used which can include: 
  • For the neonatal population oral sucrose can be used. 
Layers of the spine

The procedure 1:36

  • Prep the trolley by cleaning with a detergent wipe and allow it to dry before the procedure set up 
  • Open the dressings pack onto the clean trolley and using a non-touch technique drop the sterile gloves, cleaning solution and lumbar puncture needle into the sterile area. 
  • Wash hands and don sterile gloves 
  • Put a sterile drape under the patient’s buttocks, on the right and left side of the desired site and at the top leaving the spine exposed. It’s a good idea to keep the nappy on a neonate during the procedure and pull it slightly further down to prevent faeces accidentally sliding into the sterile field during the procedure. 
  • Clean the area using the chlorhexidine solution to disinfect the skin around the procedure site. Do not place the used swab on the sterile field but dispose of immediately in the bin. Wait for the skin to dry 
  • Take the tops off the specimen pots and keep them on your sterile field ready 
  • Identify the desired space as described above  
  • If using lignocaine infiltrate at this step 
  • Position the needle with the bevel facing up towards the ceiling
  • Direct the needle towards the umbilicus 
  • Resistance will be met often felt as the needle moves through the ligamentum flavum
  • Keep advancing slowly – a pop may be felt as the epidural space is now crossed and the subarachnoid space is entered a few millimetres more. 
  • Remove the stylet and check for CSF 
  • If CSF fluid Is present collect 6-10 drops of CSF in each container. Number the container depending on analyses required. 
  • Re-insert the stylet (to reduce the risk of head) and in one swift manoeuvre, remove the needle and stylet. 
  • Apply pressure to the site 
  • Use a tegaderm dressing so that the site is visible to staff to assess for infection 

Trouble-shooting

  • If, when you initially insert the needle the neonate or child moves, do not advance, keep the needle in place and wait. Allow the child to settle, and re-check the position, then continue to advance. 
  • If the CSF is blood stained this can still be collected for culture and if it runs clear can be collected for a cell count at this point.

For More useful tips for LP’s check out this post by dftb Ben Lawton. Pro tips for LPs in kids, Don’t Forget the Bubbles, 2015. Available at:
https://doi.org/10.31440/DFTB.7969

References 

Other references 

  1. https://www.rch.org.au/kidsinfo/fact_sheets/Lumbar_puncture/ 

Petechiae in Children – the PiC Study

Cite this article as:
Tessa Davis. Petechiae in Children – the PiC Study, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.30782

Today the Lancet has published the long-awaited results of the Petechiae in Children (PiC) study. Team DFTB got our hands on a pre-publication copy to read, summarise, and analyse for you. So let’s get to it.

This PERUKI study by Waterfield et al. is a prospective, multicentre cohort study:

Waterfield T, Maney J-A, Fairley D, Lyttle MD, McKenna JP, Roland D, Corr M, McFetridge L, Mitchell H, Woolfall K, Lynn F, Patenall B, Shields MD, Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study, The Lancet, 2020

Why is this study needed?

We are all somewhat terrified of children with fever and a non-blanching rash. We don’t want to miss meningococcal sepsis. Current guidelines are based on data from before the introduction of the Meningococcal B (2015) and C (1999) vaccines and consider a prevalence of 10-20% of meningococcal infection in children with fever and non-blanching rash.

Who were the patients?

The paper looked at children under 18 years old presenting to 37 Paediatric Emergency Departments in the UK over a 16 month period. Children were included if they had a fever (>38oC) and new onset of a non-blanching rash or features suggestive of meningococcal infection. Children were excluded if they had a pre-existing haematological condition or if they already had a diagnosis of Henoch-Schonlein purpura.

1513 patients were screened. 179 were excluded due to not meeting the criteria, not consenting, or a language barrier. Five that were enrolled had incomplete data leaving 1329 children were enrolled and included – the median age was 24 months, and 59% were male. Most children were vaccinated with 73% having had at least one dose of the Meningococcal B vaccine, and 77% having had at least one dose of the Meningococcal C vaccine.

What was the intervention?

There was no intervention here. Included patients were recruited at the point of meeting the criteria, using ‘recruitment prior to consent‘ and then consent was obtained soon after (usually within 24 hours). Data were collected contemporaneously: patient symptoms, blood test results, and treatment. A positive case was identified by being positive on PCR, or with a positive growth from another body sample (e.g. blood culture, or CSF). Patients were also checked for re-attendance to the hospital within 7 days. Results were also confirmed with the Public Health Agency – as meningococcal disease is a notifiable condition, this was a good method of picking up any missed cases.

What were the outcomes measured?

The primary outcome was assessing the performance of eight clinical guidelines on identifying children with invasive meningococcal disease (NICE meningitis (CG102); NICE sepsis (NG51); London; Chester; Bristol; Nottingham; Newcastle-Birmingham-Liverpool; and Glasgow).

The secondary outcomes were: performance of the eight guidelines in identifying children with other bacterial infections; and also looking at a cost comparison of each of the eight guidelines.

What were the results?

Of all 1334 children, 86% had a blood test and 45% had antibiotics. For patients admitted to hospital, the median length of stay was one night. 11 patients were admitted to PICU (2%) and two patients died (<1%).

Eight of these 11 PICU patients had N. meningitidis as did both of the patients who died. Seven patients had invasive bacterial infection (five with pneumococcal infection, one with E. Coli, and one with Group A Strep).

19 (1%) of patients in the cohort had meningococcal disease. 17 of these had N. meningitidis B, one had N. meningitidis C, and one had N. meningitidis W. Overall there were 26 patients (2%) with invasive bacterial infection (19 with meningococcal disease and 7 with an invasive bacterial infection).

346 patients (26%) did not have standard testing, and of these 19 patients (5%) had one unplanned re-attendance within seven days. However, none of these required readmission, antibiotics, or bacterial infection.

And how did the guidelines do?

All eight guidelines identified all of the 19 cases of meningococcal disease and all 26 cases of invasive bacterial infection (so the sensitivity of all of them is 100%). Specificity varied though. The NICE sepsis guideline stratified every patient as having a bacterial infection and therefore had a specificity of zero, making it the lowest specificity out of all the guidelines (closely followed by NICE meningitis guidelines with a specificity of 1%). This strategy clearly has cost implications too which is why the two NICE guidelines were also the most expensive per patient (£660.41 for the NICE sepsis guidelines).

Coming out top of the guideline ranking was the Barts Health NHS Trust guideline with a sensitivity of 100%, a specificity of 36%, and a cost of £490.29. This makes it the most accurate and also the cheapest.

Here’s the Barts Health NHS Trust guideline:

What about when we don’t follow the guidelines?

In practice, the guidelines were adhered to in 46% of the patients in the cohort. Deviation from guidelines resulted in fewer antibiotics being given. However, it also resulted in two patients being discharged with early meningococcal disease (they were subsequently treated and did not need PICU admission). Clinician decision-making increased the specificity (i.e. clinicians treated fewer people with antibiotics who didn’t have an invasive bacterial infection), but unfortunately reduced the sensitivity to 89%. Clinician decision-making did have the lowest cost per patient.

You’ve heard the facts, but how good was the paper?

As Ken Milne says…let’s get nerdy (and consider the CASP checklist for cohort studies)

Yes.

Research without prior consent was used to avoid recruitment delaying any treatment plans. However consent was obtained as soon as possible after inclusion in the study (usually within 24 hours).

Yes. Objective measurements were used for a blood test and PCR results. Risk factors for meningococcal disease are subjective and were based on contemporaneous clinical assessment – but this is what we do in practice so is a good reflection.

Yes. Note, however, that two patients with meningococcal disease were not included – one was not enrolled and the other was deemed by local staff to be inappropriate for inclusion.

Yes.

Yes, and also results were also checked with the Public Health Agency which would have allowed pick up of any missed meningococcal positive results.

There is a 1% prevalence of meningococcal disease in a mainly immunised population of children with fever and a non-blanching rash. The Barts Health NHS Trust guideline was the most accurate out of all the guidelines and with the lowest cost per patient.

Yes.

Yes. However, they would not be transferrable to populations with lower rates of vaccine uptake or a higher disease prevalence. The data was not shared on whether those with meningococcal disease were unimmunised or not, and therefore it would be prudent to be more cautious if your patient is not vaccinated.

Previous data was from prior to the meningococcal vaccination so this is the first and largest study since then.

What did the authors conclude and what can we take away from this study?

Since the advent of a vaccination programme and increased vaccine uptake, the rates of meningococcal disease are lower. Although previous data suggested 10-20% of children with fever and a non-blanching rash had meningococcal disease, in fact this study shows that only 1% had meningococcal disease.

Using a cautious guideline like NICE results in a lower specificity and higher cost. Tailored guidelines can increase the specificity and reduce the cost per patient without compromising on 100% sensitivity. The Barts Health NHS Trust guideline was the top performing guideline.

And finally, a comment from the authors themselves:

From Tom Waterfield:

The Petechiae in Children study represents the best available evidence regarding the assessment and management of febrile children with non-blanching rashes in the UK and clearly demonstrates that a lighter touch, tailored approach, is favourable to a test/treat all approach as currently advised by NICE. Moving to a tailored approach will reduce the need for invasive procedures, improve antimicrobial stewardship and save money. 

In vaccinated populations where the prevalence of invasive meningococcal disease is low the presence of Petechiae alone should no longer be viewed as a red flag and should not be used to justify immediate treatment with broad spectrum antibiotics. The emphasis and teaching should shift away from worrying about all non-blanching rashes with greater emphasis on the importance of identifying purpuric rashes as they confer the greatest risk of invasive meningococcal disease. 

Finally the PiC study demonstrates the importance of well designed prospective research studies in identifying risk factors for sepsis. Traditional approaches utilising retrospective reporting of symptoms from convenience samples of children with sepsis results in an over estimation the risks. This in turn leads to the development of overly aggressive clinical practice guidelines that are poorly adhered to. 

Note from Tessa: I am an employee of Barts Health but was not involved in the PiC study or in writing the Barts Health NHS Trust guideline.

The DFTB Podcast: How to use the clinical signs of meningitis.

In our first podcast produced by the team at ‘2 Paeds In A Pod’ in conjunction with the Archives of Disease in Childhood, Education and Practice Edition, we talk to Dr Tom Waterfield about his co-authored paper on how to use the clinical signs of meningitis in children. The paper is the Editor’s Choice article in the February 2020 edition of ADC Education and Practice and can be found here: https://ep.bmj.com/content/105/1/46

Don't Forget the Bubbles
Don't Forget the Bubbles
The DFTB Podcast: How to use the clinical signs of meningitis.







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The 30th Bubble Wrap

Cite this article as:
Grace Leo. The 30th Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19868

Article 1: What’s the risk of infants 29-90 days having both UTI and meningitis?

Nugent, J., et al Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis. Journal of Paediatrics; 2019 June [eprint] doi: 10.1016/j.jpeds.2019.04.053

What’s it about?

UTI remains the most common serious bacterial infection in infants, and infants under 28 days routinely undergo a complete septic work up when presenting to ED with a fever. For infants aged between 29 – 90 days, the decision to LP is guided by clinical findings and left up to the treating physician. So, what are the chances that febrile baby with the positive urinalysis also has meningitis?

Why does it matter?

This systematic review looked at the pooled prevalence of co-existing meningitis, bacterial or aseptic. The authors searched 3 databases for studies reporting on the rates of meningitis in infants aged 29 – 90 days who had abnormal urinalysis or culture results (but were not necessarily febrile at presentation) who also had LPs performed as part of their work up. A total of 20 studies (3 prospective and 17 retrospective) were identified.

The review found the pooled prevalence of concomitant bacterial meningitis in infants with UTI was 0.25% (95% CI, 0.09%-0.70%). This translates to a number needed to investigate with LP for 1 diagnosis of meningitis of 400. The pooled prevalence for aseptic meningitis over the 20 studies was not able to be calculated, but in some studies the prevalence was as high as 29%.

Clinically Relevant Bottom Line:

Based on this systematic review, the risk of bacterial meningitis in infants aged 29-90 days with evidence of UTI is low, but the decision to LP should always take into consideration the clinical picture, as opposed to a calculated pre-test probability.

Reviewed by: Tina Abi Abdallah

Article 2: Anima sana in corpore sano: Does a healthy body equal a healthy soul?

Easterlin MC, et al. Association of Team Sports Participation With Long-term Mental Health Outcomes Among Individuals Exposed to Adverse Childhood Experiences. JAMA Pediatr. 2019 May 28 [Epub ahead of print].

What’s it about?

Adverse childhood experiences (ACEs) and/or mental health problems are unfortunately very common, but the impact and extent of these events may differ from person to person. This article addresses whether team sports may influence well being in adulthood after ACEs. ACEs were defined as physical and sexual abuse, emotional neglect, parental alcohol misuse, parental incarceration, and living with a single parent extracted from the data of the National Longitudinal Study of Adolescent to Adult Health (National Population sample of US adolescents – 1994 and 2008). Multivariable logistic regression models were used to score factors associated with team sport participation. About half of the participants (9668 individuals included in the study – 4888 (49.3%)) reported 1 or more ACEs. Among those with ACEs, team sports participation during adolescence was significantly associated with lower odds of receiving a diagnosis of depression, anxiety or having current depressive symptoms (adjusted odds ratios, 0.76, 0.70 and 0.85 respectively).

Why does it matter?

Adverse childhood experiences can have long-term mental health consequences, but the knowledge of factors improving mental health after these events is lacking. This study showed an association with team spots and improved mental health and could be an ‘easy’ tool to improve well being in traumatised children.

Clinically Relevant Bottom Line:

Team sport participation in adolescence was associated with better mental health outcomes in children with ACEs. As suggested by the authors, team sports may be an important and scalable resilience builder.

Reviewed by: Anke Raaijmakers 

Article 3: Another look at risk factors for cervical spine injury in children with blunt trauma

Leonard JC, et al. Cervical Spine Injury Risk Factors in Children with Blunt Trauma. Pediatrics 2019, 144 (1). doi.org/10.1542/peds.2018-3221

What’s it about?

Four tertiary care hospitals which are part of the USA based Paediatric Emergency Care Applied Research Network (PECARN) ran a prospective observational study to look at risk factors of cervical spine injury in children with blunt trauma. They then compared the PECARN model with a de novo model of risk factors. After screening  11809 children with blunt trauma, approximately were found to be eligible and 4144 children were enrolled. Of 4091 children, 1.8% (74) had a cervical spine injury.  Children who didn’t receive cervical spine imaging had medical record and subsequent call follow up (if no imaging) to verify the absence of injury.  Treating ED providers filled out electronic questionnaire prior to knowledge of cervical spine image results. These questionnaires assessed for risk factors including injury mechanism, patient variables and physical findings.

Fourteen risk factors were identified as having significant association with CSIs in this study. PECARN criteria currently include 8 risk factors (high-risk MVC, diving mechanism, conditions predisposing for CSI, neck pain, reported inability to move neck, altered mental status, limited neck range of motion on exam, substantial torso injury and focal neurological deficits). Three of these variables were not found to be independently associated with CSIs in the analysis of data collected: high risk MVC, conditions predisposing for CSI and limited neck range of movement on examination

A de novo model was proposed of 7 variables: diving mechanism, axial load, neck pain, reported inability to move neck, altered mental status, respiratory distress, and intubation.

Comparing PECARN with this de novo model slightly increased the sensitivity (90.5 to 91.9%) and specificity (45.6% to 50.3%). Extrapolated imaging rates using the PECARN and de novo risk model would decrease from 78.2% to 55.1% and 50.5% respectively and roughly halve CT scan. Both models missed children with CSIs – 7 in PECARN and 6 with the de novo model however on retrospective chart review 6 of the 7 missed children had a PECARN risk factor. None of those missed had surgical intervention but two were managed with medical devices (brace or rigid cervical collars).

The Bottom Line

This study presents data from 4 US trauma centres to improve identification of cervical spine injury risk factors in children. A de novo model with 7 risk factors has been examined and compared with the existing PECARN model and would yield slightly improved results and would have missed one less child with CSI in the group of over 4000 children studied.

Reviewed by: Grace Leo

Article 4: Drowning in the school holidays

Peden A et al. The association between school holidays and unintentional fatal drowning among children and adolescents aged 5-17 years. Journal of Paediatrics and Child Health. 2019 May; 55(5), pp. 533-538.

Why does it matter?

Australia is an island with 85% of its population living within 50 km of the coastal line. Thanks to a mostly temperate climate, many families and young people enjoy spending time at beaches, rivers and lakes, as well as many households having swimming pools. Therefore, drowning becomes a very real problem, especially for children and young people. In fact, drowning is a leading killer of young people, however children and adolescents aged 5-17 years have one of the lowest rates. This could be due to the protective effect of time spent in formal schooling and this study shows how the risk of drowning differs during time spent at school versus school holidays.

What’s it about?

The investigators extracted the data from the Australian Royal Life Saving National Fatal Drowning Database over 2005-2014. A total of 188 children/adolescents aged 5-17 years drowned during the study period. There was a significant difference between drowning incidence during school holidays (including public holidays) and school days (P value <0.01), with relative risk (RR) of drowning on a holiday being 2.40 times higher than on a school day (CI 1.82-3.18). The risk was higher for children 5-9 years (RR = 3.05; CI 1.98-4.72) than adolescents 10-17 years (RR = 2.02; CI 1.38-2.93). The risk was similar for males and females in this age group. Most drowning incidents occurred at a river, creek or stream, as opposed to a beach or swimming pool.

Clinically Relevant Bottom Line:

As might be expected the rate of drowning in children and adolescents is much higher during school holidays than during formal schooling (with this study finding a relative risk 2.4 times higher). Although there are limitations to this study,  it advocates for ongoing drowning risk reduction strategies but particularly in the lead-up to school holiday periods in school-aged children and adolescents.

Reviewed by: Jennifer Moon

Article 5: The global impact of rotavirus vaccine in children under 5 years of age

Aliabadi N, et al. Global impact of rotavirus vaccine introduction on rotavirus hospitalisations among children under 5 years of age, 2008–16: ndings from the Global Rotavirus Surveillance Network. Lancet Glob Health 2019; 7: e893-903

Why does it matter?

In 2015, Rotavirus gastroenteritis  accounted for an estimated 250,000 deaths and 1·9 million episodes per year of severe acute gastroenteritis requiring hospital admis­sion in the under 5 year old age group. This paper cites that rotavirus vaccination has an efficacy of ranging from 57% to 85% for RV1 and from 45% to 90% for RV5 based on countries’ mortality strata. WHO recommends rotavirus vaccination as part of the national immunisation scheme for all countries. This study helps to assess the impact of introduction of rotavirus vaccinations.


What’s it about?

This paper presents the findings of the World Health Organisation (WHO) co-ordinated Global Rotavirus Surveillance Network (GRSN) to examine the rates of rotavirus confirmed hospital admissions prior to and following introduction of rotavirus vaccine globally between 2008-16 across 69 countries. Whilst it covers areas in Africa, the Americas, Eastern Mediterranean and European region, some of the countries the GRSN does not include are UK, American, Canadian, Russia, Australia or New Zealand. As China joined after 2016 it was also not included in the assessed population.

The prospective study looked at children under 5 years old admitted to hospital across the GRSN sites with acute gastroenteritis who subsequently had stool PCR within 48 hours to assess for rotavirus infection. It assessed the difference in cases pre and post-vaccine periods. The was a main analysis of data included sites with over 1 year of enrolment and over 100 specimens tested per year (305789 cases across 69 countries). Three further sensitivity analysis looked at cases 1) that did not have both pre and post vaccine data 2) regions with vaccine coverage <60% or vaccine not introduced, 3) Slightly relaxed lab inclusions to account for smaller labs. There was insufficient data to be able to combine these three groups. The study reports one third of children (32.9%) included had confirmed rotavirus gastroenteritis. Presentations of rotavirus gastroenteritis reduced 38% pre-vaccination to 23% post vaccination of cases included (with a relative reduction of 39.6%, CI 35.4-43.8). This data uses the mean proportion of children who were positive and the actual range between the two groups overlapped. The three other sensitivity analysis showed similar rates of overall reduction in rotavirus presentations.

The Bottom Line

This WHO-GSRN large impact analysis of rotavirus vaccination in children under 5 included 305,789 children, of which one third had confirmed rotavirus gastroenteritis. Between pre and post-vaccination periods, there was a relative decline in rotavirus gastroenteritis hospital presentations of almost 40%.  Rotavirus vaccination is effective in reducing hospital admissions for rotavirus gastroenteritis and should be considered for introduction in countries not yet covered such as part of Africa and southeast Asia.

(Ed note: If you’re interested in gastroenteritis, you may also be interested to know that Archives of Disease of Childhood has just published a systematic review and meta-analysis looking at Gelatin tannate (a protective gelatin with  astringent, antibacterial, and anti-inflammatory properties) in the use of acute diarrhoea and gastroenteritis in children. There was no difference with placebo).

Reviewed by: Grace Leo

If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to. 

ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?

Cite this article as:
Grace Leo. ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17786

Vaccines have been instrumental in reducing rates of bacterial meningitis. However bacterial meningitis still represents 4-19% (1) of cases of meningitis and has been estimated to be cause 2% of all child deaths (2). Timely administration of antibiotics helps save lives with adult research suggesting that every hour of delayed treatment increases the risk of death or permanent disability by 10-30% (3). So how swiftly do we investigate and treat children with suspected meningitis? The paper from Archives of Disease of Childhood featured in our second #DFTB_JC sought to answer this question:

 

What’s it about?

This was a prospective cohort study of 388 children who attended three UK paediatric tertiary centres between 2011-2. They had been either hospitalised with suspected meningitis or underwent lumbar puncture (LP) during sepsis evaluation.

Of the 388 children, 18% (70) were given a diagnosis of meningitis but only 13 were documented as bacterial and 26 as viral with and 31 patients having no known or identified cause. Just over half the children (57%) had seen a doctor in the same illness prior to ED presentation.

The median time from initial hospital assessment to antibiotic administration was 3.1 hours.  The time to LP was even longer at 4.8 hours, but once discounting intentional postponement for reasons including convulsions, concern regarding raised intracranial pressure, coagulopathy or shock, this time reduced to 3 hours. Over half of the children (62%) had their LP following antibiotics.

In further discussion with the corresponding author @manishs_  the mean was chosen due to skewing of the data and the time from initial hospital assessment was equivalent to arrival in ED. The time between initial assessment and LP ranged from 0-183 hours whilst the time between initial assessment and antibiotics ranged from 0 to 136 hours. For the 221 patients who they had data in hours available; only 31 received antibiotics in the first hour. However 131 of the 221 patients did receive antibiotics in the first 4 hours.

 

 

The general sentiment from the twitter discussion was  that the median time of 3.1hours to antibiotic administration was longer than expected, and suboptimal. Whilst the actual time point may have been somewhat surprising; many could identify common reasons for antibiotic delay and in particular, discussion about the difficulties that lumbar puncture can pose in different age groups and its contribution towards delay of antibiotics.

“It surprised me. Think we generally give abx before LP in children and LP before abx in babies… probably because of less anxiety around the procedure in babies. But no excuse for 3 hour delay in any age group really.” – @DrRoseM

 

 

 

We then delved deeper into the importance of LP before or after antibiotics and factors affecting unintentional LP delay. Paediatrician from Ontario, Tom Lacroix shared concern that with improved vaccines, he has seen skill attrition.

“…I wonder how much of delay is bc we have become unaccustomed to doing LPs. I have seen a fall in LPs 90%+ since intro of pneumococcal conjugate vaccine” – @drtom_lacroix

Across in the UK, the perceived anxiety surrounding performing an LP in older children was raised including staffing challenges, concerns about pain and procedural sedation.

“In neonates we rush to get the LP done within an hour, but in older children it always seems to take a lot longer. Do we have misplaced anxiety in this age group?” – @TessaRDavis

“…It takes one NICU nurse to flex a 6 day old up for an LP, but a play specialist, at least two nurses and one parent to get an older child in position for an LP” – @edd_broad

Differences in practice in terms of performing a FBC and Coags screen prior to LP were also highlighted.

“Not sure about mandatory, but I’ve been taught (and continue to practice) confirming PLT > 50×10^9/L prior to LP. ” – @henrygoldstein

“…Unless evidence of coagulopathy ie purpura. Do LP and then give abx” – @DocAnthonyT

 

 

 

In the supplementary tables from the paper, of all children in the study, just under a quarter (24.7%) had bacterial and/or viral CSF PCR performed. Of the 70 children who had meningitis, CSF PCR was performed on only 9 (13%). The rate was slightly higher for meningitis of cause unknown (6 of 29 patients, 21%). The authors commented that this represents a significant underutilisation, particularly as CSF PCR is recommended in the current UK guidelines. The suspected cause of this was a long turnaround time to PCR.

However the benefits of positive viral CSF PCR results would include reducing length of treatment and inpatient stay as well as building a more accurate understanding of true disease rates.

The results of this paper contrast with experiences of our journal club participants where CSF PCR appeared to be a more common order, particularly in the neonatal setting:

“Might depend on the CSF WCC for the bacterial PCR? If zero, I wouldn’t necessarily send bacterial PCR (but will still frequently send viral PCR)…Parechovirus PCR is automatically sent for our neonates. #DFTB_JC ” – @DrSarahMcNab

“NICU where I work send viral PCRs as standard with turnaround in 24 hours. Think you still need to request in paeds. ” – @DavidKing83

 

Paediatric Registrar Rose provided a good summary of what she learned from the article and the #DFTB_JC chat:

take home- give the abx as soon as possible and definitely within 1 hour. If unable to do LP pre abx due to delays etc then do LP ASAP after abx. Consider PCR as a valuable tool to aid decision re duration of treatment” – @DrRoseM

From the DFTB team, the discussion has made us rethink how each step in assessment and management of suspected meningitis may delay optimal care. In particular we’ll be thinking about how strong the evidence is behind ‘the golden hour’ of antibiotic administration, the anxiety surrounding LPs in older children and evidence behind performing coagulation studies prior to LP…now that sounds like a potential post for the future.

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper.

 

Please join us for our next ADC/DFTB Journal Club on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST) January’s featured FREE access article from @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter, hosted by @DFTB_Bubbles. Remember to use the hashtag #DFTB_JC for all related posts.

Bacterial co-infection

Cite this article as:
Andrew Tagg. Bacterial co-infection, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16783

Often we are asked to look at a febrile infant with what appears to be a viral illness. But could there be something else going on? If you believe in Occam’s Razor or the law of parsimony then you might think the simplest solution, the obvious viral illness, is the cause of the fever. But what about Hickam’s Dictum – the patient can have as many diseases as they please?