Journal Article

Bulging fontanelle in febrile infants: is lumbar puncture mandatory?

Kozer, E, Mordish, Y, Shacham, S, Goldman, M, Bahat, H

2009

Overview

Objective:To determine the aetiologies and clinical characteristics of infants with fever and a bulging fontanelle.Design:The medical records of all febrile infants with a bulging fontanelle who underwent a lumbar puncture from January 2000 to February 2008 in Assaf Harofeh Medical Center, a university affiliated hospital in central Israel, were identified.Results:153 patients met the inclusion criteria. The male to female ratio was 100:53; age range was 3–11 months with a mean age of 5.6 (SD 1.8) months and a median age of 5 months. Cerebrospinal fluid pleocytosis was found in 42 cases (27.3%), including one case of bacterial meningitis (0.6%). Other leading diagnoses were aseptic meningitis (26.7%), upper respiratory tract infection (18.3%), viral disease not otherwise specified (15.6%), roseola infantum (8.5%) and acute otitis media (6.5%). Appearance on admission was described as good to excellent in 113 (73.8%) infants, none of whom had bacterial meningitis. 32 had aseptic meningitis and 17 had other bacterial disease (pneumonia, acute otitis media, pyelonephritis, bacteraemia, shigella or salmonella gastroenteritis). All the latter had, upon admission, symptoms, signs, laboratory tests or imaging studies suggesting a bacterial aetiology.Conclusions:In this large cohort, all infants who appeared well on admission and had normal clinical, laboratory and imaging studies had benign (non-bacterial) disease. In an infant who appears well and has no evidence of bacterial disease, it is reasonable to observe the infant and withhold lumbar puncture. Prospective studies should be carried out to confirm this approach.

• Publisher: BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health,BMJ Publishing Group,BMJ Publishing Group Ltd,BMJ Publishing Group LTD
• Subject: Abnormalities / Anatomy / Bacteria / Bacterial diseases / Bacterial infections / Biological and medical sciences / Bone Diseases, Infectious - diagnosis / Bone Diseases, Infectious - etiology / Chi-Square Distribution / Chicken pox / Childhood fever / Cranial Fontanelles / Data Analysis / Demographic aspects / Departments / Diagnosis / Diagnostic tests / Diarrhea / Ear diseases / Emergency medical care / Etiology / Evidence / Exanthema Subitum - cerebrospinal fluid / Exanthema Subitum - complications / Febrile convulsions / Febrile seizures / Female / Fever / Fever - etiology / Fever in children / Gastroenteritis / General aspects / Health aspects / Humans / Illnesses / Infant / Infants / Laboratory tests / Leukocytosis - cerebrospinal fluid / Leukocytosis - complications / Lumbar puncture / Malaria / Male / Medical Evaluation / Medical records / Medical sciences / Meningitis / Meningitis, Aseptic - cerebrospinal fluid / Meningitis, Aseptic - complications / Meningitis, Bacterial - cerebrospinal fluid / Meningitis, Bacterial - complications / Miscellaneous / Organic Chemistry / Original articles / Otitis Media - cerebrospinal fluid / Otitis Media - complications / Patient Selection / Patients / Pediatrics / Physical Examinations / Prevention and actions / Public health. Hygiene / Public health. Hygiene-occupational medicine / Puncture / Records (Forms) / Respiratory tract / Respiratory Tract Infections - cerebrospinal fluid / Respiratory Tract Infections - complications / Retrospective Studies / Rhinitis / Risk Assessment - methods / Risk factors / Rotavirus / Salmonella / Seizures / Skull / Spinal Puncture / Spine / Streptococcus infections / Tonsillitis / Viral diseases / Virus Diseases - cerebrospinal fluid / Virus Diseases - complications / Viruses / West Nile virus / Young Children