In the under 3-year-old child
Bacterial meningitis is difficult to diagnose in its early stages in this age group. The classic signs of neck rigidity, photophobia, headache, and vomiting are often absent. A bulging fontanelle is a sign of advanced meningitis in an infant, but even this serious and late sign will be masked if the baby is dehydrated from fever and vomiting. Almost all children with meningitis have some degree of raised intracranial pressure, so that, in fact, the signs and symptoms of meningitis are primarily those of raised intracranial pressure. The following are signs of possible meningitis in infants and young children:
• Drowsiness (often shown by lack of eye contact with parents or doctor).
• Irritability that cannot be easily soothed by parent.
• Unexplained pyrexia.
• Convulsions with or without fever.
• Apnoeic or cyanotic attacks.
Older children of 4 years and over
These children are more likely to have the classic signs of headache, vomiting, pyrexia, neck stiffness, and photophobia. Some present with coma or convulsions. In all unwell children, and children with an unexplained pyrexia, a careful search should be made for neck stiffness and for a purpuric rash. The finding of such a rash in an ill child is almost pathognomic of meningococcal infection for which immediate treatment is required (see Chapter 10).
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