title: Bulging fontanelle in febrile infants: is lumbar puncture mandatory?
abstract: OBJECTIVE
  To determine the aetiologies and clinical characteristics of infants with fever and a bulging fontanelle.
  
  
  METHODS
  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.
authors.affiliation: Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin 70300, Israel. shirashacham1@gmail.com
authors.forename: S
authors.initials: S
authors.lastname: Shacham
authors.forename: E
authors.initials: E
authors.lastname: Kozer
authors.forename: H
authors.initials: H
authors.lastname: Bahat
authors.forename: Y
authors.initials: Y
authors.lastname: Mordish
authors.forename: M
authors.initials: M
authors.lastname: Goldman
mesh_terms: D001850:Bone Diseases, Infectious / Q000175:diagnosis / Q000209:etiology*; D016009:Chi-Square Distribution; D055762:Cranial Fontanelles; D005077:Exanthema Subitum / Q000134:cerebrospinal fluid / Q000150:complications; D005260:Female; D005334:Fever / Q000209:etiology*; D006801:Humans; D007223:Infant; D007964:Leukocytosis / Q000134:cerebrospinal fluid / Q000150:complications; D008297:Male; D008582:Meningitis, Aseptic / Q000134:cerebrospinal fluid / Q000150:complications; D016920:Meningitis, Bacterial / Q000134:cerebrospinal fluid / Q000150:complications; D010033:Otitis Media / Q000134:cerebrospinal fluid / Q000150:complications; D018579:Patient Selection; D012141:Respiratory Tract Infections / Q000134:cerebrospinal fluid / Q000150:complications; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D013129:Spinal Puncture; D014777:Virus Diseases / Q000134:cerebrospinal fluid / Q000150:complications