Clinical features suggestive of meningitis in children: a systematic review of prospective data.
BACKGROUND
Clinical diagnosis of pediatric meningitis is fundamental; therefore, familiarity with evidence underscoring clinical features suggestive of meningitis is important.


OBJECTIVE
To seek evidence supporting accuracy of clinical features of pediatric bacterial meningitis.


METHODS
A review of Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed was conducted for all articles of relevance. Articles contained prospective data of clinical features in children with laboratory-confirmed bacterial meningitis and in comparison groups of those without it. Two authors independently assessed quality and extracted data to calculate accuracy data of clinical features.


RESULTS
Of 14 145 references initially identified, 10 met our inclusion criteria. On history, a report of bulging fontanel (likelihood ratio [LR]: 8.00 [95% confidence interval (CI): 2.4-26]), neck stiffness (7.70 [3.2-19]), seizures (outside febrile-convulsion age range) (4.40 [3.0-6.4]), or reduced feeds (2.00 [1.2-3.4]) raised concern about the presence of meningitis. On examination, jaundice (LR: 5.90 [95% CI: 1.8-19]), being toxic or moribund (5.80 [3.0-11]), meningeal signs (4.50 [2.4-8.3]), neck stiffness (4.00 [2.6-6.3]), bulging fontanel (3.50 [2.0-6.0]), Kernig sign (3.50 [2.1-5.7]), tone up (3.20 [2.2-4.5]), fever of >40°C (2.90 [1.6-5.5]), and Brudzinski sign (2.50 [1.8-3.6]) independently raised the likelihood of meningitis. The absence of meningeal signs (LR: 0.41 [95% CI: 0.30-0.57]) and an abnormal cry (0.30 [0.16-0.57]) independently lowered the likelihood of meningitis. The absence of fever did not rule out meningitis (LR: 0.70 [95% CI: 0.53-0.92]).


CONCLUSIONS
Evidence for several useful clinical features that influence the likelihood of pediatric meningitis exists. No isolated clinical feature is diagnostic, and the most accurate diagnostic combination is unclear.
Division of Pediatric Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada. scurtis@ualberta.ca
Sarah
S
Curtis
Kent
K
Stobart
Ben
B
Vandermeer
David L
DL
Simel
Terry
T
Klassen
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016013:Likelihood Functions; D008297:Male; D016920:Meningitis, Bacterial / Q000175:diagnosis*; D011237:Predictive Value of Tests