How Long After Neonatal Meningitis Should An Infant Have a Hearing Screening?

Patient Presentation
A 14-day-old male came to the emergency room after 8 hours of poor feeding, lethargy and irritability. He was not febrile, but his sibling had been sick with a febrile illness. The past medical history showed a full term male born to a G2P2 female who had prenatal care and whose laboratories were negative. He had an uneventful neonatal course, went home on time and was gaining weight at his 1 week followup appointment. The pertinent physical exam showed a lethargic infant who was difficult to arouse and had a poor cry. His vital signs were normal without temperature instability. Head examination had a bulging fontanelle. Pupils were 3 mm and reactive. Cardiac exam showed no murmur. Genitourinary showed normal male genitalia. Skin examination revealed no rashes. The rest of his examination was normal.

The diagnosis of suspected meningitis and/or sepsis was made. A septic workup was performed at the same time the infant was given intravenous fluids. After the lumbar puncture, blood culture, and urine culture were drawn ampicillin and cefotaxime were started. The laboratory evaluation showed a complete blood count hemoglobin of 15 g/dl, hematocrit of 45%, white blood cells count of 21.2 x 1000/mm2, and his C-reactive protein and erythrocyte sedimentation rate were 1.2 mg/dl and 11 mm/hr respectively. Lumbar puncture had 19 white blood cells, 3 red blood cells, a glucose of 53 mg/dL, and protein of 77 mg/dL. His urinalysis, chest radiograph and other laboratories were negative. During the patient’s clinical course he was transferred from the local emergency room to a regional children’s hospital for further management. Upon admission the infant was more alert and appeared hungry, but still was irritable and had a bulging fontanelle. At 24 hours after ER presentation, he was acting like a normal infant and the fontanelle had decreased a great deal. By 48 hours the fontanelle was normal. All cultures were eventually negative. He was discharged after 10 days of antibiotics for the presumed diagnosis of culture-negative neonatal meningitis. Because he had received ototoxic medication and had presumed meningitis, a hearing screening was performed prior to discharge and was negative. He was to followup with his local physician within 3 days of discharge and was scheduled for another hearing screening at 6 months of life.

Discussion
Hearing loss can range from profound deafness to fairly minor loss. The causes vary based on age, type of loss (sensoryneuronal or conductive), degree and audiometric configuration. Sensorineuronal hearing loss involves the cochlea and neural connections to the brain and auditory cortex. Conductive hearing loss involves structures from the external ear to the oval window. Deafness is defined as a hearing loss > 90 dB. A differential diagnosis of hearing loss can be found here.

Learning Point
After bacterial meningitis children should be screened for potential hearing loss. Data supports that screening in the hospital is effective. Many children can be identified at that time. Screening if not done while inpatient should be done soon – usually within days/weeks of discharge. Additional screening using validated child development screening should also be completed and are recommended by the American Academy of Pediatrics. Additional formal screening to identify late sequelae of bacterial meningitis or as a consequence of ototoxic drug exposure probably should occur at some interval, but the author was unable to identify an exact timing. Discussion with a pediatrician who is also a hearing screening expert felt that if one hearing screening was already normal, then a followup evaluation at 6 months would be appropriate. However, if the initial screening was abnormal then referral to an audiologist and/or otolaryngologist for formal evaluation was necessary and the results of these evaluations should determine the appropriate followup. While currently there are no specific recommendations for the timing of a followup hearing screening after bacterial meningitis, 6-9 months in normally growing and developing infants is probably reasonable, particularly if the infant has had normal hearing screenings before. If an infant appears to have any problems with hearing by caregiver report or other suspicion, then a hearing screening should be done sooner.

Questions for Further Discussion
1. What sequelae can occur because of meningitis?
2. What resources are available locally to support children and families who having hearing deficits?
3. For a neonate who receive ototoxic medications in the perinatal period (such as for maternal fever, or elevated laboratory testing), when should they receive a followup hearing screening?
4. What is in the differential diagnosis of lethargy and irritability in a neonate?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Meningitis and Hearing Disorders and Deafness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Richardson MP, Williamson TJ, Reid A, Tarlow MJ and Rudd PT. Otoacoustic Emissions as a Screening Test for Hearing Impairment in Children Recovering From Acute Bacterial Meningitis. Pediatrics 1998;102;1364.

Koomen I, Grobbee DE, Roord JJ, et. al. Hearing Loss at School Age in Survivors of Bacterial Meningitis: Assessment, Incidence, and Prediction. Pediatrics 2003;112;1049.

American Academy of Pediatrics. Joint Committee on Infant Hearing. Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Pediatrics. 2007:120(4).

de Jonge RC, Sanders MS, Terwee CB, Heymans MW, Gemke RJ, Koomen I, Spanjaard L, van Furth AM. Independent validation of an existing model enables prediction of hearing loss after childhood bacterial meningitis. PLoS One. 2013;8(3):e58707.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When in the Future Should An Adolescent Be Screened for Breast Cancer?

    Patient Presentation
    A 16-year-old female came to clinic for her health supervision visit. She had no concerns. Her mother who had recently finished treatment for breast cancer was wondering when her daughter should start screening mammograms. The past medical history was negative. The family history was positive for her mother and maternal grandmother both with BRCA gene negative breast cancer. The pertinent physical exam showed normal vital signs and growth parameters in the 75-90%. Her examination was negative. The diagnosis of a healthy adolescent with a strong family history of breast cancer was made. The pediatrician reviewed breast self-examination techniques with the young woman. She also said that she was not sure about when screening mammograms should be started so she would research the question and contact the family.

    Discussion
    Breast cancer is the most common cancer in women and is estimated to occur in 12% of women during their lifetimes. Although primary breast cancer is uncommon in children and adolescents it does occur. Most breast masses are benign in children and adolescents, and primary breast cancer is very uncommon. For a review of the differential diagnoses of breast masses see What is the Differential Diagnosis of a Breast Mass?.

    In the general population annual screening using mammography is recommended starting at age 40 years. All women should be taught to do breast self-examination.

    Learning Point
    According to the American College of Radiology, high risk women (which includes those with a BRCA gene mutation, those first degree relatives who are untested for the BRCA gene mutation, women who had chest wall radiation between ages 10-30 years and women with a 20% or greater lifetime risk of breast cancer) should begin having screening mammograms at age 25-30 years, or 10 years before the age the first degree relative was diagnosed with their breast cancer, whichever is later. Women who had radiation should begin at 8 years after therapy but not before age 25. Magnetic resonance imaging is considered a complimentary examination to mammography and is also recommended for these high risk patients as the combination of mammography and MRI has the highest sensitivity for screening. Clinical breast examinations should be done every 6-12 months depending on the patient’s specific risk factors.

    Questions for Further Discussion
    1. When should children and adolescents who have first degree relatives with other cancers begin screening themselves such as colon cancer?
    2. What is the risk of a secondary malignancy after treatment for a primary malignancy?
    3. How common is breast cancer in males?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Breast Cancer and Mammography.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Alberta Provincial Breast Tumour Team. Risk reduction and surveillance strategies for individuals at high genetic risk for breast and ovarian cancer. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2011 Apr. 14 p.

    Mainiero MB, Lourenco A, Mahoney MC, et. al. Expert Panel on Breast Imaging. ACR Appropriateness Criteria® breast cancer screening. Reston (VA): American College of Radiology (ACR); 2012. 5 p.
    Available from the Internet at http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf (cited 9/7/13).

    MD Anderson Cancer Center. Breast Cancer Screening: Increased Risk. Available from the Internet at http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-topics/prevention-and-screening/cancer-screening-guidelines/breast-cancer-screening-exams-increased-risk.html (rev. 2013, cited 9/6/13).

    Children’s Hospital of Philadelphia. Breast Self-Examination. Available from the Internet at: http://www.chop.edu/healthinfo/breast-self-examination.html (cited 9/5/13)

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How Common Are Post-Dural Puncture Headaches in Children?

    Patient Presentation
    A 9-year-old female came to the emergency room with headache, fever and nucal rigidity. A lumbar puncture was performed with results consistent with viral meningitis. After the lumbar puncture the patient’s headache seemed better when she was lying down but would get worse when she sat up or tried to walk. This was consistent over the next 3 days after which she was referred to a regional children’s hospital for evaluation and management. Upon admission, her fever had resolved after 24 hours and she was able to eat and drink, but intravenous fluids were maintained to ensure adequate hydration. Her headache was described as an occipital headache with some throbbing that occurred when she sat up. She denied vertigo and had minimal back pain at the lumbar puncture site. The family denied any medications other than what had been given in the hospital which included acetaminophen, ibuprofen and ceftriaxone which was stopped after cultures came back negative for bacterial meningitis. The past medical and family history revealed a fully-immunized child and were otherwise non-contributory. The radiologic evaluation from the outside hospital of an MRI of the spine was normal.

    The pertinent physical exam showed a tired child in no distress lying in bed. Her vital signs were normal including blood pressure and growth parameters in the 10-25%. HEENT showed no papilledema. Her neurological examination revealed a patient who was alert and oriented x 4 with normal cranial nerves. Her DTRs were +2/+2 with normal strength and tone. Cerebellar maneuvers were normal. Her skin showed a small healing puncture over the lower spine.

    The diagnosis of a post-dural puncture headache was made. After discussion with the family, the patient was treated with oral caffeine. Within an hour the patient was able to sit up and walk around the room without a headache. However after being up for about 4-5 hours, the headache returned. The headache resolved with lying recumbent. Caffeine was again given and the patient again was able to sit, walk and play. The headache again seemed to return after about 8 hours but was much less in intensity. Caffeinated beverages were then used along with some acetaminophen to maintain pain control. The patient went home after approximately 36 hours and on followup had complete resolution 2 days later.

    Discussion
    Post-dural puncture headache or spinal headache as they are often called, are headaches that occur within 7 days of a lumbar puncture and remit within 14 days of the lumbar puncture. They begin or worsen within 15 minutes of being in an upright position and improve or stop within 30 minutes of lying down. The headaches are described as a throbbing, dull and severe pain worse mainly in the occipital area, but can occur with radiation to the eyes, forehead or neck. Nausea, emesis, stiff neck, and visual or auditory changes may also occur. Most spinal headaches occur within 1-2 days of the lumbar puncture and spontaneously resolve after 5 days of headache (range 1-12 days).
    The etiology is unknown but it is thought that the lumbar puncture allows a small cerebrospinal fluid leak to occur causing intracranial hypotension, downward sagging of the brain and subsequent pulling on the pain sensitive meninges and large blood vessels. Lumbar puncture techniques which may decrease the risk of spinal headaches include using a small gauge, non-cutting needle, orienting the bevel or opening of the needle parallel to the longitudinal dural fibers and replacement of the stylet before removing the needle.

    Treatment usually begins with 1-2 days of supportive therapy including hydration, analgesics and bed rest. Medical treatment may include oral or IV caffeine. An epidural blood patch may also be attempted where ~10-15 ml of autologous blood is placed into the epidural space as close as possible to the lumbar puncture site. The success rate is 75-96%.

    Learning Point
    One prospective study of children ages 2-16 years showed 27% with some type of headache, 9% with a positional headache and 40% with backaches. Frequency of headaches increased with age, female gender in older patients and those with higher cerebrospinal fluid cell counts.

    Other studies cite 2-15% occurence rate for spinal headaches.

    Questions for Further Discussion
    1. What are the classic cerebrospinal fluid findings for different types of meningitis? see What Are the Initial Cerebrospinal Fluid Findings in Differential Types of Meningitis?
    2. Describe the key elements of informed consent?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Headache

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Janssens E, Aerssens P, Alliët P, Gillis P, Raes M. Post-dural puncture headaches in children. A literature review. Eur J Pediatr. 2003 Mar;162(3):117-21.

    Ebinger F, Kosel C. Pietz J. Rating D. Headache and Backache After Lumbar Puncture in Children and Adolescents: A Prospective Study. Pediatrics. 2004;113(6):1588 -1592.

    St Noble V, Davagnanam I, Farmer S. Intractable headache after lumbar puncture. BMJ. 2011 Aug 8;343:d4529.

    Kokki M, Sjövall S, Kokki H. Epidural blood patches are effective for postdural puncture headache in pediatrics–a 10-year experience. Paediatr Anaesth. 2012 Dec;22(12):1205-10.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Organisms Cause Acute Epiglottitis in the Post- H. influenza Vaccination Era?

    Patient Presentation
    While in the resident workroom, the attending and resident overheard their Otolaryngology colleagues discussing a 3-year-old female who came into the emergency room with respiratory distress and problems swallowing, and was eventually diagnosed and treated for acute epiglottitis. Since a patient with this disease was unusual, the otolaryngology residents shared that the patient had been intubated for 36 hours and now on day 3 was doing very well and was drinking. She had been fully immunized and that to date no organism has been identified. They were planning on changing to oral antibiotics and asked the pediatric team their advice about duration of therapy. After doing a literature search and discussing the patient with the pediatric infectious disease specialist (who already knew about the patient), the team recommended a total of 10 days of therapy. The team also considered whether an immune workup was needed, but the infectious disease specialist already had a detailed history and had previously advised that it wasn’t necessary at this time.

    Discussion
    Epiglottitis is also known as supraglottitis and is caused by inflammation of the supraglottic structures and epiglottis. Usually the cause is infectious but other trauma such as thermal injuries or ingestions can also cause the disease. Before the widespread use of its conjugated immunization, Haemophilus influenza type b was the most common cause and it was usually thought of as a pediatric disease process. In the pre-immunization time period, acute epiglottitis in children was 3.47-6.0 cases per 100,000, and in the post-immunization period has declined to 0.3-0.7 cases per 100,000. However it appears that < 1 year old children remain at increased risk in the post-immunization time period.

    Adult incidence has remained constant at 1-4 cases per 100,000. The average age range in the post-immunization period has increased to ~44 years. The adult presentation is also slightly different with odynophagia, dysphagia and voice changes being the most common signs. It may often have a slower clinical course too.

    For the pediatric population, respiratory distress, dysphagia and drooling are considered the classic signs, but any symptoms of respiratory distress should alert the clinician to also consider epiglottitis in the differential diagnosis. Many of the cases of pediatric epiglottitis occur in fully immunized children. Surface and blood cultures are often negative so empiric antibiotics are usually begun.

    Learning Point
    Infectious causes of acute epiglottitis include:

    • Bacterial
      • Haemophilus influenzae type b and non-typeable
      • Bacteroides species
      • Kingella kingae
      • Moraxella catarrhalis
      • Streptococcus pneumoniae*
      • Streptococcus pyogenes*
      • Other Streptococcus species including agalactiae, viridins
      • Staphylococcus aureus
    • Viral
      • Epstein-Barr
      • Herpes simplex
      • Parainfluenza
      • Varicella zoster

    *the most common bacterial causes in the post-immunization period currently

    Questions for Further Discussion
    1. How can one differentiate between acute epiglottitis, croup, bacterial tracheitis, and retropharyngeal abscess?
    2. When should an immune workup be considered for a patient with a severe infectious disease?
    3. What emergency management should be given for patients with acute upper airway obstruction?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Haemophilus Infections and Throat Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Briem B, Thorvardsson O, Petersen H. Acute epiglottitis in Iceland 1983-2005. Auris Nasus Larynx. 2009 Feb;36(1):46-52.

    Shah RK, Stocks C. Epiglottitis in the United States: national trends, variances, prognosis, and management. Laryngoscope. 2010 Jun;120(6):1256-62.

    Guardiani E, Bliss M, Harley E. Supraglottitis in the era following widespread immunization against Haemophilus influenzae type B: evolving principles in diagnosis and management. Laryngoscope. 2010 Nov;120(11):2183-8.

    Derber CJ, Troy SB. Head and neck emergencies: bacterial meningitis, encephalitis, brain abscess, upper airway obstruction, and jugular septic thrombophlebitis. Med Clin North Am. 2012 Nov;96(6):1107-26.

    Felter RA. Emergent Management of Pediatric Epiglottitis. Medscape.
    Available from the Internet at http://emedicine.medscape.com/article/801369-overview. (rev. 07/18/2013, cited 9/3/2013).

    ACGME Competencies Highlighted by Case

  • Patient Care
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital