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.
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.
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?
- Symptom/Presentation: Crying and Colic
- Age: Newborn
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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
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.
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.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
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.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital