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Paediatric Considerations in Critical Care 697

189
children are common, with about 4–10% of children 66% of disease. There are two main peaks of disease.
181
having an unprovoked seizure without recurrence. The 0–4-years age group represents 31% of all cases and
Children between the ages of six months and six years are with 17% occurring in the 15–19-years age group. 189 The
more likely to develop seizures. 182 Children, particularly incidence of meningococcal disease in children aged 0–4
those under five years, are at higher risk, as the developing years is 10/100,000. Of children with invasive meningo-
181
brain has a lower threshold for seizures. Febrile convul- coccal disease, 47% have meningitis, with or without
sions occur in 2–5% of children, commonly between the sepsis. 190,191 The mortality rate of meningococcal menin-
183
ages of 6 and 60 months. Non-febrile seizures are typi- gitis in children under five years of age is below 1%; with
cally more common in the neonatal period, with the sepsis present, the rate increases up to 10–15%.
incidence falling with age. 182
The incidence of invasive pneumococcal disease (IPD)
Management has significantly dropped since the introduction of
routine vaccination, with a reported rate of 23.4 cases per
Management of the paediatric patient with seizures is 100,000 children aged less than five years in 2005. The
192
similar to management of the adult (see Chapter 17), but highest peak of IPD is seen in children aged one year with
there are some specific paediatric considerations. The a rate fluctuating between 26.5, 37 and 51/100,000 in
paediatric patient who is suffering seizures is more sus- Australia, North America and Europe, respectively. 193-196
ceptible than an adult to hypoglycaemia. Hypoglycaemia The highest Australian incidence occurs in the Northern
may lead to secondary brain injury during and after sei- Territory, with Indigenous children at highest risk. 197
zures. Blood sugar levels should always be checked in Other risk factors include extreme prematurity, chronic
children suffering from seizures and intravenous fluids lung disease, trisomy 21 (Down syndrome), diabetes and
containing glucose administered. 182,184 cystic fibrosis. Clinical manifestations or symptoms vary
The care of the seizing or post-ictal child is generally sup- with the age of the child, duration of the illness and
portive and includes monitoring for signs of ongoing history of antibiotic use for the current illness. These are
seizures, administration of appropriate anticonvulsants, outlined in Table 25.8.
and regular assessment of neurological function. In young
infants, seizures may be difficult to determine and may Management
include stiffening, staring and lip smacking rather than Initial management of the infant or child with meningitis
obvious clonic activity. 185,186 includes assessment and management of the airway,
breathing, circulation and disability. Once the initial
MENINGITIS resuscitation has been completed, consideration should
Meningitis is an acute inflammation of the meninges be given to correcting any biochemical abnormalities. In
that usually develops over 1–2 days. A fulminant form of particular, blood sugar level should be checked and
meningitis caused by Neisseria meningitidis or meningo- corrected in the early management phase. Once menin-
coccal disease may develop over several hours. Organisms gitis is suspected, a lumbar puncture (LP) is generally
causing bacterial meningitis vary by age group. In infants performed to confirm diagnosis, but if the child is hae-
under three months of age, group b Streptococcus, E. coli, modynamically unstable or has ongoing seizures, prob-
Streptococcus pneumoniae and Listeria are the most likely lems with ventilation or signs of raised intracranial
agents. In children over three months of age meningococ- pressure, the LP should be delayed and blood cultures
166,199
cus, Haemophilus influenzae type b and Streptococcus pneu- obtained.
moniae are more common. 172 The most common causes Steroid use in meningitis has some benefit in reducing
of viral meningitis in infants and children include herpes morbidity in adults, 195 but not in children. However, it
200
simplex virus and the enteroviruses. 187 Tuberculous men- was shown to reduce the risk of severe hearing loss in
ingitis, while still rare, is becoming more common, par- children with bacterial meningitis. 201
ticularly in immigrant families or those with recent travel
to affected areas. Bacterial meningitis continues to have
a poorer outcome than other forms of meningitis, despite TABLE 25.8 Symptoms of meningitis in infants
advances in therapy. 188 and children

Incidence Infants under 3 Infants over 3 months
Data on the incidence of meningitis in Australia is limited months and children
to the major bacterial types, particularly for infants and l Hypothermia or fever l Fever
children over two months of age. Hib, meningococcal l Irritability or lethargy l Headache
and pneumococcal infections are all notifiable. Since the l High-pitched cry l Photophobia
introduction of the Hib vaccine in1993, Hib infection has l Seizures l Kernig’s sign (inability to extend leg)
fallen to 1.2/100,000 in 2005. 189 Of all reports of infec- l Apnoea l Brudzinski’s sign (flexion of hip and
knee in response to neck flexion)
tion only 28% were meningitis, and the majority of infec- l Poor feeding and/or l Lethargy or irritability
vomiting
tions were in children under two years of age. 189 l Nausea and vomiting
l Seizures and neck stiffness
Meningococcus is the main cause of meningitis in chil- l Confusion and coma occurring at a
dren. It occurs seasonally, with the main peak in Australia fairly late stage
between June and October. Serogroups A, B and C account
for 90% of cases in Australia, with serogroup B causing Adapted from (190, 198).