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ORIGINAL ARTICLE  
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 9-13
Predictors of acute bacterial meningitis among children with a first episode of febrile convulsion from Northern India: A prospective study


Department of Paediatrics, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

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Date of Web Publication20-Nov-2014
 

   Abstract 

Context: There is limited data to support need of lumbar puncture among Indian children aged less than 5 years presenting with a first episode of fever and seizure. Aims: To determine the incidence and clinical predictors of meningitis among children aged 6-60 months presenting with a first episode of febrile convulsion. Settings and Designs: A prospective study was conducted on 35 children (6-60 months) with a first episode of febrile convulsion subjected to lumbar puncture in a tertiary care teaching hospital of North India. Materials and Methods: Clinical characteristics were compared between the two groups: Children with meningitis (n = 17) and children without meningitis (n = 18). Statistical Methods: Multivariate logistic regression was applied to assess the independent predictors of meningitis. Results: A total of 120 children were screened; 35 children subjected to lumbar puncture were finally enrolled. The mean (SD) age of enrolled children was 18.49 (10.79) months. The incidence of meningitis was 48.6% (17/35). Children with meningitis significantly had a higher proportion of children with high grade (temperature >104°F) fever (P = 0.005), received prior antibiotics (P = 0. 041), had lower hemoglobin levels (P = 0.04) and lower blood sugar levels (P = 0.03) as compared to children with no meningitis. On multivariate logistic regression, it was observed that high-grade fever was an independent predictor of meningitis (odds ratio: 0.03 [0.001-0.86] [P = 0.04]). Conclusion: We found that the presence of high-grade fever was an important predictor of meningitis among children aged 6-60 months presenting with a first episode of febrile convulsion.

Keywords: Children, India, febrile convulsion, meningitis

How to cite this article:
Singh A, Silayach J, Gathwala G, Kaushik JS. Predictors of acute bacterial meningitis among children with a first episode of febrile convulsion from Northern India: A prospective study. Ann Trop Med Public Health 2014;7:9-13

How to cite this URL:
Singh A, Silayach J, Gathwala G, Kaushik JS. Predictors of acute bacterial meningitis among children with a first episode of febrile convulsion from Northern India: A prospective study. Ann Trop Med Public Health [serial online] 2014 [cited 2019 Nov 14];7:9-13. Available from: http://www.atmph.org/text.asp?2014/7/1/9/144999

   Introduction Top


Febrile seizures are common among children aged 6-60 months following an acute febrile illness in whom intracranial infection or inflammation has been excluded. The current indications for lumbar puncture are presence of positive meningeal signs in any age group, history of fever and seizure in an unimmunized or partially immunized child aged 6-12 months. These guidelines laid by American Academy of Pediatrics are based on the clinical profile of children from United States. [1]

However, we believe these guidelines could not be extrapolated to the Indian population owing to the difference in ethnic background, socio demographic profile and poor immunization status (47.3% children immunized). [2] The yield of meningitis associated with febrile seizure from western data has been reported to range from 2% to 5%. [1] Data from Indian children is limited to a retrospective study where it was observed that the prevalence of meningitis with simple febrile seizure and complex febrile seizure were 0.86% and 4.81% respectively. [3] There is limited data to answer the research question as to whether lumbar puncture is indicated in all Indian children aged 6-60 months presenting with a first episode of fever and seizure. Hence, we designed the present study to determine the incidence and clinical predictors of meningitis among children aged 6-60 months presenting with a first episode of febrile convulsion.


   Materials and Methods Top


This was a prospective observational study conducted at the Department of Pediatrics, Pt B D Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana from December 2012 to May 2013. It is a tertiary care, government funded, teaching hospital that caters to referrals from the city of Rohtak and the surrounding rural districts of Haryana. Clearance was obtained from the institutional ethical committee. The study protocol was fully explained to the parents/guardian, and informed written consent was obtained.

Children aged 6-60 months presenting to the emergency department with a first episode of febrile convulsion who were subjected to lumbar puncture were enrolled in the study. Children with developmental delay, progressive or nonprogressive neurological disorder and epilepsy were excluded from the study. Children who had a lumbar puncture prior to admission, previous nonfebrile seizure, recent trauma, and recent neurosurgical intervention were also excluded.

All eligible children were recruited consecutively in the study. Following demographic baseline data were collected: Age, gender, address, telephone number. Occupation, education and monthly income of the parents were also recorded, and socioeconomic status assigned based on revised kuppuswamy classification. Duration and grading of fever, along with the type of seizure was elicited. High-grade fever was defined as the temperature >104°F. History of previous antibiotic treatment in the last 72 h was recorded. History of irritability decreased feeding, and lethargy was also elicited. Physical signs of meningitis including neck rigidity and meningeal signs were assessed in all children.

Laboratory investigations including hemoglobin, serum electrolytes (sodium (Na + ) and potassium (K + )) and blood sugar were done in all children. The decision to perform a lumbar puncture stayed with the emergency physician. Broadly, indications of lumbar puncture in the first episode of febrile convulsion in children aged 6-60 months include clinical features of meningitis including meningeal signs, any complex febrile convulsion, persistence of postictal confusion and pretreatment with antibiotics for more than 24 h. Informed consent for lumbar puncture was obtained for those children where the cerebrospinal fluid (CSF) examination was considered. Diagnosis of meningitis was made when one of following criteria was fulfilled: CSF gram staining revealing microorganism, CSF pleocytosis >10 cells/HPF, positive CSF culture of any organism. Based on CSF analysis, study subjects were divided into two groups, "children with meningitis" and "children with no meningitis." Clinical, demographic and laboratory features were analyzed and compared between the two groups.

All the data were entered in Microsoft Excel 2007 by two investigators (AS, JS) and was cross checked with original data. All categorical variables were depicted as the number, proportion and continuous variables presented as mean standard deviation (SD). The categorical variables and continuous variables were compared between two groups ("children with meningitis" and "children with no meningitis") by Chi-square test or Fisher's exact test and unpaired Student's t-test, respectively. All the variables found significant on univariate analysis were subjected to multivariate logistic regression to assess the independent predictors of meningitis. All the statistical analysis was performed using SPSS 15.0 version (SPSS Inc. IL, USA). P < 0.05 was considered as significant.


   Results Top


A total of 120 children with febrile convulsion presented to the emergency during the study period of whom 42 (35%) children underwent lumbar puncture. Among these 42 children, 35 children (males 23 [65.7%] and females 12 [34.3%]) were finally enrolled in the study (7 excluded: 3 epilepsy, 2 cerebral palsy and 2 progressive neurological disorder). The mean (SD) age of enrolled children was 18.49 (10.79) months. An assessment of socioeconomic status, it was observed that the majority of the fathers were educated up to high school (16 [45.7%]), were unskilled workers (15 [42.9%]) and belonged predominantly to rural background 20 (57.1%). Similarly, mothers were educated up to middle school (13 [38.2%]) and were housewives/unemployed (28 [82.4%]).

The majority of children had generalized tonic-clonic seizure (28 [80%]), high-grade fever (12 [34.3%]), symptom of irritability (25 [71.4%]), staring eyes (22 [62.9%]) and abnormal cry (16 [45.7%]) at the time of admission. The mean (SD) fever-seizure interval was 2.86 (3.24) h. Family history of seizure was present in only one (2.9%) child. Focus of fever was found to be respiratory in the majority of cases 11 (31.43%). Among children enrolled 14 (40%) were on antibiotics prior to admission. Most of the children had no motor deficit (31 [88.6%]) on neurological examination.

In comparison of baseline clinical characteristics, it was observed that high-grade fever was present significantly more among children with meningitis (P = 0.005) [Table 1]. However, children with meningitis had received prior antibiotics (P = 0. 041) and were found to have significantly higher numbers of antibiotic doses prior to hospitalization (P = 0.03) [Table 1]. Mean (SD) hemoglobin level amongst the children having meningitis (8.9 [2.16] g/dl] was significantly lower than those with no meningitis (10.4 [1.16] g/dl) (P = 0.04). Blood sugar was also found to be significantly lower (101.5 {22.39}) among children with meningitis when compared to children with no meningitis (128.6 {28.47}) (P = 0.03) [Table 1]. On multivariate logistic regression, it was observed that high-grade fever was an independent predictor of meningitis among children of age 6-60 months who present with the first episode of febrile convulsion (odds ratio: [OR] 0.03 [0.001-0.86] [P = 0.04]) [Table 2].
Table 1: Comparison of baseline characteristics between: Children with meningitis (n = 17) and children with no meningitis (n = 18)

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Table 2: Predictors of meningitis among children aged 6-60 months with fi rst episode of febrile convulsion

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   Discussion Top


Our study revealed 48.6% incidence of acute bacterial meningitis among children (6 months to 5 years) with a first episode of febrile convulsion who were subjected to lumbar puncture based on clinical suspicion. We found that high-grade fever, prior antibiotic use, the higher number of antibiotic doses, low hemoglobin and low blood sugar were found to be significant predictors of meningitis among children aged 6-60 months who presented with a first episode of febrile convulsion.

The present prospective observational study provides an insight into factors that predict meningitis among Indian children aged <5 years. Lumbar puncture is an invasive investigation indicated for children suspected of meningitis. Data on rate of meningitis among children presenting with febrile convulsion is limited to children from US and UK where the immunization rates are excellent and use of pneumococcal and Hib vaccination is a part of their routine immunization schedule. We believe that the extrapolation of these data on Indian children where the immunization rate is only 50% (NFHS3) is not justified. [2]

Considering the poor immunization status and lower socioeconomic status, we anticipated that the prevalence of meningitis would be much higher among our study population. Interestingly, we found that almost half (48.57%) of our study subject was found to have meningitis among those subjected to lumbar puncture based on clinical suspicion. It is alarmingly higher than that observed by other authors from India (2.4%). [3] This could probably be explained by our inclusion of study subjects. To answer the research question as to whether lumbar puncture is indicated in all children with meningitis, it would be ideal to subject all children with febrile convulsions to undergo a lumbar puncture. However, owing to ethical consideration, we enrolled only those children who had already undergone a lumbar puncture. The proportion of children who underwent lumbar puncture in our study was 35%. The rate of lumbar puncture is consistent with other studies. [3],[4]

Data from first world countries reveal that the overall incidence of bacterial meningitis among their children presenting with febrile convulsion was 0.8 (95% confidence interval [CI]: 0.73-0.88), which has further decreased to 0.23% (95% CI: 0.0-0.46) in post vaccination era. [5] Similarly, the rate of acute bacterial meningitis among children presenting with a first episode of complex febrile convulsion was 0.9% (95% CI: 0.2-2.8). [6] Hence, it was concluded that routine lumbar puncture of children with febrile convulsion is unjustified in fully immunized children. [7] In a prospective study on 377 Australian children aged 2 months to 10 years, rate of proven or probable acute bacterial meningitis among children with single seizure and meningism or coma was 17.2%. [8] In contrast, a study from Ghana had revealed a yield of 10.2% of acute bacterial meningitis (ABM) among children (3 months to 15 years) presenting with febrile convulsion. [9] A study from Nepal had revealed a yield of bacterial meningitis to be 17% among children 6 months to 5 years presenting with a first episode of febrile convulsion. [10] Data from India are limited to a retrospective study, where the prevalence of meningitis was 2.4% in children with first febrile seizures, 0.86% in simple febrile seizures, and 4.81% in complex febrile seizures. [3]

In a systematic review of prospective data, clinical predictors of meningitis were presence of being toxic or moribund (likelihood ratio [LR]: 5.80 [95% CI: 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]), raised tone (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. [11] They also observed that 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. We observed high-grade fever (>104°F) to be an independent predictor of meningitis among children with first febrile convulsion. In another study, predictors of ABM were assessed in 554 children in Papua New Guinea and found that neck stiffness, kernig's and brudzinski's signs and, in children <18 months of age, a bulging fontanel had positive LRs >−4.3 for proven/probable ABM. Multiple seizures and deep coma were less predictive (LR Ό 1.5-2.1). [12]

According to AAP, febrile convulsions are associated with a temperature ≥100.4°C. In clinical practice, we have observed that children with meningitis usually have a high-grade fever. We have found in our study that febrile convulsing children with meningitis have proportionately high-grade fever than children with no meningitis. It is well-known that clinical signs of meningitis are masked on administration of prior antibiotics. On the contrary, we have observed that febrile convulsing child coming with prior antibiotic usage and a higher number of antibiotic doses have increased the risk of meningitis. This probably could be due to longer duration of prior illness and consultation of multiple practitioners and receiving higher doses of antibiotics among children with meningitis. It was also observed that meningeal signs were present in only 5 (29.4%) children with meningitis.

In a case-control study done in India, it was seen that the iron deficiency anemia is the most important risk factor for febrile convulsion. In another study, it was also found to be a significant relationship between anemia and bacterial meningitis. [13] In our study, we found that hemoglobin level was relatively low in meningitis children. It was because iron deficiency anemia is very much prevalent in Indian setup and might be due to a predisposition to infection in a nutritionally compromised child.

It was found that there was a male predominance in our enrolled cases. Majority of children were from the rural background that represents a true picture of the prevalence of meningitis in our society. Most of the parents were educated up to high school and were unskilled workers/unemployed showing low socioeconomic status of the parents of a febrile convulsing child.

Limitations of this study were the small sample size and short study period. Moreover, the physician's decision for performing a lumbar puncture was biased for predictors of meningitis. The implication of the present study could be to decrease burden on laboratory and screening of children who require invasive investigation like lumbar punctures, so that it might be helpful in discharging of those children in whom the lumbar puncture is not warranted.

Hence, we conclude that the predictors of meningitis are prior antibiotic used, number of doses of antibiotics, hemoglobin level, blood sugar level and a high grade fever in which high grade fever was found to be an independent predictor of meningitis among children aged 6-60 months who presented with a first episode of febrile convulsion.


   Acknowledgements Top


It has been approved for short term studentship programme (STS 2013) sponsored by Indian Council of Medical Research (ICMR) to promote research among undergraduate medical students of India.

 
   References Top

1.
Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics 2011;127:389-94.  Back to cited text no. 1
    
2.
Vashishtha VM. Routine immunization in India a reappraisal of the system and its performance! Indian Pediatr 2009;46:991-2.  Back to cited text no. 2
    
3.
Batra P, Gupta S, Gomber S, Saha A. Predictors of meningitis in children presenting with first febrile seizures. Pediatr Neurol 2011;44:35-9.  Back to cited text no. 3
    
4.
Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics 2009;123:6-12.  Back to cited text no. 4
    
5.
Carroll W, Brookfield D. Lumbar puncture following febrile convulsion. Arch Dis Child 2002;87:238-40.  Back to cited text no. 5
    
6.
Kimia A, Ben-Joseph EP, Rudloe T, Capraro A, Sarco D, Hummel D, et al. Yield of lumbar puncture among children who present with their first complex febrile seizure. Pediatrics 2010;126:62-9.  Back to cited text no. 6
    
7.
Oluwabusi T, Sood SK. Update on the management of simple febrile seizures: Emphasis on minimal intervention. Curr Opin Pediatr 2012;24:259-65.  Back to cited text no. 7
    
8.
Laman M, Manning L, Hwaiwhange I, Vince J, Aipit S, Mare T, et al. Lumbar puncture in children from an area of malaria endemicity who present with a febrile seizure. Clin Infect Dis 2010;51:534-40.  Back to cited text no. 8
    
9.
Owusu-Ofori A, Agbenyega T, Ansong D, Scheld WM. Routine lumbar puncture in children with febrile seizures in Ghana: Should it continue? Int J Infect Dis 2004;8:353-61.  Back to cited text no. 9
    
10.
Joshi Batajoo R, Rayamajhi A, Mahaseth C. Children with first episode of fever with seizure: Is lumbar puncture necessary? JNMA J Nepal Med Assoc 2008;47:109-12.  Back to cited text no. 10
    
11.
Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: A systematic review of prospective data. Pediatrics 2010;126:952-60.  Back to cited text no. 11
    
12.
Laman M, Manning L, Greenhill AR, Mare T, Michael A, Shem S, et al. Predictors of acute bacterial meningitis in children from a malaria-endemic area of Papua New Guinea. Am J Trop Med Hyg 2012;86:240-5.  Back to cited text no. 12
    
13.
Kumari PL, Nair MK, Nair SM, Kailas L, Geetha S. Iron deficiency as a risk factor for simple febrile seizures - a case control study. Indian Pediatr 2012;49:17-9.  Back to cited text no. 13
    

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Correspondence Address:
Jaya Shankar Kaushik
Department of Paediatrics, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana - 124 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.144999

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