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Febrile Infant: Lumbar Puncture Considerations

  • There is substantial evidence Inflammatory Markers (IM) are predictive of invasive blood infections including bacterial meningitis. For this age group, the number of meningitis cases in published studies is still relatively small, 64 cases in 25 917 febrile infants (0.25%).
  • Data is unavailable comparing prevalence in IM-positive versus IM-negative infants, but decision rules and models that include IMs have sensitivities greater than 90%.
  • Individual IMs are seldom sensitive or specific for detecting bacteremia or meningitis.
  • However, individual values that are exceedingly high or low or finding several abnormal IMs should be considered in decision-making because they, in all likelihood, increase the risk of bacterial meningitis.
  • The AAP committee supports not performing an LP in well-appearing infants meeting the specified criteria.
  • For an estimated prevalence of meningitis in 29- to 60-d-old infants of 0.25% and using a prediction rule or model with a sensitivity of 90%, the chance of missing a case of meningitis would be 0.025%.
  • Therefore, 4000 successful LPs would be required to avoid a delay in the detection of 1 case of bacterial meningitis.
  • If no IM is abnormal, the AAP committee does not include a positive urinalysis result as an indicator for performing an LP.

Pantell, R. H., Roberts, K. B., Adams, W. G., Dreyer, B. P., Kuppermann, N., O’Leary, S. T., ... & Teichman, J. S. (2021). Evaluation and management of well-appearing febrile infants 8 to 60 days old.Pediatrics,148(2

These pathways do not establish a standard of care to be followed in every case. It is recognized that each case is different, and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare a pathway for each. Accordingly, these pathways should guide care with the understanding that departures from them may be required at times.