Meningitis in the newborn

Meningitis is a dangerous infectious and inflammatory pathology, since the disease process spreads to the membranes of the brain and spinal cord. Especially severe and unfavorable is meningitis in newborns: the disease is caused by a viral, bacterial or fungal infection, can affect the nervous system, and in some cases, even the death of the baby is possible. The most negative prognosis has meningitis of bacterial origin.

Epidemiology

The incidence of meningitis in the world ranges from 5 to 140 cases per 100 thousand people, regardless of age. At the same time, newborns account for the largest number of cases. For example, purulent meningitis is diagnosed in approximately one out of 2.5 thousand newborn children. Meningoencephalitis is found in one child out of 3 thousand children who were born alive. More accurate data cannot be obtained due to the impossibility of carrying out diagnostic measures in some underdeveloped countries. [1]

Up to 80% of cases of meningitis in newborns are found in children born prematurely. The degree of probability of a fatal outcome depending on the country's development is in the range from 14 to 75%. Severe complications develop in approximately 20-50% of patients. The most common complications are loss of vision and hearing, hydrocephalus, muscle cramps, epilepsy, inhibition of psychomotor development. [2]

Causes of the meningitis in newborns

In order for meningitis to begin its development, the penetration of the pathogen (microbe, virus or fungus) into the cranial cavity of the fetus or newborn child is necessary. Often, the disease appears as a result of transmission of the infection from mother to baby.

No less rare are cases where the development of meningitis is associated with a traumatic brain injury - for example, in severe childbirth. Pathogenic flora, causing an inflammatory process, enters the cranium.

Nevertheless, the most common type of infection is the penetration of the pathogen through the circulatory system. This is possible when the infection crosses the placental barrier, or develops as a secondary disease.

A particular degree of risk is present in debilitated infants with inadequate immune defenses - for example, premature and lightweight babies. And in children with immunodeficiency states (for example, with AIDS), meningitis of fungal etiology is often found.

Risk factors

High risk factors for meningitis in newborns may include:

• infectious and inflammatory diseases of the mother;
• intrauterine hypoxia;
• obstetric procedures performed for diagnostic or therapeutic purposes;
• resuscitation with asphyxia of the newborn;
• premature birth;
• low birth weight;
• morphofunctional insufficiency;
• intracranial injury in childbirth;
• prolonged parenteral administration of drugs to the baby;
• metabolic pathologies (for example, galactosemia). [3]

Certain groups of children have the highest risk of developing meningitis. We are talking about the following categories:

• children born prematurely;
• babies born after a difficult pregnancy in the mother;
• children who have undergone intrauterine hypoxia, infectious processes;
• babies with impaired functions of the nervous system;
• newborns with traumatic injuries of brain structures;
• children who have other infectious foci (sinusitis, endocarditis, respiratory or intestinal infection, etc.). [4]

Pathogenesis

The mechanism for the development of meningitis in newborns has significant differences from such a mechanism for the appearance of infection in older children and adult patients. An infectious lesion that subsequently provokes meningitis occurs during fetal development, during childbirth, or in the first days after the birth of the baby. [5]

Intrauterine meningitis is usually clinically detected within 2-3 days from the moment the baby is born. Postnatal inflammation develops a little later, for example, after 4 days of life.

The dominant causative agent of early meningitis is a representative of the microflora of the mother. Late neonatal meningitis refers primarily to hospital infections.

In addition to the period of the onset of meningitis formation, the presence of other infectious foci is considered an important pathogenetic link. If meningitis in a newborn develops independently, without other visible infectious processes, then they speak of a primary or isolated disease. If there is a combination of infectious foci, then meningitis is attributed to secondary pathologies. For example, this is possible if meningitis occurs against the background of pneumonia, sepsis, omphalitis, etc. [6]

Early meningitis in newborns is most often caused by β-hemolytic group B streptococcus, colic Escherichia, listeria monocytogenes. Most causative agents of late meningitis are conditionally pathogenic microorganisms. These can be pedagogical representatives of the enterobacteriaceae family, less often - pseudomonas, flavobacteria and other non-fermenting microbes. Very rarely, meningitis caused by enterococcus spp. 

Newborns with a prolonged presence of intravenous catheters have an increased risk of developing meningitis, caused by staphylococcus aureus, coagulase-negative staphylococci, aeruginosa pseudomonasis and candida infection.

The most likely routes of transmission are:

• The hematogenous pathway, which becomes possible as a result of widespread bacteremia. For example, in three out of four cases, the “culprit” of purulent meningitis is precisely bacteremia. Most often, the infection initially enters the respiratory tract, but sometimes meningitis can be primary.
• The contact path is considered the most probable with suppuration of cephalohematoma, with otitis media, osteomyelitis of the skull and cranium, inflammation of the skin and soft tissues, with a congenital malformation of the central nervous system, etc.
• Infection is possible from the lymphatic system and perineural spaces: this path of infection is considered the most rare.

Symptoms of the meningitis in newborns

Symptoms of meningitis in newborns are most often a combination of common infectious manifestations and neurological disorders. The severity of the clinical picture depends on the gestation period, body weight of the infant, the degree of development of its organs and systems, on whether there are any associated pathologies. [7]

The first signs of early and late meningitis are slightly different:

Symptoms	Early meningitis	Late meningitis
The time of appearance of the first signs	The first 2 days from birth	Not earlier than a week old
Common Infectious Symptoms	Prevail	Not prevail
Respiratory distress	Are characteristic	Not characteristic
Neurological disorders	Not characteristic	Are characteristic
Infectious source	Newborn mom	Mom newborn, medical staff, tools
Chance of death	Relatively high	Relatively low
Prematurity	Inherent	Not inherent
Pregnancy and childbirth complications	Maybe	Has no connection

If we consider the general somatic symptoms, then in the first place, attention is drawn to infectious intoxication, the signs of which are considered:

• grayish-pale skin color, "marble" pattern;
• yellowing of the skin and mucous membranes;
• increase or decrease in body temperature;
• cardiopalmus;
• impaired intestinal motor function;
• vomiting
• lethargy or lack of sucking reflex;
• enlarged liver / spleen;
• lack of weight gain. [8]

Neurological symptoms are usually extensive. In some newborns, depression of the central nervous system is detected, which is manifested by drowsiness, apathy, weakness of reflexes, and muscular hypotension. Other babies may be dominated by signs of hyper-excitement, pathological cries, trembling hands, legs, chin, and cramps. [9]

The spread of pathology to the cranial nerves is manifested by nystagmus, “floating” eyeballs, strabismus of the same type, etc.

A large fontanel protrudes and strains, the back cervical muscles are stiff (rigid): all these are typical signs for meningitis in newborns, and they are especially pronounced in babies born prematurely. In some children, an increasing diametrical enlargement of the head is noted, which entails craniosynostosis.

Among the later manifestations, the following are considered the most characteristic:

• throwing the head back;
• meningeal symptoms;
• the position of the body on its side, the head is thrown back, the knees are pressed to the tummy.

Lessage syndrome is sometimes noted: the baby is lifted up, holding the “armpits”, while its legs remain bent at the knees.

Stages

Meningitis in newborns can go through four stages of development:

• The first stage: during the course of labor, the bacteria first enter the fetus, the infection begins to spread along the upper respiratory tract and digestive system. Distribution is not accompanied by a clear immune response and clinical symptoms.
• The second stage: the infectious agent enters the bloodstream, bacteremia develops, after which the bacteria bypass the liver penetrate the central nervous system.
• Third stage: the infection spreads to the soft membranes of the spinal cord and brain.
• The fourth stage: the membranes of the brain become inflamed, the likelihood of disturbances in the cerebral parenchyma increases.

Forms

Meningitis is primary and secondary.

Primary meningitis in newborns can be purulent (streptococcal, pneumococcal, meningococcal nature) or serous (provoked by cytomegalovirus, herpes, mumps, tuberculosis infection, Coxsackie, etc.).

Secondary meningitis in newborns develops in the form of complications of purulent cephalohematoma, open head injury, surgical neurosurgical procedures, pulmonary abscess, septic process.

In addition, meningitis is classified depending on the pathogenetic factor: for example, inflammation can be bacterial, viral, fungal or protozoal.

Bacterial meningitis of newborns occurs most often and can develop during the prenatal period, during labor, or after the baby is born.

Purulent meningitis in newborns is caused by a bacterial infection - meningococci, staphylococci, streptococci, etc. Bacteria penetrate the placental barrier inside the child’s body if a pregnant woman suffers from infectious and inflammatory pathologies, such as pyelitis. Purulent form of meningitis is especially dangerous and in every second case it is fatal for a newborn. Even in the case of recovery, the child has adverse consequences in the form of inhibition of mental development, paralysis, etc.

Secondary purulent meningitis in a newborn is a consequence of an already existing purulent process in the body - for example, omphalitis, sepsis, cephalohematoma, salmonellosis, pulmonary abscess.

Viral meningitis in newborns has the most favorable prognosis. Infection can be represented by various types of viruses, and the clinical picture is manifested by pain in the head, rigidity of the cervical muscles, dyspepsia. Symptoms of a viral lesion are also characteristic: tonsillitis, conjunctivitis, etc.

Herpetic meningitis in newborns develops under the influence of the herpes simplex virus type I and II. Infection often occurs during labor if a woman has genital herpes. The prognosis of the pathology is relatively favorable. [10]

Congenital meningitis in newborns is a disease that the baby receives during fetal development - for example, during infectious and inflammatory processes in the mother's body. If we are talking about acquired meningitis, then infection occurs after the baby is born, or during childbirth.

Complications and consequences

The risk of complications increases with the delayed detection of meningitis, with illiterate medical tactics (or in the absence of treatment at all), with serious developmental defects, severe respiratory disorders, intrauterine infection. In this case, convulsions and cerebral edema can become the most common negative consequences.

Among the long-term complications, the following are most often said:

• inflammatory reaction in the walls of the ventricles of the brain;
• inflammation of the ventricular ependyma;
• cerebral abscesses;
• hydrocephaly.

The development of such complications of meningitis in newborns is usually observed against the background of untimely or improper treatment.

In turn, neonatal meningitis can become a trigger for the development of both hydrocephalus and multicystic processes of encephalomalacia or porcephalus, atrophic changes. Such consequences directly affect the quality of the baby’s life forecast.

Diagnostics of the meningitis in newborns

Experts point out that meningitis in newborns is usually not accompanied by unambiguous clinical signs, sufficient for early diagnosis. That is why additional laboratory tests play an important role:

• general clinical blood test (leukopenia is considered a negative sign);
• blood biochemistry (assessment of CRP, total protein and fractions, urea, creatinine, total bilirubin, glucose, transaminases);
• determination of blood coagulation quality;
• determination of the concentration of procalcitonin.
• Instrumental diagnostics is also of no small importance:
• X-ray examination of the cranium and organs located in the chest;
• fundus assessment by an ophthalmologist;
• electroencephalography;
• electrocardiography.

In any of the cases of presumed meningitis in newborns, the analysis of cerebrospinal fluid is of crucial diagnostic value. This study is performed without fail if the child has no contraindications, such as:

• shock state;
• thrombohemorrhagic syndrome;
• severe cerebral edema;
• optical disk edema (papilloedema).
• CSF analysis may include:
• determination of the number of cells with their morphological assessment;
• study protein and glucose;
• bacterioscopic examination of a fixed drop of cerebrospinal fluid with Gram stain;
• inoculation of cerebrospinal fluid on an elective nutrient medium with an antibioticogram;
• identification of microbial antigens in cerebrospinal fluid (use of latex-agglutination reaction, RIEF method).

Computed tomography and magnetic resonance imaging are used when there is a suspicion of a brain abscess, thromboembolism, heart attack, hemorrhage in the subarachnoid brain structures. [11]

Differential diagnosis

Differential diagnosis is carried out with intracranial hemorrhage, with cerebrospinal puncture playing a decisive role. With hemorrhage in the cerebrospinal fluid, altered red blood cells, a high content of total albumin, are noted. It is also necessary to exclude meningism - a pathology for which clinical and general cerebral signs are typical, while there are no pathological changes in the cerebrospinal fluid.

Meningitis of the early neonatal period should be distinguished from birth trauma to the central nervous system. If necessary, perform ultrasound GM or computed tomography.

Treatment of the meningitis in newborns

Meningitis in newborns needs urgent treatment in a hospital setting: in the intensive care unit or ICU. Often there is a need for artificial lung ventilation, cardiotonic maintenance therapy, vigilant monitoring of basic vital signs. It is important to constantly monitor the water-electrolyte balance, the level of glucose in the blood, etc. The acute period of meningitis is a contraindication for breastfeeding. It is appropriate to express milk and give it to the child from a syringe or bottle. If the sucking reflex is absent, the infant is fed by sensing.

The bacterial form of meningitis in newborns is an indication for prescribing antibiotic therapy: penicillins often become the drugs of choice. After performing cerebrospinal puncture, the treatment is reviewed in favor of an antibiotic that is extremely suitable for influencing the detected pathogen. [12]

With a viral etiology of meningitis, diuretics are prescribed (to prevent cerebral edema and to stabilize pressure), anticonvulsants and antiallergic drugs. In addition, symptomatic therapy is performed.

A confirmed and identified fungal pathogen requires the administration of antifungal drugs. In addition, immunocorrection, vitamin therapy are indicated.

Medication

Neonatal microbial meningitis in newborns is most often treated with such antibiotics, depending on the pathogen:

• with Escherichia coli or streptococcal infection, ampicillin is prescribed with gentamicin (cefotaxime);
• with the defeat of L. Monocytogenes, ampicillin is prescribed, or its combination with gentamicin.

If during the study of cerebrospinal fluid, gram-positive and gram-negative microorganisms are detected, then they begin treatment with ceftriaxone or cefotaxime. In determining pseudomonas, the combined use of amikacin with ceftazidime is effective.

If the identification of the pathogen was not successful, then empirical treatment is prescribed using cephalosporin antibiotics of the third generation.

To eliminate seizures, 0.5% diazepam is administered at a dosage of 1-3 mg per kilogram of weight in the form of intravenous or intramuscular injections (intravenously slowly with 10% glucose). Phenobarbital in an amount of up to 10 mg per kilogram of body weight per day (orally) is suitable as a maintenance drug.

Immunocorrection drugs are immunoglobulins (for example, pentaglobin), which are administered with obvious manifestations of suppressed immunity. At the end of the acute period, it is possible to use viferon suppositories, in the composition of which there is RFL α-2b. The dose is 150 thousand IU twice a day, for ten days. Sometimes viferon is replaced with kipferon.

After normalizing the composition of the cerebrospinal fluid, they go on to treatment with neuroprotectors and neurotrophic agents.

Vitamins

At the recovery stage of meningitis, a necessary measure is the intake of vitamins, which will allow to establish the basic vital processes in the body of a newborn. The most effective are vitamins of the B-group - in particular, B ₁, B ₆, B ₁₂.

Vitamin preparations optimize the processes of tissue metabolism, tone the muscles and nervous system, improve the body's adaptation after treatment, and establish the majority of biochemical reactions.

The additional introduction of vitamins and essential microelements significantly accelerates the rehabilitation process.

Physiotherapeutic treatment

Physiotherapy for meningitis in newborns is connected at the stage of recovery and may consist of classical massage and the use of other hardware procedures. Electrophoresis with vitamins and certain drugs helps to relax or, conversely, activate the necessary muscle groups. For coordination disorders, magnetic therapy, electrosleep, and laser-magnetic therapy are used: these methods help restore the functionality of the central nervous system.

Perhaps the use of other techniques. They are selected by the doctor depending on the characteristics of a particular situation.

Alternative treatment

The use of alternative recipes for the treatment of meningitis in newborns is more than risky, because this is a serious and serious pathology that requires urgent medical intervention. Nevertheless, such recipes exist, and we will give some of them - mainly for the purpose of familiarization. We remind you: in any case, meningitis in newborns cannot be treated independently, and any therapeutic actions should be coordinated with your doctor.

1. An infusion of poppy seeds is prepared in milk: one teaspoon of poppy is ground to a porridge, placed in a thermos, filled with 125 ml of freshly boiled milk, tightly closed and left to stand for 8 hours. Infusion is given to the child three times a day, one tablespoon each.
2. Prepare a barley broth: take 2 tbsp. L unpeeled barley kernels, pour 250 ml of boiling water and boil over low heat for a quarter hour. Then they are removed from the heat and cooled, filtered, and given to the child three times a day.
3. Cranberries infusion is prepared: 20 g of crushed berries (it is possible together with leaves) are poured with 300 ml of boiling water, insisted for 4 hours, filtered. Give the child 30 ml of infusion three times a day.

Herbal treatment

• Lavender plant relieves muscle tone, eliminates pain, relieves cramps. To treat meningitis, an infusion of 40 g of lavender and 500 ml of boiling water is prepared. A warm infusion is gradually given to the baby, and warm lotions are also applied to the neck and back of the neck.
• Prepare an infusion of mint leaves: 2 tsp. 200 ml of boiling water is poured onto a dry sheet, insisted for an hour. Next, the infusion is filtered, cooled, given to the baby three times a day, 5 ml each. A similar infusion can be prepared from chamomile.
• The infusion of linden flowers and rose hips are prepared as follows: ¼ cups of raw material is poured into 500 ml of boiling water, insisted for 20 minutes, filtered. Give the child three times a day for 1 tsp.

Some herbalists advise giving the baby infusions on a camel thorn, wormwood, valerian root, mistletoe, and hemophilus. However, we repeat: any of the proposed recipes can not be used without first consulting a doctor.

Homeopathy

Meningitis in newborns is a disease that is difficult to treat and unpredictable in terms of the development of adverse effects. Nevertheless, it requires immediate medical intervention, because the slightest delay can cost not only health, but also the life of the baby. Therefore, a rare homeopath will take the responsibility to prescribe any remedies in this situation.

However, there are a number of homeopathic remedies recommended by specialists for the treatment of childhood meningitis:

• Zincum cyan. X4 and Tabakum X3 (alternate after about an hour and a half);
• Zincum cyan. X3-X4 and Arsen iodine. X4 (with a prolonged course of meningitis);
• Aconite, Baptisia, belladonna, Bryonia, Digitalis, Gelsemin, Kuprum, Physostigma, Tsimitsifuga - in individually selected dosages.

Belladonna is recommended not only as a therapeutic, but also as a prophylactic. This drug improves blood circulation in the head, prevents the development of inflammatory processes. For prevention, children are offered to take the drug three times a day in the sixth division.

Surgery

The surgeon's help with meningitis in newborns may be needed only with the development of some complications - for example, with purulent inflammation, brain abscess. The standard course of the disease does not require surgery.

Prevention

Unfortunately, there is no specific prophylaxis to prevent the development of meningitis in newborns. At the same time, an adequate and thoughtful approach, the implementation of preventive measures during pregnancy can reduce the risk of pathology formation.

• Pregnancy should be carefully planned.
• A woman should be registered in a antenatal clinic on time, undergo an ultrasound examination in a timely manner, and take the necessary tests.
• During pregnancy, the expectant mother should fully eat, abandon bad habits, avoid stress, if possible, have more rest and walk in the fresh air.
• It is important to carry out the prevention of infectious diseases during pregnancy.
• If necessary and on the advice of a doctor, multivitamin complex preparations can be taken.
• If the doctor insists on inpatient treatment or supervision, then it is necessary to listen to his recommendations.

Forecast

If untreated, meningitis in newborns is fatal. Timely treatment measures significantly improve the prognosis, however, the weight of the child, the severity of the pathology and the severity of the clinical picture also play a significant role. [13]

Mortality in infants treated with microbial meningitis is estimated at about 15%. The most unfavorable are inflammatory processes accompanied by vasculitis or a brain abscess. The likelihood of developing neurological complications in the form of inhibition of mental development, loss of auditory function is present in every second surviving child in whom the disease was caused by a gram-negative intestinal microorganism. 

The quality of the prognosis to some extent also depends on the number of infectious pathogens found in the cerebrospinal fluid during diagnosis. [14]

Meningitis in newborns caused by group B streptococcus is less likely to be fatal, in contrast to the early septic complications triggered by the same infection.