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Am J Perinatol 2022; 39(01): 099-105
DOI: 10.1055/s-0040-1714397
Original Article

Is Lumbar Puncture Avoidable in Low-Risk Neonates with Suspected Sepsis?

Richie Dalai
1   Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
,
Sourabh Dutta
1   Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
,
Arnab Pal 
2   Department of Biochemistry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
,
Venkataseshan Sundaram
1   Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
,
Muralidharan Jayashree
1   Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract

Objective Performing lumbar punctures (LP) in all clinically suspected neonatal sepsis, as per current recommendations, results in many “negative” LPs. LPs are not without their own risks. With the intention of minimizing unnecessary LPs among neonates, we aimed to identify a subgroup at extremely low risk of developing possible meningitis so that an LP could be safely avoided in it.

Study Design This was a prospective, observational, and cross-sectional study in a level III neonatal unit. We included 300 episodes, in which LP was performed for suspected sepsis. We recorded a comprehensive set of clinico-demographic variables, laboratory parameters, sickness score, organ dysfunction score, and organ localization and studied association of these factors with “definite (culture positive) or possible meningitis.” “Possible” meningitis was defined with liberal criteria, intending not to miss any meningitis. A subgroup without a single factor associated with “definite or possible meningitis” was analyzed for incidence of meningitis.

Results There were 121 episodes of “definite or possible meningitis” among 300 episodes of sepsis. On unadjusted analysis, apnea, irritability, high-pitched cry, seizures, neutrophilia, high C-reactive protein (CRP), score for acute neonatal physiology and perinatal extension II (SNAPPE-II), urine output, and leukomalacia were associated with “definite or possible” meningitis (p < 0.05). On multivariate analysis, no apneas, no neutrophilia, and normal CRP were independently associated with “no definite or possible meningitis.” Nevertheless, the subgroup that had a combination of no apneas, no neutrophilia, and normal CRP (n = 118) had a 29% probability of “definite or possible meningitis.”

Conclusion The lowest risk subgroup had a 29% chance of having “definite or possible” meningitis. There is no subgroup that we could identify among neonates with suspected sepsis, in which it is safe to avoid an LP.

Key Points

  • LP are performed in all cases of late onset neonatal sepsis.

  • Previous authors unsuccessfully tried to identify high-risk groups for performing LP.

  • We were unable to identify an extremely low-risk group in which LP could be safely avoided.

Keywords

neonate - meningitis - lumbar puncture - low risk

Supplementary Material



Publication History

Received: 25 November 2019

Accepted: 17 June 2020

Article published online:
21 July 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Furyk JS, Swann O, Molyneux E. Systematic review: neonatal meningitis in the developing world. Trop Med Int Health 2011; 16 (06) 672-679
    CrossrefPubMedGoogle Scholar
  • 2 Smith PB, Garges HP, Cotton CM, Walsh TJ, Clark RH, Benjamin Jr DK. Meningitis in preterm neonates: importance of cerebrospinal fluid parameters. Am J Perinatol 2008; 25 (07) 421-426
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Eldadah M, Frenkel LD, Hiatt IM, Hegyi T. Evaluation of routine lumbar punctures in newborn infants with respiratory distress syndrome. Pediatr Infect Dis J 1987; 6 (03) 243-246
    CrossrefPubMedGoogle Scholar
  • 4 Weiss MG, Ionides SP, Anderson CL. Meningitis in premature infants with respiratory distress: role of admission lumbar puncture. J Pediatr 1991; 119 (06) 973-975
    CrossrefPubMedGoogle Scholar
  • 5 Garges HP, Moody MA, Cotten CM. et al. Neonatal meningitis: what is the correlation among cerebrospinal fluid cultures, blood cultures, and cerebrospinal fluid parameters?. Pediatrics 2006; 117 (04) 1094-1100
    CrossrefPubMedGoogle Scholar
  • 6 Isaacs D, Barfield C, Clothier T. et al. Late-onset infections of infants in neonatal units. J Paediatr Child Health 1996; 32 (02) 158-161
    CrossrefPubMedGoogle Scholar
  • 7 Joshi P, Barr P. The use of lumbar puncture and laboratory tests for sepsis by Australian neonatologists. J Paediatr Child Health 1998; 34 (01) 74-78
    CrossrefPubMedGoogle Scholar
  • 8 Rubin LG, Sánchez PJ, Siegel J, Levine G, Saiman L, Jarvis WR. Pediatric Prevention Network. Evaluation and treatment of neonates with suspected late-onset sepsis: a survey of neonatologists' practices. Pediatrics 2002; 110 (04) e42
    CrossrefPubMedGoogle Scholar
  • 9 Stewart D. The normal cerebro-spinal fluid in children. Arch Dis Child 1928; 3 (14) 96-108
    CrossrefPubMedGoogle Scholar
  • 10 Stoll BJ, Hansen N, Fanaroff AA. et al. To tap or not to tap: high likelihood of meningitis without sepsis among very low birth weight infants. Pediatrics 2004; 113 (05) 1181-1186
    CrossrefPubMedGoogle Scholar
  • 11 Visser VE, Hall RT. Lumbar puncture in the evaluation of suspected neonatal sepsis. J Pediatr 1980; 96 (06) 1063-1067
    CrossrefPubMedGoogle Scholar
  • 12 Wiswell TE, Baumgart S, Gannon CM, Spitzer AR. No lumbar puncture in the evaluation for early neonatal sepsis: will meningitis be missed?. Pediatrics 1995; 95 (06) 803-806
    PubMedGoogle Scholar
  • 13 Patrick SW, Schumacher RE, Davis MM. Variation in lumbar punctures for early onset neonatal sepsis: a nationally representative serial cross-sectional analysis, 2003-2009. BMC Pediatr 2012; 12: 134
    CrossrefPubMedGoogle Scholar
  • 14 Srinivasan L, Harris MC, Shah SS. Lumbar puncture in the neonate: challenges in decision making and interpretation. Semin Perinatol 2012; 36 (06) 445-453
    CrossrefPubMedGoogle Scholar
  • 15 Pappano D. “Traumatic tap” proportion in pediatric lumbar puncture. Pediatr Emerg Care 2010; 26 (07) 487-489
    CrossrefPubMedGoogle Scholar
  • 16 Speidel BD. Adverse effects of routine procedures on preterm infants. Lancet 1978; 1 (8069): 864-866
    CrossrefPubMedGoogle Scholar
  • 17 Weisman LE, Merenstein GB, Steenbarger JR. The effect of lumbar puncture position in sick neonates. Am J Dis Child 1983; 137 (11) 1077-1079
    PubMedGoogle Scholar
  • 18 Dapaah-Siakwan FMS, Lodhi S, Mikhno A, Cameron G. White Cell Indices and CRP: predictors of meningitis in neonatal sepsis?. Int J Pediatr 2016; 4: 1355-1364
    PubMedGoogle Scholar
  • 19 Milcent K, Faesch S, Gras-Le Guen C. et al. Use of procalcitonin assays to predict serious bacterial infection in young febrile infants. JAMA Pediatr 2016; 170 (01) 62-69
    CrossrefPubMedGoogle Scholar
  • 20 Bonsu BK, Harper MB. Utility of the peripheral blood white blood cell count for identifying sick young infants who need lumbar puncture. Ann Emerg Med 2003; 41 (02) 206-214
    CrossrefPubMedGoogle Scholar
  • 21 Flidel-Rimon O, Leibovitz E, Eventov Friedman S, Juster-Reicher A, Shinwell ES. is lumbar puncture (LP) required in every workup for suspected late-onset sepsis in neonates?. Acta Paediatr 2011; 100 (02) 303-304
    CrossrefPubMedGoogle Scholar
  • 22 Brik R, Hamissah R, Shehada N, Berant M. Evaluation of febrile infants under 3 months of age: is routine lumbar puncture warranted?. Isr J Med Sci 1997; 33 (02) 93-97
    PubMedGoogle Scholar
  • 23 Richardson DK, Corcoran JD, Escobar GJ, Lee SK. SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001; 138 (01) 92-100
    CrossrefPubMedGoogle Scholar
  • 24 Cetinkaya M, Köksal N, Özkan H. A new scoring system for evaluation of multiple organ dysfunction syndrome in premature infants. Am J Crit Care 2012; 21 (05) 328-337
    CrossrefPubMedGoogle Scholar
  • 25 Kahl L, Hughes HK. The Harriet Lane Handbook E-Book: Mobile Medicine Series. Elsevier Health Sciences; 2017
    Google Scholar
  • 26 Hendricks-Muñoz KD, Shapiro DL. The role of the lumbar puncture in the admission sepsis evaluation of the premature infant. J Perinatol 1990; 10 (01) 60-64
    PubMedGoogle Scholar
  • 27 Schwersenski J, McIntyre L, Bauer CR. Lumbar puncture frequency and cerebrospinal fluid analysis in the neonate. Am J Dis Child 1991; 145 (01) 54-58
    PubMedGoogle Scholar