Meningitis in newborns

Meningitis is a dangerous infectious and inflammatory pathology, since the painful process spreads to the membranes of the brain and spinal cord. Meningitis in newborns is considered especially severe and unfavorable: 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. Meningitis of bacterial origin has the most negative prognosis.

Epidemiology

The incidence of meningitis in the world fluctuates between 5 and 140 cases per 100,000 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 newborn child out of 2.5 thousand. 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 neonatal meningitis cases are found in premature babies. The fatality rate, depending on the country's level of development, ranges 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 spasms, epilepsy, and psychomotor retardation. [ 2 ]

Causes meningitis in newborns

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

No less rare are cases when the development of meningitis is associated with a craniocerebral injury - for example, during difficult childbirth. Pathogenic flora gets into the cranium, causing an inflammatory process.

However, the most common type of infection is penetration of the pathogen through the bloodstream. This is possible when the infection overcomes the placental barrier or develops as a secondary disease.

There is a particular risk in weakened babies with insufficient immune protection, such as premature and low-weight infants. And in children with immunodeficiency conditions (for example, with AIDS), meningitis of fungal etiology is often detected.

Risk factors

Factors that increase the risk of meningitis in newborns include:

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

Certain groups of children are at the highest risk of developing meningitis. These include:

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

Pathogenesis

The mechanism of meningitis development in newborns differs significantly from the mechanism of infection in older children and adult patients. The infectious lesion, which subsequently provokes meningitis, occurs during the period of intrauterine 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 child is born. Postnatal inflammation develops somewhat later, for example, after 4 days of life.

The dominant pathogen of early meningitis is a representative of the mother's microflora. Late meningitis of newborns is mainly a hospital infection.

In addition to the period of the onset of meningitis, 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 we speak of a primary or isolated disease. If there is a combination of infectious foci, then meningitis is classified as a secondary pathology. 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 streptococcus group B, Escherichia coli, Listeria monocytogenes. Most pathogens of late meningitis are opportunistic microorganisms. These may be representatives of the enterobacteria family, less often - pseudomonas, flavobacteria and other "non-fermenting" microbes. Meningitis caused by enterococcus spp. is very rare.

Newborns with long-term intravenous catheters are at increased risk of developing meningitis caused by Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, and Candida infections.

The most likely routes of infection transmission are considered to be the following:

• Hematogenous route, which becomes possible as a result of widespread bacteremia. For example, in three out of four cases of purulent meningitis, bacteremia is the "culprit". Most often, the infection initially enters the respiratory tract, but sometimes meningitis can be primary.
• The contact route is considered the most likely in cases of suppuration of cephalohematoma, otitis media, osteocranial osteomyelitis, inflammation of the skin and soft tissues, congenital anomalies in the development of the central nervous system, etc.
• Infection can enter from the lymphatic system and perineural spaces: this route of infection is considered the rarest.

Symptoms meningitis in newborns

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

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

Symptoms	Early meningitis	Late meningitis
Time of appearance of the first signs	The first 2 days from the moment of birth	Not earlier than one week of age
General signs of infection	Prevail	Do not prevail
Respiratory disorders	Characteristic	Not typical
Neurological disorders	Not typical	Characteristic
Infectious source	Mother of a newborn	Mother of a newborn, medical staff, instruments
Probability of fatal outcome	Relatively high	Relatively low
Prematurity	Inherent	Not inherent
Complications during pregnancy and childbirth	Maybe	No connection

If we consider general somatic symptoms, then first of all, infectious intoxication attracts attention, the signs of which are considered to be:

• grayish-pale skin color, “marbled” pattern;
• yellowing of the skin and mucous membranes;
• increase or decrease in body temperature;
• increased heart rate;
• violation of intestinal motor function;
• vomit;
• lethargy or absence of the sucking reflex;
• enlarged liver/spleen;
• no weight gain. [ 8 ]

Neurological symptoms are usually extensive. Some newborns show depression of the central nervous system, which manifests itself as drowsiness, apathy, weak reflexes, and muscle hypotonia. Other babies may show signs of hyperarousal, abnormal cries, trembling of the hands, feet, and chin, as well as convulsions. [ 9 ]

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

The large fontanelle protrudes and tenses, the posterior cervical muscles are unyielding and hard (rigid): all these are typical signs of meningitis in newborns, and they are especially pronounced in premature babies. Some children experience an increasing diametrical enlargement of the head, which leads to craniosynostosis.

Among the late manifestations, the most characteristic are the following:

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

Sometimes Lesage syndrome is observed: the baby is lifted by holding the “armpits”, while his legs remain bent at the knees.

Stages

Meningitis in newborns can go through four stages of development:

• Stage one: during labor, bacteria first enter the fetus's body, and the infection begins to spread through the upper respiratory tract and digestive system. The spread is not accompanied by a clear immune response or clinical symptoms.
• The second stage: the infectious agent enters the bloodstream, bacteremia develops, after which the bacteria bypass the liver and enter the central nervous system.
• Stage three: The infection spreads to the membranes of the spinal cord and brain.
• Stage four: the membranes of the brain become inflamed, and the likelihood of disturbances in the brain parenchyma increases.

Forms

Meningitis can be primary and secondary.

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

Secondary meningitis in newborns develops as a complication of purulent cephalohematoma, open TBI, surgical neurosurgical procedures, pulmonary abscess, and septic process.

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

Bacterial meningitis in newborns occurs most often and can develop during the intrauterine 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 into the child's body - if the pregnant woman suffers from infectious and inflammatory pathologies, for example, pyelitis. The purulent form of meningitis is especially dangerous and in every second case ends in death for the newborn. Even in case of recovery, the child has adverse effects in the form of mental retardation, paralysis, etc.

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

Viral meningitis in newborns has the most favorable prognosis. The infection can be represented by various types of viruses, and the clinical picture is manifested by headaches, stiff neck muscles, dyspepsia. Symptoms of viral infection are also characteristic: tonsillitis, conjunctivitis, etc.

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

Congenital meningitis in newborns is a disease that the baby gets during intrauterine 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 late detection of meningitis, with incompetent medical tactics (or with no treatment at all), with serious developmental defects, severe respiratory disorders, intrauterine infection. The most common negative consequences can be seizures and cerebral edema.

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

• inflammatory reaction in the walls of the ventricles of the brain;
• inflammation of the ependyma of the ventricles;
• brain abscesses;
• hydrocephalus.

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

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

Diagnostics 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 the quality of blood clotting;
• determination of the concentration content of procalcitonin.
• Instrumental diagnostics are also of great importance:
• X-ray examination of the skull and organs located in the chest;
• assessment of the fundus by an ophthalmologist;
• electroencephalography;
• electrocardiography.

In any case of suspected meningitis in newborns, the analysis of cerebrospinal fluid is of decisive diagnostic importance. This study is mandatory if the child has no contraindications, such as:

• state of shock;
• thrombohemorrhagic syndrome;
• severe cerebral edema;
• edema of the optic disc (papilloedema).
• CSF analysis may include:
• determination of the number of cells with their morphological assessment;
• study of protein and glucose content;
• bacterioscopic examination of a fixed drop of cerebrospinal fluid with Gram staining;
• Cultivation of cerebrospinal fluid on an elective nutrient medium with an antibiogram;
• identification of microbial antigens in cerebrospinal fluid (using the latex agglutination reaction, RIEF method).

Computer and magnetic resonance imaging are used when there is a suspicion of a brain abscess, thromboembolism, infarction, or hemorrhage in the subarachnoid brain structures. [ 11 ]

Differential diagnosis

Differential diagnostics are performed with intracranial hemorrhage, with cerebrospinal puncture playing a decisive role. In case of hemorrhage, altered erythrocytes and a high content of total albumin are noted in the cerebrospinal fluid. It is also necessary to exclude meningism, a pathology for which clinical and general brain signs are typical, while pathological changes in the cerebrospinal fluid are absent.

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

Treatment meningitis in newborns

Meningitis in newborns requires immediate treatment in a hospital setting: in the intensive care unit or ICU. There is often a need for artificial ventilation, cardiotonic supportive therapy, and constant monitoring of basic vital signs. It is important to constantly monitor the water-electrolyte balance, blood glucose levels, etc. The acute period of meningitis is a contraindication for breastfeeding. It is appropriate to express milk and give it to the baby from a syringe or bottle. If the sucking reflex is absent, the baby is fed by probing.

Bacterial meningitis in newborns is an indication for antibiotic therapy: penicillins are often the drugs of choice. After performing a cerebrospinal puncture, treatment is revised in favor of an antibiotic that is most suitable for the action on the detected pathogen. [ 12 ]

In case of viral etiology of meningitis, diuretics are prescribed (to prevent cerebral edema and to stabilize blood pressure), anticonvulsants and antiallergic drugs. Symptomatic therapy is also administered.

A confirmed and identified fungal pathogen requires the prescription of antifungal drugs. In addition, immune correction and vitamin therapy are indicated.

Medicines

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

• in case of Escherichia coli or streptococcal infection, ampicillin with gentamicin (cefotaxime) is prescribed;
• In case of L. monocytogenes infection, ampicillin is prescribed, or its combination with gentamicin.

If gram-positive and gram-negative microorganisms are detected during the examination of the cerebrospinal fluid, then therapy with ceftriaxone or cefotaxime is started. When determining pseudomonas, the combined use of amikacin with ceftazidime is effective.

If identification of the pathogen is unsuccessful, then empirical treatment is prescribed using third-generation cephalosporin antibiotics.

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

Immunocorrecting drugs are immunoglobulins (for example, pentaglobin), which are administered when there are obvious manifestations of suppressed immunity. At the end of the acute period, it is possible to use Viferon suppositories, which contain RCLI α-2b. The dose is 150 thousand IU twice a day for ten days. Sometimes Viferon is replaced with Kipferon.

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

Vitamins

At the recovery stage of meningitis, a necessary measure is taking vitamins that will help to establish the main vital processes in the newborn's body. The most effective are considered to be vitamins of the B group - in particular, B ₁, B ₆, B ₁₂.

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

Additional administration of vitamins and essential microelements significantly accelerates the rehabilitation process.

Physiotherapy treatment

Physiotherapy for neonatal meningitis is included at the recovery stage and may include classical massage and other hardware procedures. Electrophoresis with vitamins and some medications help to relax or, conversely, activate the necessary muscle groups. Magnetic therapy, electrosleep, and laser-magnetic therapy are used for coordination disorders: these methods help to restore the functionality of the central nervous system.

Other methods may also be used. They are selected by the doctor depending on the specific situation.

Folk remedies

Using folk recipes to treat meningitis in newborns is more than risky, because we are talking about a serious and severe pathology that requires urgent medical intervention. However, such recipes exist, and we will provide some of them - mainly for informational purposes. We remind you: meningitis in newborns should never be treated independently, and any treatment should be agreed with the attending physician.

1. Make a poppy infusion with milk: grind one teaspoon of poppy seeds into a mushy mass, place in a thermos, pour in 125 ml of just boiled milk, close tightly and leave for 8 hours. Give the infusion to the child three times a day, one tablespoon at a time.
2. Prepare a barley decoction: take 2 tablespoons of unhulled barley grains, pour 250 ml of boiling water and boil over low heat for a quarter of an hour. Then remove from heat and cool, filter, give to the child to drink three times a day.
3. Prepare a cranberry infusion: pour 20 g of crushed berries (with leaves) with 300 ml of boiling water, leave for 4 hours, filter. Give the child 30 ml of the infusion three times a day.

Herbal treatment

• The lavender plant relieves muscle tone, eliminates pain, and relieves cramps. To treat meningitis, prepare an infusion of 40 g of lavender and 500 ml of boiling water. Give the baby a little warm infusion, and apply warm compresses to the back of the head and the back of the neck.
• An infusion of mint leaves is prepared: 2 teaspoons of dry leaves are poured with 200 ml of boiling water and infused for an hour. Then the infusion is filtered, cooled, and given to the baby three times a day, 5 ml each time. A similar infusion can also be prepared from chamomile.
• An infusion of linden flowers and rose hips is prepared as follows: ¼ cup of raw material is poured with 500 ml of boiling water, infused for 20 minutes, filtered. Give the child 1 teaspoon three times a day.

Some herbalists recommend giving the baby infusions of camel thorn, wormwood, valerian root, mistletoe, and burnet. However, we repeat: any of the suggested recipes should 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. However, it requires immediate medical intervention, because the slightest delay can cost not only the health, but also the life of the baby. Therefore, a rare homeopath will take responsibility for prescribing 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 approximately every one and a half hours);
• Zincum cyan. X3-X4 and Arsen iodine. X4 (in case of protracted meningitis);
• Aconite, Baptisia, belladonna, Bryonia, Digitalis, Gelsemine, Cuprum, Physostigma, Cimicifuga – in individually selected dosages.

Belladonna is recommended not only as a therapeutic but also as a preventive remedy. This drug improves blood circulation in the head area and prevents the development of inflammatory processes. For preventive purposes, children are advised to take the drug three times a day in the sixth division.

Surgical treatment

Surgery for meningitis in newborns may be needed only if certain complications develop, such as purulent inflammation or brain abscess. The standard course of the disease does not require mandatory surgical intervention.

Prevention

Unfortunately, there is no specific prevention 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 developing pathology.

• Pregnancy should be carefully planned.
• A woman should register with a women's health clinic on time, undergo an ultrasound examination on time, and take the necessary tests.
• During pregnancy, the expectant mother should eat well, give up bad habits, avoid stress, rest as much as possible and walk in the fresh air.
• It is important to take preventive measures against infectious diseases during pregnancy.
• If necessary and on the advice of a doctor, you can take multivitamin complex preparations.
• If the doctor insists on inpatient treatment or observation, then you need to listen to his recommendations.

Forecast

Without treatment, meningitis in newborns ends in death. Timely treatment significantly improves the prognosis, but the child's weight, the severity of the pathology and the severity of the clinical picture also play a significant role. [ 13 ]

Mortality in newborns treated for microbial meningitis is estimated at approximately 15%. The most unfavorable are inflammatory processes accompanied by vasculitis or brain abscess. The probability of developing neurological complications in the form of mental retardation, loss of hearing function is present in every second surviving child whose disease was caused by a gram-negative intestinal microorganism.

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

Meningitis in newborns caused by group B streptococcus has a lower mortality rate than early septic complications caused by the same infection.