Safety and Success of Lumbar Puncture in Young Infants: A Prospective Observational Study

Incidence of Traumatic Lumbar Punctures in Neonates and Infants

OBJECTIVES

The objective of this study is to examine factors accounting for the incidence of traumatic lumbar puncture (TLP) in infants younger than 1 year old.

STUDY DESIGN

Retrospective analysis of cerebrospinal fluid (CSF) data from 1,240 neonatal (≤28 days) and 399 infant lumbar puncture (LP) procedures was conducted. Data from two successive LP procedures were obtained from 108 patients. Logistic regression analysis was used to assess factors accounting for the incidence of TLP in the second LP procedure. The following categorical variables were entered into the model: whether the first procedure was traumatic according to criteria of ≥500 and ≥10,000 erythrocytes/µL, whether the LP procedures were performed within a week, and whether the patient was neonatal at the first procedure.

RESULTS

The incidences of TLP were 42.9% in neonates and 22.5% in infants for the criterion of ≥500 erythrocytes/µL, and 16.6 and 10.3% for the criterion of ≥10,000 erythrocytes/µL. Compared with a nontraumatic first LP procedure, if the first procedure was traumatic according to the criterion of ≥10,000 erythrocytes/µL, the odds ratio (OR) of TLP in the second procedure was 5.86 (p = 0.006). Compared with a longer time, if the successive procedures were performed within a week, the OR of TLP was 9.06 (p < 0.0001) according to the criteria of ≥500 erythrocytes/µL and 3.34 (p = 0.045) according to the criteria of ≥10,000 erythrocytes/µL. If the patient was neonatal at the first procedure, the OR of TLP at the second puncture was 0.32 (p = 0.031) according to the criterion of ≥500 erythrocytes/µL.

CONCLUSION

The incidence of TLP in neonates is twice as high as that in infants. Successive LP procedures performed within a week and a highly blood-contaminated CSF sample in the first procedure each multiplied the odds of TLP in the second procedure, whereas being a neonate at the time of the first procedure reduced the odds of TLP.

KEY POINTS

· Traumatic LPs increase diagnostic uncertainty.. · Traumatic LPs are twice as common in neonates as in infants.. · Two LPs performed within a week multiplied the odds of traumatic LP.. · Erythrocyte-based criteria for traumatic LP affect the incidence of TLP..

Proportion of Successful Lumbar Punctures in Infants Younger Than Three Months

It is important to perform lumbar punctures (LPs) without a single traumatic tap in infants younger than three months owing to the risk of serious complications. The proportion of LPs in which clear cerebrospinal fluid (CSF) was obtained has been previously reported, but some of the procedures involved a traumatic tap. The present study aimed to identify the proportion of LPs in which clear CSF was obtained without a single traumatic tap and the factors associated with successful LPs in infants younger than three months. This retrospective, observational study included children younger than three months who underwent an LP in the pediatric emergency department between April 2018 and March 2021. The primary outcome was the proportion of successful LPs, defined as LPs obtaining clear CSF without a single traumatic tap. Multiple logistic regression analysis was used to identify factors related to successful LPs. Of 126 eligible patients, 121 were included. Among these, 83 (69%) were in the successful group. No factors significantly associated with successful LPs were found. Larger studies based on an accurate definition of successful LPs, such as that provided by this study, are needed to investigate related factors to increase the rate of successful LPs in this age group.

Late-Onset Sepsis Evaluation and Empiric Therapy in Extremely Low Gestational Age Newborns

BACKGROUND

Little is known about late-onset sepsis (LOS) evaluations in extremely low gestational age newborns (ELGANs). We describe frequencies of LOS evaluation in ELGANs, infant characteristics, and empiric therapy choices during evaluations.

METHODS

Cohort study of infants 22-28 weeks gestational age (GA) discharged from 243 centers from 2009 to 2018, excluding infants with congenital anomalies, discharged or deceased prior to postnatal day (PND) 2, or admitted after PND 2. A new LOS evaluation was defined as the first blood culture obtained between PND 3 and 90, or one obtained ≥1 day following a negative culture and ≥10 days from prior positive cultures. We determined numbers of evaluations and percentage positive by GA, center, and over time. We described characteristics associated with positive evaluations, infants with LOS, and empiric antimicrobials. We calculated descriptive and comparative statistics using Wilcoxon rank sum, Fisher's exact, or Pearson chi-square tests, as appropriate.

RESULTS

Of 47,187 included infants, 67% had ≥1 LOS evaluation and 21% of evaluated infants had ≥1 LOS (culture positive) episode; 1.6 evaluations occurred per infant and 10% were positive. The percentage of infants evaluated and positive for LOS was higher at earlier GA. LOS was associated with inotrope support (15% vs. 9%; p < .001) and invasive mechanical ventilation (66% vs. 51%; p < .001). Infants with positive cultures were more likely than infants with negative cultures to receive empiric antimicrobials during the LOS evaluation (95% vs. 73%; p < .001).

CONCLUSIONS

Among ELGANs, earlier GA and postnatal age were associated with LOS evaluation and positive cultures. Most infants undergoing evaluation were started on empiric antimicrobials.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.99, 95% CI 0.88 to 1.12; RD 0.00, 95% CI -0.06 to 0.05; I2 = 47% and 46% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts as specified in this review. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position (I2 = not applicable; 2 studies; 1102 infants; high-certainty evidence; in one of the study median and IQR to report time to perform the lumbar puncture were 8 (5-13) and 8 (5-12) in the lateral and sitting position, respectively, I2 = not applicable; 1 study, 1082 infants; in the other study: mean difference 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Positioning for lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.

OBJECTIVES

To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I2 = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.

AUTHORS' CONCLUSIONS

When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.

Lumbar puncture position in infants-a systematic review and meta-analysis

To analyze the optimal lumbar puncture position in infants. A systematic review and meta-analysis. Infants (age < 1 year). December 2022 in PubMed, Scopus, and Web of Science. Randomized controlled trials focusing on lumbar puncture positions were included. Other lumbar puncture position than standard lateral decubitus position. First puncture success and overall success rate. Secondary outcome was desaturation during puncture and procedure-related harms. Risk of bias 2.0 assessment was performed. Outcomes are reported as risk ratios (RR) with 95% confidence intervals (CI). We screened 225 abstracts, and six studies were included. Four studies compared sitting position, one study head elevated lateral position, and one study prone position to lateral position. Risk of bias was high in two studies. First puncture success rate in sitting position (RR 1.00, CI: 0.78-1.18; 2 studies) and overall success rate in sitting position were similar to lateral position (RR 0.97, CI: 0.87-1.17; 3 studies). First attempt success rate was higher in elevated lateral position (RR 1.48, CI: 1.14-1.92; 1 study) and in prone position (RR 1.09, CI: 1.00-1.17; 1 study).  Conclusion: Sitting position seems to be equally effective in terms of first attempt and overall success in lumbar puncture than standard lateral position. Elevated lateral position and prone positions had better first attempt success than standard lateral position, but these were assessed only in one study each and thus further studies in these positions are needed.  Trial registration: This review was registered in PROSPERO. ID: CRD42022382953. What is Known: •  Success rate in lumbar puncture has been poor and first attempt success rate has varied between 50 to 80% in literature. •  Optimal lumbar puncture positions for infants have been debated between sitting and lateral decubitus position mostly. What is New: •  This is the first meta-analysis focused on lumbar puncture positions in infants, and it found that sitting position was equal to standard lateral position. • Prone position and head elevated lateral positions had higher first puncture success rates, but these were assessed both only in one study, which creates uncertainty to the finding.

Indications, Measurements, and Complications of Ten Essential Neonatal Procedures

About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.

Lumbar Puncture and Meningitis in Infants with Proven Early- or Late-Onset Sepsis: An Italian Prospective Multicenter Observational Study

Background: To evaluate the rates of lumbar puncture (LP) in infants with culture-proven sepsis. Study design: We prospectively enrolled 400 infants with early- or late-onset sepsis due to Group B streptococcus (GBS) or Eschericha coli, diagnosed within 90 days of life. Rates of LP and potential variables associated with LP performance were evaluated. Moreover, cerebrospinal fluid (CSF) characteristics and results of the molecular analysis were investigated. Results: LP was performed in 228/400 (57.0%) infants; 123/228 LPs (53.9%) were performed after antibiotic initiation, hampering the ability to identify the pathogen in the CSF culture. However, polymerase chain reaction increased the probability of positive results of CSF analysis compared to microbiological culture (28/79, 35.4% vs. 14/79, 17.7%, p = 0.001). Severe clinical presentation and GBS infection were associated with higher LP rates. The rate of meningitis was 28.5% (65/228). Conclusions: Rates of LP are low in culture-proven neonatal sepsis and antibiotics are frequently given before LP is carried out. Thus meningitis may be underestimated, and the chances of giving an effective therapy to the newborn are reduced. LP should be performed before the start of antibiotics when there is a clinical suspicion of infection.

Do Spinal Needle Sizes Affect the Development of Traumatic CSF in Neonatal LP Procedures?

Lumbar puncture (LP) is widely employed to evaluate infectious, neurological and metabolic diseases in the newborn. Neonatal LP is a difficult procedure with 45–54% success rates. Although there are studies examining traumatic LP failure, studies on the effects of needle sizes are limited. This study was intended to investigate the effect of needle sizes on LP traumatization. Term and premature babies who underwent LP in the neonatal intensive care unit between 30 November 2017 and 30 July 2019 were included in the study by retrospective file scanning. LP was performed by a pediatric or neonatal specialist using a 22 Gauge pen (G) or 25 G pen spinal needle in all cases, with all patients being placed in the lateral decubitus position. The primary outcome was to evaluate the effect of needle sizes used in LP on traumatization. The secondary outcome was to evaluate traumatization rates and complications. A statistically significant difference was determined in the rate of traumatized LP and desaturation development between needle sizes and CSF microscopic findings (p = 0.031, p = 0.005, and p = 0.006, respectively). The study data show that 25 G pen-tip spinal needles cause less traumatic LP in neonates than 22 G pen-tip spinal needles.

Late-Onset Sepsis Mortality among Preterm Infants: Beyond Time to First Antibiotics

Objective: To investigate the impact of timing, in vitro activity and appropriateness of empirical antimicrobials on the outcome of late-onset sepsis among preterm very low birth weight infants that are at high risk of developing meningitis. Study design: This retrospective study included 83 LOS episodes in 73 very low birth weight infants born at ≤32 weeks' gestation with positive blood and/or cerebrospinal fluid culture or polymerase chain reaction at >72 h of age. To define the appropriateness of empirical antimicrobials we considered both their in vitro activity and their ideal delivery through the blood-brain barrier when meningitis was confirmed or not ruled out through a lumbar puncture. The primary outcome was sepsis-related mortality. The secondary outcome was the development of brain lesions. Timing, in vitro activity and appropriateness of empirical antimicrobials, were compared between fatal and non-fatal episodes. Uni- and multi-variable analyses were carried out for the primary outcome. Results: Time to antibiotics and in vitro activity of empirical antimicrobials were similar between fatal and non-fatal cases. By contrast, empirical antimicrobials were appropriate in a lower proportion of fatal episodes of late-onset sepsis (4/17, 24%) compared to non-fatal episodes (39/66, 59%). After adjusting for Gram-negative vs. Gram-positive pathogen and for other supportive measures (time to volume administration), inappropriate empirical antimicrobials remained associated with mortality (aOR, 10.3; 95% CI, 1.4-76.8, p = 0.023), while timing to first antibiotics was not (aOR 0.9; 95% CI, 0.7-1.2, p = 0.408; AUC = 0.88). The association between appropriate antimicrobials and brain sequelae was also significant (p = 0.024). Conclusions: The risk of sepsis-related mortality and brain sequelae in preterm very low birth weight infants is significantly associated with the appropriateness (rather than the timing and the in vitro activity) of empirical antimicrobials. Until meningitis is ruled out through lumbar puncture, septic very low birth weight infants at high risk of mortality should receive empiric antimicrobials with high delivery through the blood-brain barrier.

Assessment of infant position and timing of stylet removal to improve lumbar puncture success in neonates (NeoCLEAR): an open-label, 2 × 2 factorial, randomised, controlled trial

BACKGROUND

Newborn infants are the highest-risk age group for bacterial meningitis. Lumbar punctures are therefore frequently performed in neonates, but success rates are low (50-60%). In Neonatal Champagne Lumbar punctures Every time-A Randomised Controlled Trial (NeoCLEAR), we sought to optimise infant lumbar puncture by evaluating two modifications to traditional technique: sitting position versus lying down and early stylet removal (stylet removal after transecting the subcutaneous tissue) versus late stylet removal.

METHODS

NeoCLEAR was an open-label, 2 × 2 factorial, randomised, controlled trial, conducted in 21 UK neonatal and maternity units. Infants requiring lumbar puncture at 27⁺⁰ to 44⁺⁰ weeks corrected gestational age and weighing 1000 g or more were randomly assigned (1:1:1:1) to sitting position and early stylet removal, sitting position and late stylet removal, lying position and early stylet removal, or lying position and late stylet removal using a 24/7, web-based, secure, central randomisation system. Block randomisation was stratified within site by corrected gestational age (27⁺⁰ to 31⁺⁶ weeks, 32⁺⁰ to 36⁺⁶ weeks, 37⁺⁰ to 40⁺⁶ weeks, or 41⁺⁰ to 44⁺⁰ weeks), using variable block sizes of four and eight with equal frequency. Laboratory staff were masked to allocation. The primary outcome was successful first lumbar puncture, defined as obtaining a cerebrospinal fluid sample with a red blood cell count of less than 10 000 cells per μL. The primary and secondary (including safety) outcomes were analysed by the groups to which infants were assigned regardless of deviation from the protocol or allocation received, but with exclusion of infants who were withdrawn before data collection or who did not undergo lumbar puncture (modified intention-to-treat analysis). This study is registered with ISRCTN, ISRCTN14040914.

FINDINGS

Between Aug 3, 2018, and Aug 31, 2020, 1082 infants were randomly assigned to sitting (n=546) or lying (n=536), and early (n=549) or late (n=533) stylet removal. 1076 infants were followed-up until discharge and included in the modified intention-to-treat analysis. 961 (89%) infants were term, and 936 (87%) were younger than 3 days. Successful first lumbar puncture was more frequently observed in sitting than in lying position (346 [63·7%] of 543 vs 307 [57·6%] of 533; adjusted risk ratio 1·10 [95% CI 1·01 to 1·21], p=0·029; number needed to treat=16). Timing of stylet removal had no discernible effect on the primary outcome (338 [62·0%] of 545 infants in the early stylet removal group and 315 [59·3%] of 531 in the late stylet removal group had a successful first lumbar puncture; adjusted risk ratio 1·04 [95% CI 0·94-1·15], p=0·45). Sitting was associated with fewer desaturations than was lying (median lowest oxygen saturations during first lumbar puncture 93% [IQR 89-96] vs 90% [85-94]; median difference 3·0% [2·1-3·9], p<0·0001). One infant from the sitting plus late stylet removal group developed a scrotal haematoma 2 days after lumbar puncture, which was deemed to be possibly related to lumbar puncture.

INTERPRETATION

NeoCLEAR is the largest trial investigating paediatric lumbar puncture so far. Success rates were improved when sitting rather than lying. Sitting lumbar puncture is safe, cost neutral, and well tolerated. We predominantly recruited term neonates younger than 3 days; other populations warrant further study. Neonatal lumbar puncture is commonly performed worldwide; these results therefore strongly support the widespread adoption of sitting technique for neonatal lumbar puncture.

FUNDING

UK National Institute for Health and Care Research.

Establishment of a predictive model for purulent meningitis in preterm infants

BACKGROUND

Purulent meningitis (PM) is an important cause of mortality and morbidity in the newborn population throughout the world. The subtle of specific clinical signs and low success rates of lumbar puncture make diagnosis of PM more difficult in preterm than in older children. The objective of this study was to establish a predict model for preterm PM in hopes of helping clinicians develop new diagnostic and treatment strategies.

METHODS

Premature infants who were admitted to The First Affiliated Hospital of Zhengzhou University from September 2017 to March 2020 were enrolled in this study. All the patients underwent lumbar puncture. We collected data encompassing maternal diseases and neonatal clinical features. Cerebrospinal fluid (CSF) culture is the gold standard for diagnosing meningitis. The PM was diagnosed according to the diagnostic criteria. All statistical analyses were performed using R 3.63 (https://www.r-project.org/). Logistic regression and least absolute shrinkage and selection operator (LASSO) regression analyses were used to establish a risk prediction model of PM. The Brier score, calibration slope, and concordance (C)-index were used to verify the accuracy of prediction model.

RESULTS

A total of 168 preterm infants were enrolled in this study, 80 boys and 88 girls, the gestational age (GA) was 26.43-36.86 weeks (32.45±2.79 weeks), the birth weight (BW) was 700-3,400 g (1,814.05±568.84 g). There were 77 preterm infants with PM while 91 without. We identified seven variables as independent risk factors for PM in preterm infants by LASSO analysis [the optimal λ was 0.080960, and log(λ) = -2.5138], including procalcitonin (PCT) on the 1st day after birth, prenatal glucocorticoid use, albumin, the 1-minute Apgar score, the use of non-invasive biphasic positive airway pressure, hemoglobin, and sex. These were used to construct a risk prediction nomogram and verified its accuracy. The Brier score was 0.17, the calibration slope was 0.966, and the concordance index was 0.82018.

CONCLUSIONS

Our prediction model could predict the risk of PM in preterm infants. Using this prediction model, it may be able to provide reference to determine whether lumbar puncture is performed and whether antibiotics are applied as soon as possible.

Neonatal septic shock, a focus on first line interventions

Septic shock is a main cause of morbidity and mortality in neonates. Septic shock evolves from compensated to uncompensated through 3 distinct phases. Prompt diagnosis is challenging, since neonatal septic shock may overlap with the physiological changes occurring at birth. The outcome of septic shock depends on a prompt recognition of symptoms and a strict adherence to cardiopulmonary resuscitation guidelines. Fluid administration plays a major role in the initial management of septic shock. If there is no response to volume filling, inotropes must be infused within one hour of onset (dopamine, dobutamine, adrenaline). Life-threatening infections require immediate and aggressive empiric use of antimicrobials. In the pediatric age, delay in antibiotic initiation for treating septic shock is associated with poor outcome and increased risk of mortality. There is a gap regarding first line interventions in neonatal septic shock. This review addresses initial interventions in the treatment of neonatal septic shock and discusses currently available evidences., These interventions may allow to improve the outcome if they are promptly carried out.

Guideline adherence in febrile children below 3 months visiting European Emergency Departments: an observational multicenter study

Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. There is practice variation in management due to differences in guidelines and their usage and adherence. We aimed to assess whether management in febrile children below 3 months attending European Emergency Departments (EDs) was according to the guidelines for fever. This study is part of the MOFICHE study, which is an observational multicenter study including routine data of febrile children (0-18 years) attending twelve EDs in eight European countries. In febrile children below 3 months (excluding bronchiolitis), we analyzed actual management compared to the guidelines for fever. Ten EDs applied the (adapted) NICE guideline, and two EDs applied local guidelines. Management included diagnostic tests, antibiotic treatment, and admission. We included 913 children with a median age of 1.7 months (IQR 1.0-2.3). Management per ED varied as follows: use of diagnostic tests 14-83%, antibiotic treatment 23-54%, admission 34-86%. Adherence to the guideline was 43% (374/868) for blood cultures, 29% (144/491) for lumbar punctures, 55% (270/492) for antibiotic prescriptions, and 67% (573/859) for admission. Full adherence to these four management components occurred in 15% (132/868, range 0-38%), partial adherence occurred in 56% (484/868, range 35-77%).

CONCLUSION

There is large practice variation in management. The guideline adherence was limited, but highest for admission which implies a cautious approach. Future studies should focus on guideline revision including new biomarkers in order to optimize management in young febrile children.

WHAT IS KNOWN

• Febrile children below 3 months have a higher risk of serious bacterial infections, which often leads to extensive diagnostics and treatment. • There is practice variation in management of young febrile children due to differences in guidelines and their usage and adherence.

WHAT IS NEW

• Full guideline adherence is limited, whereas partial guideline adherence is moderate in febrile children below 3 months across Europe. • Guideline revision including new biomarkers is needed to improve management in young febrile children.