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Clinical Features Suggestive of Meningitis in Children: A Systematic Review of Prospective Data Sarah Curtis, Kent Stobart, Ben Vandermeer, David L. Simel and Terry Klassen Pediatrics 2010;126;952; originally published online October 25, 2010; DOI: 10.1542/peds.2010-0277

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy ofPediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Clinical Features Suggestive of Meningitis in Children: A Systematic Review of Prospective Data abstract
CONTEXT: Clinical diagnosis of pediatric meningitis is fundamental; therefore, familiarity with evidence underscoring clinical featuressuggestive of meningitis is important. OBJECTIVE: To seek evidence supporting accuracy of clinical features of pediatric bacterial meningitis. METHODS: A review of Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed was conducted for all articles of relevance. Articles contained prospective data of clinical features in children withlaboratory-confirmed bacterial meningitis and in comparison groups of those without it. Two authors independently assessed quality and extracted data to calculate accuracy data of clinical features. RESULTS: Of 14 145 references initially identified, 10 met our inclusion criteria. On history, a report of bulging fontanel (likelihood ratio [LR]: 8.00 [95% confidence interval (CI): 2.4 –26]), neck stiffness(7.70 [3.2– 19]), seizures (outside febrile-convulsion age range) (4.40 [3.0 – 6.4]), or reduced feeds (2.00 [1.2–3.4]) raised concern about the presence of meningitis. On examination, jaundice (LR: 5.90 [95% CI: 1.8 –19]), being toxic or moribund (5.80 [3.0 –11]), meningeal signs (4.50 [2.4 – 8.3]), neck stiffness (4.00 [2.6 – 6.3]), bulging fontanel (3.50 [2.0 – 6.0]), Kernig sign (3.50 [2.1–5.7]),tone up (3.20 [2.2– 4.5]), fever of 40°C (2.90 [1.6 –5.5]), and Brudzinski sign (2.50 [1.8 –3.6]) independently raised the likelihood of meningitis. The absence of meningeal signs (LR: 0.41 [95% CI: 0.30 – 0.57]) and an abnormal cry (0.30 [0.16 – 0.57]) independently lowered the likelihood of meningitis. The absence of fever did not rule out meningitis (LR: 0.70 [95% CI: 0.53– 0.92]). CONCLUSIONS:Evidence for several useful clinical features that influence the likelihood of pediatric meningitis exists. No isolated clinical feature is diagnostic, and the most accurate diagnostic combination is unclear. Pediatrics 2010;126:952–960
AUTHORS: Sarah Curtis, MD, FRCPC,a,b,c Kent Stobart, MD, MSc, FRCPC,b,c Ben Vandermeer, BSc, MSc,d David L. Simel, MD, MHS,e,f and Terry Klassen, MD, FRCPC,MSca,b,c,d
aDivision of Pediatric Emergency Medicine, bDepartment of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; cWomen and Children’s Health Research Institute, Edmonton, Alberta, Canada; dAlberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; eDepartment of Medicine, Durham Veterans Affairs Medical Center, Durham,North Carolina; and fDepartment of Medicine, Duke University, Durham, North Carolina

KEY WORDS bacterial meningitis, children, meta-analysis, systematic review, diagnosis, sensitivity, specificity, likelihood ratio, accuracy, physical examination, history, signs, symptoms ABBREVIATIONS CSF—cerebrospinal fluid LP—lumbar puncture QUADAS—Quality Assessment for Diagnostic Accuracy Studies LR—likelihood...
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