Links To And Excerpts From Clinical Practice Guidelines On Pediatric Lumbar Puncture From The Royal Children’s Hospital Melbourne
Here are excerpts:
Lumbar puncture may be performed as part of the initial work up of a sick child, or later in the course of an illness once the child has stabilised if there were initial contraindications. It is preferable to obtain a CSF specimen prior to antibiotic administration, however this should not be unduly delayed in a child with signs of meningitis or sepsis.
- Suspected meningitis or encephalitis
- Suspected Sub-arachnoid haemorrhage with a normal CT
Do not do a lumbar puncture if the child is so sick that you will give antibiotics for meningitis even if the CSF is normal on microscopy.
The clinical findings that suggest you should give dexamethasone and antibiotics immediately, and delay lumbar puncture for 1-2 days until the child is improving are:
- Coma: absent or non-purposeful response to painful stimulus – squeeze ear-lobe firmly for up to 10 seconds. A child over 3 months of age should push you away and seek a parent.
- Signs of raised intracranial pressure: eg drowsy, diplopia, abnormal pupillary responses, unilateral or bilateral motor posturing or papilloedema (NB papilloedema is an unreliable and late sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of raised ICP, is not a contraindication).
- Cardiovascular compromise/ shock
- Respiratory compromise
- Focal neurological signs or seizures
- Recent seizures (within 30 minutes or not regained normal conscious level afterwards).
- Local infection (in the area where an LP would be performed)
- The febrile child with purpura where meningococcal infection is suspected.
Assessment prior to LP for contraindications?
- CT Scans if focal neurological signs
- CT Scans are not helpful in most children with meningitis.
- A normal CT scan does not tell you that the patient does not have raised ICP.
- Herniation may occur even in the presence of a normal scan.
- Don’t delay antibiotics whilst waiting for a CT
Informed verbal consent should be obtained. This should include a discussion of the benefits of the procedure in terms of possible diagnoses and potential complications. Complications of LP may include:
- Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common)
- Post-dural puncture headache (fairly common) – up to 5-15%
- Transient/persistent paresthesiae/numbness (very uncommon)
- Respiratory arrest from positioning (rare)
- Spinal haematoma or abscess (very rare)
- Tonsillar herniation (extremely rare in the absence of contraindications above)
The LP Parent Information Sheet may be useful in talking to parents about the procedure.