A 2 Month Old Baby With Irritability And Projectile Vomiting

A 2 month old baby boy is brought to the pediatrician because her mother has noticed that her baby has become excessively irritable, has a high pitched cry and refuses to feed for the last 2 days. when the mother attempted to spoon feed the child with expressed breast milk, the baby vomited it in a projectile manner.
On examination the baby had a temperature of 103 F, and was very irritable. The anterior fontanelle was bulging. The resp rate was 65/min and H/R was 102/min.

What are the causes of a bulging anterior fotanelle?

The fontanel should be examined in a quiet child held in an upright position. The fontanel is normally
flat and pulsatile. Bulging fontanel in infancy is a sign of raised intracranial tension.

Causes include:


 Physiological: Crying infant
 Drugs: Tetracycline/Vitamin A/Corticosteroid (following cessation)/Nalidixic acid
 Metabolic Disorders: Maple syrup urine disease/Galactosemia
 Hyperparathyroidism/Vitamin D-dependent rickets/Congenital hypophosphatasia
 Raised intracranial tension (meningitis, intracranial bleeding, tumor, pseudotumor cerebri, etc.)
 Hydrocephalus.

The above mentioned case was highly suspected for neonatal meningitis and was managed accordingly with lumbar puncture, blood culture and empiric intravenous antibiotics.

Neonatal Meningitis: Meningitis is an inflammation of the meninges (the coverings of the brain and the spinal cord). It is caused eiter by a virus or a bacterial infection. less commonly a fungal infection may also lead to meningitis.

Meningitis that affects babies upto 2 or 3 months of age is called neonatal meningitis. Whether viral or bacterial it can be very serious, and any delay in treatment could put the baby at risk of mental disabilities like deafness or even death.

Clinical Features: the following signs and symptoms highly suggest for a diagnosis of meningitis:

• Tense or bulging anterior fontanelle.
• High temperature ( some babies may have hypothermia too)
• Very sleepy 
• unusual grunting sounds
• Irritable when picked up
• High pitched or moaning cry
• unusual grunting sounds
• Fast/difficult breathing
• extreme shivering
• refusal to feed
• vomiting
• rash or purple bruises anywhere on the body.
• Blotchy skin
• Cold hands and feet
• sometime diarrhea 

Management:It is important to recognize the symptoms early and the suspected case of neonatal meningitis should be treated immediately with antibiotics. 

1. Whenever bacterial meningitis is suspected a lumbar puncture is indicated before giving the first dose of antibiotics.

2. After the blood and CSF cultures are sent, an IV line is maintained and monitored fluid is administered to prevent dehydration. 

3. It is very important to adequately monitor the electrolytes and blood gases.

4. Initial antibiotic usually consists of  Ampicillin 50 mg/kg 12 hrly for newborns and 8 hrly for >7 days old and an aminoglycoside (amikacin 10 mg/kg 12 hrly and 7.5 mg/kg 12 hrly for newborns). 

5. A combination of Ampicillin and cefotaxime is also appropriate.

6. The antibiotics should be given for 10 to 14 days.