Lumbar Puncture of the Newborn

Heinrich Irenäus Quincke was the first person in medical history to perform lumbar puncture (LP). Indications of lumbar puncture include suspected meningitis, suspected subarachnoid hemorrhage, administration of chemotherapeutic agents, instillation of contrast media for imaging of the spinal cord, and the evaluation of various neurologic conditions including normal pressure hydrocephalus and Guillain-Barré syndrome, and the treatment of idiopathic intracranial hypertension. Contraindications of lumbar puncture include findings of increased intracranial pressure, bleeding diathesis, cardiopulmonary instability, soft tissue infection at the puncture site, shock, respiratory insufficiency, and suspected meningococcal septicemia with extensive or spreading purpura. Altered mental status, focal neurologic signs, papilledema, focal seizure, and risk for brain abscess are indications for cranial imaging before performing LP. Lack of local anesthetic use and advancement of the spinal needle with the stylet in place were most prominent risk factors for a traumatic LP. Ultrasound may minimize the number of LP attempts and decrease patient and parent anxiety by easily identifying an insertion site. Infection, spinal hematoma, epidermoid tumor, and cerebral herniation are the main complications of LP. When LP is traumatic, the wisest approach is to assume the patient is having meningitis and start empirical therapy

Neonatal Meningitis

Neonatal meningitis continues to be a problematic issue of neonatology and pediatric infectious diseases with its incidence of 0.8–6.1 in 1000 live births, high case fatality rate, and neurological sequelae. Major risk factors for contracting meningitis in the newborn period include maternal peripartum infection, premature rupture of membranes, premature birth, fetal hypoxia, septic or traumatic birth, low birth weight, and galactosemia. The leading causative agent is group B streptococci (in almost half of the cases), and a quarter of cases are due to Escherichia coli. Vertical transmission from the mother is often the route of infection. Neonatal meningitis may not be distinguishable clinically from neonatal sepsis without meningitis. Meticulous care should be taken to perform lumbar puncture whenever the patient’s status permits since it is an indispensable tool for diagnosis. Initial empirical therapy may consist of ampicillin and cefotaxime, ampicillin and gentamicin, or ampicillin + gentamicin + cefotaxime during the first week of life. Ampicillin + gentamicin + cefotaxime for nonhospitalized infants and the same combination with the replacement of ampicillin with vancomycin for infants still in hospital are suitable options after the first week

Sepsis in Children

Sepsis is systemic inflammatory response syndrome due to a documented or suspected infection. Causative agents of sepsis include group B streptococcus, Escherichia coli, and Listeria monocytogenes in infants younger than 2 months, and community‐acquired organisms. Bacteremia may ensue in patients whose defense mechanisms have become vulnerable due to many factors. Sepsis and septic shock can be viewed as clinical pictures, which develop as consequences of proinflammatory processes/cytokines leading to a state that cannot be restrained by anti‐inflammatory processes/cytokines. As yet, a cytokine, which is uniquely associated with severe sepsis and septic shock and can be used as a biomarker, has not been discovered. Sepsis is a cytokine storm, which may adversely affect almost any organ system. Whether there is an association between the severity of sepsis or septic shock and cytokine gene polymorphisms is an important field of study. Mottled skin and prolongation of capillary refill time may help the physician recognize septic shock before hypotension emerges. The management of severe sepsis and septic shock involves (1) the hemodynamic support, (2) inotropes, vasopressors, and vasodilators, (3) antimicrobial therapy, (4) transfusions, and (5) corticosteroids as indicated. Hospital mortality of pediatric sepsis is 2–10%

High Infection-Related Mortality in Pediatric Acute Myeloid Leukemia without Preventive Antibiotics and Antifungals: Retrospective Cohort Study of a Single Center from a Middle-Income Country

Objective: This study aimed to evaluate infection-related mortality in patients with acute myeloid leukemia (AML) treated without preventive antibiotics and antifungals in a middle-income country. Materials and Methods: Infection-related mortality was evaluated retrospectively in 49 pediatric patients. Results: A total of 173 chemotherapy courses were administered as first-line chemotherapy. Four patients died during induction: one patient due to intracranial bleeding, two patients due to typhlitis, and one patient due to invasive fungal infection with pulmonary vascular invasion and massive bleeding. Another two patients died with resistant disease. During consolidation there were four infection-related deaths and one death due to cardiotoxicity. In first-line chemotherapy mortality was 22% (11/49); infection-related mortality was 14% (7/49). Event-free survival and overall survival at 6 years were 42.9% and 61.2% (95% CI: 44-76 and 66-99 months), respectively. Conclusion: Due to considerable infection-related deaths, antibacterial and mold-active antifungal prophylaxis may be tried during neutropenic periods in pediatric AML