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An early presentation

01 January 2007

Baby T was eight weeks old when his mother brought him to his GP’s morning surgery. His mother had become increasingly concerned about his general irritability and frequent crying episodes, which lasted up to two hours. These had become apparent over the past three days, not settling with breast feeding.

Baby T had been born at term by vaginal delivery after an uneventful pregnancy and had gone home on the same day. His mother, who was 32, had two other children, aged three and five, and was well supported by her husband and attentive grandparents.

Baby T was due to be immunised the following week at the surgery. Dr R gave him only a cursory examination as Baby T was asleep in the child seat, and he did not want to disturb him. He reassured his mother that it sounded as though the baby was having colicky episodes. He recommended Infacol.

At 3.00pm, Baby T’s mother rang the surgery and was put through to Dr R. She explained that she was now very worried as Baby T had missed two feeds and was either asleep or crying, and not interested in anything when awake.

Dr R asked if Baby T’s mother could see any signs of a rash, and held on whilst the mother stripped Baby T to look for any signs. She returned to the phone and said that there did not appear to be any. Dr R said that this was a bad episode of colic and that regular paracetamol should suffice in providing pain relief. No further arrangements were made or advice given about seeking help if there were any more concerns.

At 7.00pm Baby T’s mother rang the out-of-hours service as he had not had any feeds since 9.00am and was now listless, whimpering rather than crying vigorously as before. She was asked to come to the out-of-hours primary care centre and was seen by a GP who took a thorough history and examined the child, noting a full fontanelle, an altered level of consciousness and generalised lassitude. His temperature was 39.4ºC, his heart rate 180 bpm and his respiratory rate increased and shallow at 60 breaths per minute.

The GP rang for an ambulance and Baby T was taken to the local hospital. He was diagnosed with E. coli meningitis that evening. Initially the baby responded well to treatment but on day two he had prolonged generalised seizures. He developed hydrocephalus and an intraventricular shunt was inserted on day three of his admission. By 12 months he showed marked developmental delay, and had not progressed beyond the three months developmental milestones, with the prospect of life-long dependency on carers.

Expert opinion

A GP expert criticised Dr R for failing to examine Baby T in the consultation in his surgery and for the poor quality of the telephone consultation. The case was settled for a high sum, to provide for the future care of Baby T.

Learning points

  • Meningitis in infants may present with generalised non-specific symptoms and signs. These include: refusing to feed, being irritable, not wanting to be held, having a bulging fontanelle, a high pitched cry, fever, vomiting, increased respiratory and heart rate, pale or mottled skin (there may be a petechial rash, evolving into a purpuric and ecchymotic rash with time), sleepiness or being difficult to wake, cold hands and feet. The absence of a rash does not exclude a diagnosis of meningitis.
  • The symptoms and signs of meningitis can be seen in many other common childhood illnesses, such as with generalised viral infections. It is, therefore, vital to conduct a full examination after taking a detailed history and ensure that arrangements are made for following up febrile infants with or without a focus of infection.
  • A willingness to consider differential diagnoses other than the initial one (in this case, colic) is imperative owing to the varied prodromal features of meningitis, and a high index of suspicion is required.
  • In this case the GP did not put himself in a position to make a sound clinical judgment. The absence of a rash does not mean that this was not a sick child.

Further information