Negative History to Ask in Pediatric Meningitis
When evaluating a child for suspected meningitis, you must specifically ask about the ABSENCE of classic symptoms, as their absence does NOT rule out meningitis—fever, neck stiffness, and altered mental status occur together in less than 50% of cases. 1
Critical Negative Histories That Cannot Exclude Meningitis
Absence of Classic Meningeal Signs
- Neck stiffness is absent in 18-60% of pediatric meningitis cases depending on age, with sensitivity of only 51% in children 1, 2
- Kernig sign is absent in 47% of cases (sensitivity 53%) 1, 2
- Brudzinski sign is absent in 34% of cases (sensitivity 66%) 1, 2
- The younger the child, the more likely classic signs will be absent—neck rigidity is particularly unreliable in children under 12 months 3
Age-Specific Symptom Patterns to Document
Neonates and young infants (under 6 months):
- Fever is present in only 6-39% of neonatal meningitis cases 1
- Ask specifically about irritability (present in 85% of 1-5 month olds), poor feeding, respiratory distress, and abnormal skin appearance 1, 3
Infants 6-11 months:
- Impaired consciousness is the dominant feature (79% of cases) 3
- Bulging fontanel is absent in 50% of cases with open fontanels 2
Children over 12 months:
- Vomiting occurs in only 55-82% of cases 1, 3
- Headache is reported in only 75% of children over 5 years 1
Essential Historical Red Flags That Increase Risk
Anatomical Defects and Trauma History
- Always ask about any history of head trauma, even if remote (up to 12 years prior), as this creates the highest risk for recurrent bacterial meningitis through skull base defects 4, 5
- Document any prior neurosurgical procedures, including osteoplasties 6
- Ask about congenital skull or dural defects, meningomyelocele 5
Prior Infections and Exposures
- Previous episodes of meningitis suggest anatomical communication or immune deficiency 6, 5
- History of otitis media or sinusitis as potential infection sources 7
- Contact with another person with meningitis or sepsis 7
- Recent travel history 7
Rash Characteristics
- 37% of meningococcal meningitis cases have NO rash, so absence of rash does not exclude meningococcal disease 7
- When present, petechial/purpuric rash indicates meningococcal disease in 92% of cases 7
- Pneumococcal meningitis can also present with rash in 9% of cases 1
Common Pitfalls in History-Taking
The most dangerous error is using absence of classic symptoms to rule out meningitis. 1, 2 Parents frequently fail to recognize the significance of irritability, impaired consciousness, and neck rigidity—these symptoms led to medical consultation in only 6%, 22%, and 3% of cases respectively, despite being present 3.
Document specifically what symptoms are ABSENT, as this helps establish that meningitis was considered but cannot be excluded clinically. The classic triad of fever, neck stiffness, and altered mental status is present in only 41-51% of cases 1, 8.
Never delay lumbar puncture and empiric antibiotics based on negative history or absent classic signs. 7, 9 Clinical symptoms and signs alone have poor diagnostic accuracy and should not be the sole determinants for proceeding with CSF examination 2.