Bacterial meningitis: why symptoms are not as straightforward to detect in infants under three months

Leading research contends that over-reliance on classic fever symptoms by healthcare professionals may lead to missed diagnoses

Leading research contends that over-reliance on classic fever symptoms by healthcare professionals may lead to missed diagnoses

Urgent medical attention should be sought if purple marks are visible
after pressing a glass tumbler firmly against the skin. Picture: SPL


The classic symptom associated with bacterial meningitis is a fever. But now experts are warning that an over-reliance on that could lead to babies not being diagnosed in time.

Research by St George’s, University of London, found that many of the traditional symptoms are not as common as often assumed in infants less than three months of age – the group at highest risk of the disease. The study, published in the Paediatric Infectious Disease journal, showed only about half of babies under three months who have bacterial meningitis actually display fever.

‘Infants will always be more challenging to diagnose as they cannot communicate what is wrong with them’

Wake-up call

Lead researcher Paul Heath says this should act as a wake-up call to doctors and nurses as fever has ‘for decades’ been the trigger for further investigations.


cases of bacterial meningitis in infants under three months of age a year in the UK and Ireland

‘The symptoms displayed by young infants when they are seen are often non-specific.’

Professor Heath believes this issue needs to be stressed more to clinicians in guidelines and training. While National Institute for Health and Care Excellence guidelines and others do not say a fever must be present, he says they give the impression that it should be a ‘key feature’ of the infection.

And he is concerned if this does not change, death rates may not improve.

‘Unfortunately, neither the rates of bacterial meningitis in babies nor the numbers of deaths has changed since the 1980s.’

The study involved 263 infants. It found:

  • Fever – temperature above 38oC was reported in only 54% of cases.
  • Seizures in 28%.
  • Bulging fontanelle in 22%.
  • Coma in 6%.
  • Neck stiffness in 3%.

‘These results won’t come as a shock to healthcare professionals working in secondary care’

In the UK, babies under three months are 70 times more likely to get bacterial meningitis than adults. Neonates are at the highest risk of all.

Median age for symptom around 21 days old

The study found that infants who did present with fever tended to be older than infants without fever. The median age for this symptom was around 21 days old.

The study suggests that there should, therefore, be a low threshold for performing investigations on young infants.


times more likely that infants under three months will get bacterial meningitis than adults

Meningitis Research Foundation policy and evidence manager Claire Wright says this is vital to give the ‘best chance of survival’. But she is worried it does not always happen.

'The research found many of the infants had been in contact with primary care. It also suggests there may be opportunities to pick up on this sooner. We need more awareness and training.'

What should nurses be looking out for?

  • Where fever was not present, there were still some fairly marked symptoms.
  • Half had other symptoms suggestive of bacterial meningitis, including breathing problems in 33% of cases, seizures 32% and bulging fontanelle 16%.
  • There were several common features, such as poor feeding, lethargy and irritability, which can be difficult to distinguish from mild illness, the researchers said.

Meningitis: the tell-tale signs 

The Meningitis Research Foundation (MRF) has produced guidance and e-learning tools for healthcare staff.

These include a document setting out the vital signs for front-line nurses, warning septicaemia and meningitis can kill in hours. It gives the normal values for heart rate, respiratory rate and systolic blood pressure broken down by age group for children.

The guidance also lists the symptoms to investigate for septicaemia and meningitis – and what to do in a variety of scenarios. The section on young babies includes the warning that ‘fever is often absent’ and that grunting is a tell-tale sign.

The MRF policy and evidence manager Claire Wright says: ‘I would urge all nurses working with children to familiarise themselves with these.

‘Knowing what to do and acting quickly can make all the difference.’


One member of the RCN’s children and young people acute care forum is advanced paediatric nurse practitioner Coral Rees, who says this shows just what a tricky task healthcare staff face.

Low threshold for full septic screen

‘These results won’t come as a shock to healthcare professionals working in secondary care with the right training and experience.

'For children under three months of age, there is always a low threshold for performing a full septic screen and, in my experience, we treat with intravenous antibiotics until proven otherwise.

‘But you can see how healthcare professionals with a lack of experience and exposure to sick children can miss the more subtle signs.

‘Infants will always be more challenging to diagnose as they cannot communicate what is wrong with them.’


of cases involved fever being present

University of Northampton’s associate professor of children’s nursing Sarah Neill agrees. But she says the findings point to a wider issue with nursing at the moment.

Lack of awareness

‘There are a huge amount of nurses in primary care who do not have specialist children's training. The majority are adult nurses.

‘It's a similar situation with GPs and among A&E staff,’ she says. ‘It means there is a lack of awareness about dealing with acutely ill children.’

To address this, Ms Neill believes there needs to be radical rethink in the way nurse services are organised.

‘We are too wedded to the traditional way of doing things. I would like to see a universal child health nurse post created – and nurses with the right training filling the positions.

‘I would amalgamate health visiting and school nursing roles with the new child health nurse role, and ensure there is someone who has the skills and knowledge to care for children in the community all through childhood.’

Case study: ‘Listen to parents’

Natalie King’s seven-week-old son Myles died from meningococcal septicaemia in 2015. He did not have a fever – nor many of the other traditional symptoms associated with meningitis. Instead, Ms King, says the first thing she and her husband knew something was wrong was when their son woke at midnight

Myles King. Photo used with consent

‘Myles was unsettled, nothing more. We kept nursing him. A few hours later he started making a grunting noise – we thought it might be trapped wind – and then his skin went grey.’

Shortly after 5am, the couple took him to their local hospital, Frimley Park in Surrey.

Purple marks

They were immediately seen by a doctor, who spotted some purple marks on Myles. He was put on intravenous antibiotics and fluids, but nothing could be done for him. He died later that day.

‘It was devastating. The next few days were a blur,’ says Ms King.

‘But later we went back over it. We wanted to make sure everything that could have been done for Myles had been done. It was – and that was reassuring.

‘Parents want to know if everything is being done. You can’t rely on certain symptoms being displayed.

‘It is important for health professionals to believe parents – if they have a gut-feeling, listen. Sadly, I hear of cases where that hasn’t happened.’


Okike I, Ladhani S, Johnson A et al (2018) Clinical characteristics and risk factors for poor outcome in infants less than 90 days of age with bacterial meningitis in the United Kingdom and Ireland. Pediatric Infectious Disease Journal. doi: 10.1097/INF.0000000000001917

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