Pediatric Meningitis & Seizures (incl. Febrile Seizures)

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

Part A — Meningitis

1. Overview and Pathophysiology

Meningitis is inflammation of the meninges (the membranes around the brain and spinal cord). Bacterial meningitis is a medical emergency: bacteria multiply in the CSF, inflammation raises intracranial pressure (ICP), and the child can develop septic shock, brain damage, hearing loss, or die within hours. Viral (aseptic) meningitis is more common and usually milder.

Common bacterial causes by age (simplified): newborns — group B strep, E. coli, Listeria; older infants and children — Streptococcus pneumoniae, Neisseria meningitidis; H. influenzae type b is now rare thanks to vaccination. Vaccines (Hib, pneumococcal, meningococcal) have greatly reduced cases.

2. Signs and Symptoms

Increased ICP signs: bulging fontanel, increasing head circumference (infants), high-pitched cry, headache, vomiting, decreasing LOC, irritability, Cushing triad (late: bradycardia, widening pulse pressure, irregular respirations), pupil changes, seizures.

3. Diagnostics (ranges vary)

Also: blood cultures (before antibiotics, but don’t delay antibiotics), CBC, CRP/procalcitonin, electrolytes (watch for SIADH → hyponatremia), glucose, CT before LP if signs of high ICP or focal deficits.

Lumbar puncture positioning: infant — side-lying with head and knees flexed or sitting upright leaning forward; older child — side-lying “cannonball.” Watch the infant’s airway and SpO₂ during flexion (can obstruct breathing).

4. Priority Nursing Care

1. Droplet precautions for suspected bacterial meningitis (especially meningococcal) until 24 hours of effective antibiotics
2. Start IV antibiotics as soon as ordered — don’t delay for LP if it can’t be done quickly; dexamethasone may be given before/with first antibiotic dose in selected cases
3. Neuro checks (LOC, pupils, fontanel, irritability, seizures), head circumference daily in infants
4. Seizure precautions
5. Quiet, dim environment; minimize stimulation; HOB elevated ~30° (ICP); position of comfort (often side-lying)
6. Fluids as ordered — strict I&O, daily weight, Na⁺ (SIADH risk); avoid both overload and hypovolemia
7. Monitor for septic shock and DIC (petechiae spreading, bleeding)
8. Pain and fever management
9. Hearing screen after recovery (sensorineural hearing loss is a common complication); developmental follow-up
10. Close contacts of meningococcal (and some Hib) cases need antibiotic prophylaxis (e.g., rifampin, ciprofloxacin, or ceftriaxone) — report to public health per policy

Part B — Seizures in Children

5. Overview

A seizure is abnormal, excessive electrical brain activity. In children, causes include fever, infection (meningitis, encephalitis), electrolyte imbalance (low Na⁺, Ca²⁺, glucose), head injury, toxins, epilepsy, and in newborns, hypoxic injury.

Febrile seizures — the most common seizures in childhood:

• Age 6 months – 5 years (peak 12–18 months), with fever ≥ 38 °C and no CNS infection or prior afebrile seizure
• Simple: generalized, < 15 minutes, once in 24 hours — benign, no lasting brain damage
• Complex: focal, ≥ 15 minutes, or repeats in 24 hours → more evaluation
• Often occurs as the temperature rises quickly at the start of an illness
• About a third recur with later fevers; epilepsy risk is only slightly higher than the general population
• Antipyretics make the child comfortable but do NOT prevent febrile seizures (AAP)
• Workup focuses on the fever source; LP considered if signs of meningitis, or in young infants/incompletely vaccinated children per provider

6. Seizure First Aid and Nursing During a Seizure

1. Stay with the child; note the time (start and end) and describe the seizure
2. Protect from injury — ease to the floor/bed, move objects away, cushion the head
3. Turn on the side (recovery position) to let secretions drain
4. Nothing in the mouth; don’t restrain
5. Loosen tight clothing; suction and oxygen ready at the bedside
6. After: check airway, breathing, SpO₂, VS, neuro status; expect postictal drowsiness/confusion; check glucose
7. Seizure lasting ≥ 5 minutes = treat as status epilepticus

7. Status Epilepticus — Emergency

Continuous seizure ≥ 5 minutes or repeated seizures without recovery.

1. ABCs, oxygen, suction, IV/IO access, glucose check
2. First-line benzodiazepine: IV lorazepam, or if no IV: intranasal or buccal midazolam, IM midazolam, or rectal diazepam
3. If continuing: levetiracetam, fosphenytoin, or valproate (second-line per protocol); phenobarbital in neonates
4. Watch for respiratory depression after benzodiazepines; prepare for intubation

8. Antiseizure Medications

Teach: take every day at the same time, never stop abruptly (rebound seizures), drug levels as ordered, interactions, medical alert ID.

9. Education

• Febrile seizures: reassurance (simple febrile seizures are not harmful); first aid steps; call 911 for seizures ≥ 5 minutes, breathing problems, or no recovery; antipyretics are for comfort, not prevention; no cold baths or alcohol rubs
• Epilepsy safety: supervise bathing/swimming (showers for older kids), helmets for biking, school seizure action plan, sleep hygiene, avoid triggers
• Meningitis prevention: vaccines (Hib, pneumococcal, meningococcal), hand hygiene, don’t share drinks/utensils; prophylaxis for close contacts as directed

10. Memory Aids

• Bacterial CSF: “Cloudy, High protein, Low sugar” (bacteria eat the sugar)
• Infant meningitis = “Bulge, Cry, Won’t feed” — neck stiffness may be absent
• Petechial rash + fever = “meningococcemia until proven otherwise”
• Droplet until 24 hours of antibiotics
• Seizure: “Time it, side it, safe it, don’t stuff it” — 5 minutes = status
• Febrile seizure ages: 6 months to 5 years (peak 12–18 months)

11. NCLEX-Style Practice Questions

1. A 7-month-old has fever, a high-pitched cry, poor feeding, and a bulging anterior fontanel. Which action should the nurse take first?

A. Place the infant on droplet precautions and notify the provider
B. Measure the head circumference
C. Give oral acetaminophen and recheck in an hour
D. Encourage the parent to breastfeed

Answer: A. These signs suggest bacterial meningitis, an emergency. Isolate to protect others and get immediate evaluation and antibiotics. The other actions don’t address the urgency.

2. Which CSF results are most consistent with bacterial meningitis?

A. Clear fluid, normal glucose, normal protein
B. Cloudy fluid, low glucose, high protein, high neutrophils
C. Clear fluid, high glucose, low protein
D. Bloody fluid, normal glucose, low WBC

Answer: B. Bacteria consume glucose, and inflammation raises protein and neutrophils. Viral meningitis typically has clear fluid with normal glucose.

3. An 18-month-old with a temperature of 39.5 °C has a generalized seizure lasting 2 minutes, then becomes drowsy. The parent asks how to prevent this next time. Which response is best?

A. “Give fever medicine around the clock at the first sign of illness to prevent it.”
B. “Fever medicines help comfort but haven’t been shown to prevent febrile seizures.”
C. “Your child will need daily antiseizure medication.”
D. “Give a cool alcohol rub when a fever starts.”

Answer: B. Antipyretics do not prevent febrile seizures (AAP). Simple febrile seizures usually don’t need daily medication, and alcohol rubs are unsafe.

4. A child is having a generalized tonic-clonic seizure in bed. Which nursing actions are appropriate? Select all that apply.

A. Turn the child onto the side
B. Place a padded tongue blade between the teeth
C. Note the time the seizure started
D. Hold the arms and legs still
E. Prepare to give a benzodiazepine if the seizure lasts 5 minutes

Answer: A, C, E. Side-lying protects the airway; timing guides treatment; seizures ≥ 5 minutes need rescue medication. Never put objects in the mouth (B) or restrain (D).

5. A child is diagnosed with meningococcal meningitis. Which statement about isolation is correct?

A. “Airborne precautions are needed until the rash fades.”
B. “Droplet precautions are needed until 24 hours after effective antibiotics.”
C. “No isolation is needed after the lumbar puncture.”
D. “Contact precautions are needed for the entire hospital stay.”

Answer: B. N. meningitidis spreads by respiratory droplets; precautions continue until 24 hours of effective therapy. Close contacts may need prophylactic antibiotics.

References

Chamarthi, V. S., Samanta, D., & Chamarthi, P. P. (2026). Febrile seizure. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448123/

Glauser, T., Shinnar, S., Gloss, D., Alldredge, B., Arya, R., Bainbridge, J., Bare, M., Bleck, T., Dodson, W. E., Garrity, L., Jagoda, A., Lowenstein, D., Pellock, J., Riviello, J., Sloan, E., & Treiman, D. M. (2016). Evidence-based guideline: Treatment of convulsive status epilepticus in children and adults. Epilepsy Currents, 16(1), 48–61. https://doi.org/10.5698/1535-7597-16.1.48

National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page

Runde, T. J., Anjum, F., & Hafner, J. W. (2023). Bacterial meningitis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470351/

Subcommittee on Febrile Seizures. (2011). Febrile seizures: Guideline for the neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics, 127(2), 389–394. https://doi.org/10.1542/peds.2010-3318