Can You Avoid Lumbar Puncture in Febrile Neonates?

I don’t have a problem with lumbar punctures in febrile neonates. In fact, my son ended up with three lumbar punctures before aging out of the febrile seizure protocols. I do have a problem, however, with doing unnecessary spinal taps. The emotional stress of a neonatal LP on parents is significant, and the physical stress of the procedure on the infant is also substantial.     The pain of the needle and the unique restraint required for the procedure are also potentially problematic. The pain of the needle can be minimized by EMLA cream (eutectic mixture of local anesthetics [lidocaine and prilocaine]) and local anesthesia. The risk of patient hypoxia is a well-recognized complication when scrunching a baby into a lateral, recumbent fetal position. No matter your level of experience, a number of traumatic taps will unavoidably occur (10-35%). (Pediatr Emerg Care 2011;27[11]:1057.)   Even though the red and white blood cell counts can work with various formulas, the abnormal cell counts and the Gram stain’s crowded field leave a degree of diagnostic uncertainty in the end.   Controversy exists on this topic. Some providers feel strongly that lumbar punctures should be performed on every febrile infant under 90 days of age. Others, including many pediatricians, feel confident in assessing individual risks and recommending lumbar punctures on a case-by-case basis. (JAMA 2004 10;291[10]:1203.) Neonates under 30 days old are placed in a separate category by most ...
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