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How Serious is Pediatric Urinary Tract Infection?

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If your child has a fever, becomes listless, cries often, does not play as usual, eats and drinks less than normal, and feels pain when urinating, it is easy as a parent to spot that something is not right and take the child to the hospital for diagnosis and treatment of urinary tract infection. However, if the child only has a fever, drinks milk a little less than normal, and becomes somewhat lethargic, these undiscriminating symptoms need to be diagnosed by a doctor. But does a pediatric urinary tract infection require urgent diagnosis and treatment? To answer this question, we first need to understand how serious pediatric urinary tract infection is.

Prevalence of pediatric urinary tract infection

A urinary tract infection has a greater effect on the kidney of a child than one might think, especially in children younger than five years. Among children over two years of age, girls are more susceptible to urinary tract infections than boys at a ratio of 4:1, or 8% of girls in this age group compared to 2% of boys. However, for children aged under one year old, the gender ratio is roughly equal.

Problems or complications developing during infection

  • High fever that may lead to convulsions
  • Dehydration and starvation
  • Septicemia, one year of age in particular
  • Meningitis, especially in babies under the age of one month

Reasons why doctors are concerned about urinary tract infection

  • Renal scarring which damages kidney tissue, gradually expands and affects the functions of the kidney
  • High blood pressure in children, and the potential for preeclampsia in the future
  • Chronic kidney disease

These main problems, especially renal scarring which often occurs in the early stages of the infection, can potentially lead to high blood pressure and chronic kidney disease. These conditions can have many serious complications, including a delay of growth and mental development, pallor, an imbalance of minerals and bodily hormones, abnormalities in bone density, osteoporosis, and, worst of all, end stage renal disease which requires kidney dialysis and a kidney transplant. Therefore, it is very important that children are diagnosed early and treated properly in order to prevent future complications.

What are the risk factors for renal scarring?

  • Younger age groups are at a higher risk of renal scarring. In particular, infected infants are the most susceptible.
  • Any lapse in time before receiving treatment is also a risk factor. The risk increases if the baby has had a fever for more than 48-72 hours. The longer the baby has been infected, the greater the risk.
  • The patient’s response to the treatment can depend on how much time has elapsed before receiving treatment, particularly in the first 48 hours. However, other factors may influence treatment results.
  • The type and severity of infection play important roles in the results of treatment.
  • The more often a child is infected, the higher the risk of renal scarring.
  • Congenital anomalies of the kidney are also very important factors that need to be further explored.

Causes of pediatric urinary tract infection

We will now look at the three main causes of urinary tract infection

  1. Septicemia and the haematogenous spread of infection, usually seen in children under one year old
  2. Congenital anomalies of the kidney increase the likelihood of developing an infection. The most common cause relating to this condition is a reflux of urine to the renal pelvis or the kidney.
  3. The most common cause is ascending infection, the infection of an adjacent organ ascending to the urinary tract.

Treatment, Prevention and Further Diagnosis

Urinary tract infection (UTI) is a curable disease which, with proper management, can be free of complications such as chronic or subtle UTI, complicated UTI, and additional infections shortly thereafter.

Treatment with appropriate antibiotics, either oral or intravenous, depends on the patient’s condition and severity of infection.

  • For clinically ill patients, or young patients (especially younger than 3 month-old), intravenous antibiotics are preferred and can be switched to oral after the fever is brought down for at least 24 hours.
  • For clinically well UTI patients, oral and intravenous antibiotics are equally effective.
  • It is recommended that antibiotics are taken for 3-7 days for non-febrile infections and 7-14 days for febrile infections. However, Prof. Tej Mattoo, at IPNA Congress 2019, presented his expert opinion that a 10-14 day course of antibiotics for a febrile infection is preferable.

In addition to blood and urine tests, the doctor will perform a diagnostic radiology exam to find the cause of congenital anomalies of the kidney as follows:

  • Ultrasound of the kidneys and bladder (US KUB): Guidelines for investigation are different around the world.  Thai UTI Guidelines state that all infected UTI patients younger than 5 year of age should undergo kidney and bladder ultrasound to look for abnormalities in the kidney, renal pelvis, ureter and bladder. In case of refractory, the ultrasound can be used to look for complications. US KUB exams are recommended for patients younger than 2 years in the US, and 2-3 years of age in European countries.
  •  Voiding cystourethrogram (VCUG): This exam monitors the reflux of urine to the ureter, renal pelvis, or kidney. Ultrasound is neither sensitive nor effective enough to detect this reflux. The current guidelines recommend VCUG in the following circumstances:
    • Abnormal results from a kidney and bladder ultrasound
    • Impairment of kidney function
    • Recurrence of urinary tract infection
    • Dysfunction of voiding pattern, such as urine leakage, a sense of unemptying bladder and other related symptoms
    • Family history of urinary reflux, particularly in a first degree relative
    • Non-E. coli infection; the most common pathogen that causes UTI is E. coli, which predominantly localizes in digestive systems and adjacent areas, and in feces
    • Septicemia, or toxic bacteria in the blood
    • Likely non-compliance patient
  • Renal scan: This exam is used to rule out renal scarring or to find the cause of the blockage or other related issues identified in the primary test. The decision to run this scan will be made by the doctor.

After having cured the urinary tract infection, the doctor will prescribe oral antibiotics to prevent a recurring infection. The role of antibiotic prophylaxis varies in each case, depending on the indications and the results of imaging studies. Current recommendations (IPNA Congress 2019) suggest selective use of oral antibiotics in the following cases:

  • High grade reflux of urine to the kidney
  • Recurrence of urinary tract infection (UTI)
  • Abnormal bowel voiding pattern such as constipation
  • Significant kidney and bladder anomaly
  • Renal scarring
  • Atypical UTI or abnormal clinical course
  • Presence of a kidney stone
  • Parental preference

The doctor will make periodical follow-up appointments to monitor the urine in order to reduce the possibility of a recurring infection or renal scarring.

Prevention

  • Cleaning the genitals is very important, especially for girls.
    •  Always clean thoroughly after going to the toilet.
    • Wipe from front to back. After wiping backwards, do not wipe to the front again, as doing so may bring germs from anus to the vagina or the urinary tract. The use of rinse spray, with proper direction, is also recommended.
    •  Use clean toilet paper or wet wipes, and always keep the genitals dry.
    • Diapers should be changed frequently. Change the diaper after every bowel movement. For children who have been properly toilet trained, try to stop using diapers altogether.
  • When you feel the urge to urinate, do not hold the urine in your bladder; releasing it will eradicate or reduce the volume of bacteria in the bladder in a timely manner, and help to reduce the risk of infection.
  • Constipation needs to be cured immediately. In chronic cases, bowel training has to be implemented. Constipation encourages germ production and increases the number of bacteria in the anal, rectal and gut areas, all of  which increase the opportunity for infection. In addition, constipation interferes with the regulation of urination. This can be countered in the following ways:
    • Drink your age group’s daily recommended amount of water. Adequate fluid intake will yield the following results:
      • Light yellow or transparent urine
      • Urinating at least 4-6 times per day or once every 3-4 hours (normal frequency of voiding is 3-8 times/day; however, 5-8 times per day is preferable, or even 10-12 times per day for youngsters.)
    • Increase the consumption of dietary fiber from vegetables, fruits, legumes, seeds, whole grains, whole wheat, etc.
    • Train your child to go to the toilet at the same time every day.
    • Correct position on the potty can also affect constipation. You can receive advice from your doctor as to the correct position.
  • Female patients who have fusion of the labia should consider medical treatment, as their potential risk for urinary tract infection is increased.
  • Male patients who suffer from phimosis are 8-10 times more likely to suffer from urinary tract infection than those without phimosis. Therefore, it is advisable to consult with a doctor to consider medical treatment to remove the phimosis. Children who do not respond well to medication will be counseled by their doctor for surgical options.

As you can see, pediatric urinary tract infection can be a sign telling us that there is a hidden abnormality that should not be overlooked. Therefore, it is important to have it diagnosed and treated as early as possible. Equally important is to follow-up and monitor continuously in order to prevent future complications.

Photo Credit: Matteo Bagnoli via Compfight cc

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Nanthiya Pravitsitthikul, M.D. Summary: Pediatrics Pediatric Nephrology