Sunday 24 July 2011

Urinary Tract Infection in Children

Published in Panorama



Treating Urinary Tract Infections in Children



A urinary tract infection (UTI) is very common in children, especially in those attending playschool and in young teenagers, particularly females. In fact, the condition may even affect newborns within a week of birth, reveals Dr.Meena S Karle, Paediatrician, Al Musalla Medical Centre, Dubai.

UTI is a condition where one or more structures in the urinary tract become infected after bacteria overcome its strong natural defenses. In spite of these defenses, UTIs are the most common of all infections and can occur at any time in the life of an individual. Almost 95% of cases of UTIs are caused by bacteria that typically multiply at the opening of the urethra and travel up to the bladder. UTI may be classified as infection of the lower tract involving the urethra and bladder or the upper tract when it spreads to the ureter and the kidneys also, explains Dr.Karle.

Lower UTI is mainly localized and is referred to as cystitis, involving the inflammation of the urinary bladder. Lower UTI in a small baby is very unlikely, opines Dr.Karle. “This form of UTI is more common in school children and teenagers, particularly females. The Upper UTI more commonly affects infants between the ages of 6 months to three years. It is basically a systemic infection which involves various body organs and is very complicated. Upper UTI will start and become generalized, thus involving not only the kidneys but also the chest and other organs. There may be multiple septecaemia and the entire body may be subject to bacterial infection which spreads through the blood. Hence, if it is not appropriately treated, it will lead to kidney damage and other organ damage,” emphasizes Dr.Karle. “Congenital abnormalities like vesicoureteral reflux (movement of urine upward from the bladder, rather than downward) and abnormality of the urethral valve, particularly in male children, is one of the reasons for UTI, especially of the upper tract, occurring in about 30% to 50% of cases of UTI. Bladder instability and constipation can predispose a child to urinary tract infections and exacerbate reflux. Some children without a discernable anatomic anomaly develop recurrent urinary tract infections. Many of these children manifest the condition after toilet training, when normal spontaneous voiding is prevented by social constraints.”

Repeated UTI may also result from stones in the kidney. Hygiene plays an important part in UTI. This is particularly so in babies who are on nappies and continue to stay in wet ones for long hours. Also, in young school going children, if toilet raining is not done properly, the risk of UTI is significant, explains Dr.Karle.

Symptoms of lower UTI include low grade fever, an urgency to urinate, frequent urination, burning sensation while urinating and sometimes blood in the urine.

On the other hand, whenever there is UTI of the upper tract, children will present with high grade fever. They may not present with backache as happens in adults, but they will have decreased frequency of urine and burning sensation, in addition to vomiting. But high grade fever in infants for no obvious reason should alert one to suspect UTI of the upper tract, emphasizes Dr.Karle.

However, children with urinary tract infections may not always present with symptoms. Infants may present with irritability or other subtle symptoms, such as lethargy. Older children may also have nonspecific symptoms, such as abdominal pain.

Speaking on the risks and complications of undiagnosed UTI or inadequately treated UTI, Dr.Karle reveals, “Children with chronic UTI will not present with the symptoms but they will have loss of weight and poor appetite. In such a situation it is difficult to glean the cause for the child not thriving. But UTI could be a cause for this failure to thrive! Suppose you miss out one or two minor UTI, yet the fact remains that you have missed the diagnosis! And this could lead to kidney damage. Alternatively, the UTI may not be treated adequately or appropriately because the doctor does not suspect UTI which exists alongside a throat infection with manifest symptoms. The course of antibiotics with which the child is treated for the throat infection, may be inadequate to tackle the unsuspected UTI!

UTI associated with vesicoureteral reflux can lead to renal scarring if it remains unrecognized. Since the risk of renal scarring is greatest in infants, any child who presents with a urinary tract infection prior to toilet training should be evaluated for the presence of reflux.

Children who have recurrent urinary tract infections should also be evaluated. Dr.Karle emphasizes: “Any child between the age of 6 months and two years, if it has high grade fever with shivering, chills and vomiting, must be subject to a urine examination; never avoid this!”
Urine analysis is one of the most important diagnostic measures to be undertaken to identify UTI, emphasizes Dr.Karle. A routine urine examination may reveal pus or blood cells, depending upon whether a child is having infection of the upper tract or lower tract, respectively. “It is very important to have a serial urine examination to identify if the infection is of the lower tract or upper. This is best done by taking a midstream sample of urine, though this is very difficult to get when children wear nappies.

While the most reliable method of obtaining urine for a culture is suprapubic aspiration, this procedure often causes anxiety in the children and the parents. Urine specimens may therefore be obtained by placing a plastic bag over the perineum of infants and by obtaining a voided specimen in older children. However, there is always the possibility of contamination of "bagged" and voided specimens. Therefore the results so obtained are best interpreted in conjunction with the urine analysis and the clinical setting. Whenever pus cells are found, the culture test has to be done at least three times with three urine samples taken at two-hourly intervals. This will reveal whether there is any bacteria that is growing. Depending upon the strain of bacteria present, treatment is accordingly given.”

Where the children have upper UTI, in addition to the urine culture test, other tests too have to be done. These include ultrasonography of the kidneys, ureter and bladder to rule out any congenital abnormality, especially in a male child. A DMSA renal scan is the best study for detecting renal scarring and might therefore identify patients at particular risk for reflux. Since children are at greatest risk for renal scarring in the first few years of life, reflux screening is recommended for any child who has a single urinary tract infection before toilet training has begun. Unfortunately, a renal scan will not detect reflux in children who have not yet developed scarring, and these are the very ones who might benefit most from antibiotic prophylaxis, says Dr.Karle.

Antibiotic prophylaxis can prevent recurrent urinary tract infections. Hence it is advisable to screen children with recurrent urinary tract infections who are at risk for renal scarring. However, since renal scarring usually occurs only with the reflux of infected urine, it is important to prevent UTI in the first place in children with reflux.

Cystourethrogram is done to diagnose urinary reflux. Reflux resolves spontaneously in almost 80% of patients and for this reason, the patients are initially treated on an observation protocol with prophylactic antibiotics. Patients who have breakthrough infections on prophylaxis, develop new renal scarring, have high-grade reflux or those who cannot comply with long-term antibiotic prophylaxis, may have to undergo corrective surgery for the condition, explains Dr.Karle.

Treatment of lower UTI involves intake of plenty of fluids, a course of antibiotics till the patient is completely rid of the bacteria causing the infection. Diet has to be appropriate to avoid constipation. Proper care should be taken in respect of hygiene.

Treatment of upper UTI may require the child to be admitted to the hospital and given a complete course of IV antibiotics which will cover the infection-causing bacteria.

Dr.Karlet explains, “The antibiotic course may initially be given for five days after which the urine culture must be repeated. The child’s response to the treatment will give an indication of whether the bacteria are being dealt with appropriately. Following the repeat urine culture examination, continue the antibiotic treatment for a maximum of ten or fourteen days till the bacterial growth has stopped completely.”

In instances where the child has had mild grade vesicoureteral reflux, a small dose of prophylactic antibiotic is given following its discharge from the hospital.


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