A sigh of relief came out of Jordana, proud mother of 18 months old Nina, when the pediatrician in the ER told her the physical examination was completely normal and no source for infection was found. “But why does she have fever for the last three days?”, asked Jordana, looking for answers. “Fever means an infection”, said the pediatrician, “and it may be in her bladder. We have to check a urine sample because if this is a urinary tract infection, also known as a UTI, we need to give Nina antibiotics immediately”. Sigh of concern followed.....
Urinary Tract Infection
Urinary tract infection is the existence of a bacteria in any of the parts consisting of the kidney and bladder system. The lower urinary tract is the bladder and urethra (tube carrying urine from the bladder to the end of the penis or vagina), and the upper urinary tract is the ureters (2 tubes that carry urine from the kidneys to the bladder) and the kidneys.
The main risk of UTI is in bacteria reaching the kidneys (called pyelonephritis) and if not treated, can result in long term damage to one kidney or both. While for full normal body function we need only 10% of one kidney, any damage to these sensitive organs early in life should be avoided at any cost.
The most common organism to enter the urinary tract is e. coli, the same culprit that causes bad gastrointestinal tract diarrhea and travelers’ diarrhea. Parents are extremely concerned when they hear that e.coli entered the bladder, but in everyone’s intestine e. coli is a common inhabitant. In girls, where the distance from the anus to the urethra is very short, e. coli may find its way into the urinary system, hanging (literally) to the bladder wall.
How to Identify a Urinary Tract Infection
Fever, decreased appetite, tiredness, and irritability are the first hint that your child has a UTI. But these symptoms can appear with a lot of other infections, or even when there is just fever. Children with UTIs may also seem to be in pain (and cry) when they urinate. Older children may complain of burning or itchiness when urinating. Parents may notice the diaper is wet very often or older kids need to frequently use the toilet. Sometimes parents may notice a strong odor in the child’s diapers. A child that was previously toilet trained may start wetting their pants or their bed again, and older kids will frequently complain about pain in the lower back or abdomen.
UTI by the Numbers
Boys and girls can get urinary tract infections. In the first few months of life, boys have a greater chance than girls of having a UTI. However, with age, the incidence of UTI increases among girls. Three of every 100 girls and 1 of every 100 boys will have a UTI throughout their childhood. The incidence of UTIs in girls increases during the toilet training years.
Sampling for Pus
Nina’s pediatrician was very clear. After 3 days of fever, and with no source for fever on examination, a urine sample should be sent to the lab in children under two years of age. In the lab the sample will be centrifuged, and the microscopy exam will tell if there are any white blood cells in the sample or any bacteria seen. Since our urine is usually sterile, any white cells, those body-soldiers fighting an infection, are a sign of a failing system, and penetration of bacteria. If a lot of white cells are found (ten of thousands in 1 ml) – treatment should be started as soon as possible. Other parts of the analysis include looking for presence and type of bacteria, red blood cells (blood), and nitrites, a chemical component suggesting several bacteria, such as e. coli.
There are several ways to collect a sample of urine in infants and children not yet trained to void. The goal when collecting urine is to obtain a clean sample that is not contaminated by bacteria on the skin or in the environment.
Bag Urine – a sterile bag is placed over top of the vagina or penis after the genitals have been cleaned and dried. After the child urinates, the bag is removed and sent to the lab. If the urine is found to be sterile (have no bacteria), this helps to rule out a UTI. However, if bacteria is found, a urinary tract infection may or may not be present. This is because there is a chance that bacteria from another source has contaminated the urine. Therefore this test is useful to rule out (high sensitivity) but not to rule in (low specificity) a UTI.
Catheter – In this method, the child is placed on their back and their legs are bent into a frog-like position. An antiseptic solution is applied to the meatus. A lubricant is then placed on the catheter and it is placed into the urethral meatus and pushed into the urethra until urine comes out from the bladder.
‘Clean Catch’ - this method works well for children that are toilet trained. For little boys, the meatus (opening of the penis) should be cleaned with soap. If the child is not circumcised, the foreskin should be retracted, and then the area should be cleaned. For little girls, the labia should be spread. The genital area is then cleaned with a mild soap. The child should then urinate into the toilet. After urination has begun, a sterile container should be placed in the urine stream. The container should be removed prior to the child finishing voiding. This is known as a clean catch.
Suprapubic Aspiration - this method is the most sterile means of collecting urine. It is commonly used in children under 2 years of age. The child is laid on his or her back with their legs bent in a frog-like manner. An area in the lower abdomen, above the pubic bone is cleaned with an anti-septic solution. Pressure is placed on the meatus to prevent the child from urinating during the procedure. A needle is then inserted directly, via the lower abdomen, into the bladder. The physician may perform this procedure using ultrasound imaging in order to ensure that they are placing the needle into the bladder.
Treatment for Urinary Tract Infection
Urinary tract infections are treated with antibiotics. The lab will analyze the bacteria found in the urine. Depending on the type of bacteria found and your specific geographical area, your pediatrician will prescribe an antibiotic that is used specifically for killing that type of bacteria.
In the past decades, antibiotics were over used. This resulted in bacteria becoming resistant. This means that antibiotics that once worked to kill the bacteria no longer work. This is one of the main reasons that your pediatrician may wait to prescribe antibiotics until they have received a confirmation from the lab regarding the presence and type of bacteria. Finding the most specific antibiotic for your child’s infection helps to prevent antibiotic resistance and helps to ensure the success of the treatment.
It is important for your child to complete the entire course of antibiotics as per the doctor’s prescription. Even if your child is feeling better, they should take all of the medicine. If they do not complete the full course of antibiotics there is a chance that the bacteria has not completely been removed from their system. The bacteria can re-grow and may even become resistant to the original antibiotic. This will mean that your child will need to go on more antibiotics, potentially for a longer time period, a higher dose, or even a completely different type.
Awareness to Possible Complications
One complication of an untreated urinary tract infection is a kidney infection, also known as pylonephritis. Another complication of a urinary tract infection is something called urosepsis. This is when the bacteria that has infected the urinary tract gets into the blood. This is very serious. If your doctor suspects this, they will do a blood test and look for the presence of bacteria in the blood. Children with bacteria in their blood will be admitted to hospital and receive antibiotics intravenously.
Parents and pediatricians want to identify the cause of UTI, especially if it is recurrent. There are various tests that they may order. These include:
Ultrasound – Ultrasound uses sound waves to visualize the bladder and the kidneys. Your child will be encouraged to drink water or fluids prior to the exam. A gel will be placed on their abdomen and a probe will be placed on them. The ultrasound technician will be capturing images on the screen which can later be measured and analyzed to identify abnormalities to the urinary tract.
Voiding cystourethrogram (VCUG) – A VCUG is used to evaluate the urethra, bladder and ureters. A catheter is placed into the urethra and a contrast dye is inserted. X-rays are then taken of the child’s urinary tract. The child is then asked to urinate and more x-rays are taken. This exam takes approximately 30 minutes. A VCUG is useful as it can show if the child has reflux, which is urine moving into the ureters rather than the urethra during voiding (backwards). Reflux can be be a cause of urinary tract infections.
Some children are more prone to urinary tract infections than others. Girls have a shorter urethra than males and bacteria can colonize the bladder more easily. Your child may be referred to a urologist who will do other special tests to see if there is a reason for the frequent infections. One common cause of frequent urinary tract infections is vesicoureteral reflux (VUR). This occurs when the position of the ureters on the bladder are such that urine flows from the bladder into the ureters towards the kidneys rather than into the urethra.
If your child is diagnosed with high-grade vesicouretral reflux, they may be placed on a low dose of antibiotics for prevention of urinary tract infections. Depending on the severity of the reflux, surgery or other interventions may be needed. Many children’s reflux disappears on its own.
TOP TIPS from MedSchoolForParents.com on how to prevent urinary tract infection :
1. Encourage your child to go to the bathroom regularly. Stasis of urine may lead to urinary tract infections
2. Add fiber to the diet of older children. Preventing constipation is a good way of helping to prevent urinary tract infections
3. If your child has a fever and there is no obvious source (i.e. a runny nose and cough), an appointment should be made with their family doctor or pediatrician. If the child has a UTI and it is not treated, damage may occur to the kidneys
4. Teach your child good toilet hygiene. This helps prevent bacteria from entering the urinary tract
5. In adults Cranberry juice has been shown to be effective in preventing adhesion of bacteria such as Escherichia coli to the bladder epithelium. No such evidence exists at this time for the prevention of UTI in children. Sugary juice may lead to dental caries.
RESOURCE : Dr. Goldman's, MedSchoolForParents.com Chief Medical Officer, published research on Cranberry juice for UTI
RESOURCE : American Academy of Pediatrics - Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children.