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                            Urinary tract infections

Urinary tract infection (UTI) is among the most commonly diagnosed bacterial infections of childhood.  

• Occurrence of a first-time UTI is highest for both boys and girls during the first year of life.
  
• During the first few months of life, UTIs are more common in boys, but by the first year and thereafter, both first-time and recurrent UTIs is much more common in girls.
  
• Caucasian girls are more likely to have a UTI than African-American girls.
  
• A UTI in a young child may be a sign of an abnormality in the urinary tract that could lead to repeated problems, including serious kidney disease.
  
  

What causes a urinary tract infection?

• Bacteria can sometimes get into the urinary tract (and the urine) from the skin around the rectum and genitals by traveling up a tube known as the urethra into the bladder.
  
• If the bacteria travel further up from the bladder through the ureters to the kidneys, a kidney infection (pyelonephritis) can develop.
  
• The lining of the bladder, urethra, ureters, and kidneys become irritated with a urinary tract infection.
  
• The reason girls are more likely to get a bladder infection than boys is the female urethra is much shorter so that the bacteria has less distance to travel into the bladder.

What can increase the risk of getting a UTI?

1. Anatomic abnormality

• abnormal development or blockage of one of the structures within the urinary tract including the urethra, bladder, ureters, or the kidneys 

    Posterior urethral valves - one example of an anatomic problem 
    that may occur.

                    - the valve that normally keeps the bladder from emptying can
                      sometimes be too tight or in the wrong position

                    - this prevents the bladder from emptying completely and can
                      make the urine back up and cause backpressure on the
                      kidneys

                   - this condition that occurs mostly in males is rare, but a quick
                     diagnosis is important one clue to this problem is a weak 
                     urine stream (i.e. urine dribbles out)

2. Vesicoureteral reflux

• Urine normally flows from the kidneys down the ureters to the bladder in one direction. With reflux, when the bladder fills, the urine may also flow backward from the bladder up the ureters to the kidneys.
  

3. Constipation

• large amounts of stool in the intestines can press up against the bladder and urethra making it more difficult for the bladder to completely empty. This allows bacteria to grow.
  

4. Improper wiping

• this can increase stool and bacteria around the urethra
  

5. Irritation of the opening of the urethra

• The inflammation caused by soap or bubble bath for example can lead to growth ofbacteria 
  

6. Infrequent voiding

• This gives bacteria more time to grow
  

7. Uncircumcised penis

• The uncircumcised male infant is at increased risk for a UTI because bacteria can collect in the foreskin
  
• However, because the overall risk of UTI in infant males is only around 1%, it is still questionable whether or not routine circumcision should be done for this reason.

What are the signs and symptoms of a UTI?

In an infant or very young child the signs of a UTI may be difficult to detect.

• they may only have fever
• they may just be irritable or not eat well
• a previously toilet-trained child may have “accidents”
  

In older children and adolescents:

• Pain or burning on urination
• Having to urinate frequently
• Daytime and night-time wetting
• Dribbling of urine
• Foul smelling or cloudy urine
• Fever (may not be present at all)
• Abdominal pain
• Vomiting

If the kidney(s) is infected (pyelonephritis) they may have the above signs and symptoms plus the following:

• High fever (> 102 F)
• Back pain or side pain
• Look very ill

How is a UTI diagnosed?

Testing the urine is the only way to confirm the diagnosis of a UTI.

• Urine collection: in different ways depending on the age of the child and whether or not they are toilet-trained:

1. Bagged urine - plastic collection bag is placed over your childs genital 
area using a bag is difficult and can often get contaminated

2. Clean catch urine – the child urinates into a small container after their genital area is carefully  cleaned

3. Catheterization – a small tube is placed into the urethra by the nurse.
Urine will drain directly from the bladder into a clean container through this tube.

• Urine tests:

1. Urinalysis – urine is examined for signs of infection within a short period of time

    - if this test is normal, an infection is unlikely.
    - but, occasionally this test can be completely normal despite a UTI.

2. Urine culture – this is the most accurate test to determine for sure whether or not an infection is present.

• The hospital laboratory checks to see if any bacteria grow in the urine over a 24 to 48 hour period.
  
• If your child does not improve within 2 days of antibiotic treatment as expected, your doctor may recommend having another urine specimen cultured.
  
  

How is a UTI treated?

Hospitalization may be required for some children with a UTI depending on the following factors:

   o Age

   o How the child looks (Are they ill-appearing?)
 
   o Hydration status (Is the child drinking well or has signs of
      dehydration?)

   o Signs of a kidney infection?


The following are generally recommended in the treatment of a UTI:

1. Plenty of fluids – this is very important
   
   
2. For fever and discomfort, acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil) may be helpful.
   
   
3. Cranberry juice 

• Cranberry juice prevents the growth of bacteria and from allowing the bacteria to stick to the bladder, thus being more easily flushed out of the bladder.
  

      4.   For painful urination:

• For a young child: have your child urinate while sitting in a warm bath
  
• For an older child: a medication used to decrease the burning sensation on urination (Pyridium) for a day or two may be prescribed

      5.   Antibiotics

• An antibiotic is usually started if the child’s symptoms and urinalysis suggest a UTI
  
• Once the urine culture results are known, your doctor may switch your child to another antibiotic, if necessary.
  
• The length of time for treatment will depend on the child’s age, whether the child has a straightforward UTI or pyelonephritis, and how well the infection responds to the initial antibiotic therapy.
  
     - infants and young children who receive some antibiotics
       by IV in the hospital generally are treated with antibiotics
       for a total of 7 – 14 days.
  
     - short courses (i.e. 3 days) of antibacterial therapy may 
       be used for the adolescent female with a UTI, but this
       is not recommended for younger children.
   

How long will my child be sick with a UTI once treatment is started?

• Symptoms of a UTI usually resolve after 2 days when the appropriate antibiotic is given.
  The illness may last a little longer if the kidneys are infected.
   

How can UTIs be prevented?

• Avoid irritants such as bubble baths 
  
• Teach proper wiping
       -  show your child how to wipe from front to back after
           having a bowel movement
  
• Avoid constipation
  
• Increase daily fluid intake
  
• Encouragement to urinate whenever needed and not holding it in
  
• Breastfeeding 
        -  a recent study showed that breast fed infants were
            less likely to have UTIs
  
• Drink cranberry juice 
  
• Antibiotics on a regular basis (prophylaxis)
  
     *  For children with frequent UTIs or children with an anatomical problem of the urinary tract, your   doctor may recommend a small daily dose of an antibiotic to prevent bacteria from overgrowing.
  
    *  For updates on this topic, go to UTI News (scroll down to the News topic, Urinary Tract Infections)

Do urinary tract infections have long-term effects?

• Repeated infections in abnormal urinary tracts may cause kidney damage.

                o Kidney damage may include scarring, an inability of the
                   kidney to work as well and high blood pressure.

• For this reason it is important that children with urinary tract infections receive prompt treatment and careful evaluation.

Will other tests be needed in a child with a UTI?

• Depending on your child’s age, the number of UTIs your child has previously had, or whether or not your child has pyelonephritis special imaging tests may be recommended to further evaluate your child for possible anatomical problems or reflux.
  
  
• The American Academy of Pediatrics recommends that all infants and young children 2 years of age or less with their first UTI have imaging of their urinary tract performed.
  
  
• Because no single test can tell everything about the urinary tract that might be important to know, more than one of the following tests may be needed:
  
  
  Kidney and bladder ultrasound
  
  
• This test looks for changes in the kidney size or structure as a result of possible reflux within the urinary tract.
      o It can also look for any changes in the ureters or bladder.
      o It does not tell you how well a kidney works.
  
  

             Voiding cystourethrogram (VCUG)

• This test helps determine if there is reversed flow of urine from the bladder back up to the kidneys.
  
• A liquid that can be seen on x-rays is placed into the bladder through a catheter. The bladder is filled until the child urinates.
  
• This test is usually done once the urine is clear of infection but your pediatrician or hospital doctor may choose to have it done while your child is still on antibiotics.

            
             Intravenous pyelogram

• This test involves the injection of a contrast material into a vein. The material travels to the kidneys and bladder.
  
• A series of x-rays are taken to determine the anatomy and the function of the kidneys and urinary tract.   

            Nuclear scans

• This test involves the injection of a substance into a vein to show how well the kidneys work, the shape of the kidneys, and whether urine empties from the kidneys in a normal way or whether there is a blockage somewhere.
  
• Depending on the details of your child’s illness and the results of these tests your pediatrician may refer you to a pediatric urologist or nephrologist if necessary.

When should I call my pediatrician concerning signs of a urinary tract infection in my child?

• It is best to call for specific instructions when your child first develops signs and symptoms of a UTI.
  
• You should also call your doctor anytime your child’s signs and symptoms are not improving or are worsening, especially poor fluid intake and vomiting with signs of dehydration.