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Beware of the often-overlooked signs Fever, painful urination and abdominal pain are classic signs of an infection in the urinary tract. It seems simple. However, it is not so simple in children. Irritability, failure to thrive (poor weight gain) and diarrhea are hallmarks of kidney, bladder and urine infections in infants and small children. With such subtle signs, the diagnosis may be obscure and, at times, delayed. Accurately identifying urinary tract infections (UTIs) can be a challenge for both parent and physician. A collaborative effort between parents and physicians will decrease delay and increase accuracy. Primary infections in the kidneys (pyelonephritis) tend to be accompanied by fever. Often, urinary tract infections in children do not initially involve the kidney. Therefore, the classic signs and symptoms may be overlooked. In addition, another source of infection such as an upper respiratory infection does not rule out the possibility of a concurrent urinary tract infection. And, they are more frequent (or at least diagnosed more) in girls than boys. About 3-5% of girls will have at least one UTI before 11 years of age compared to 1-3% of boys. The right diagnosis Early diagnosis and treatment of urinary tract infections can decrease kidney damage as well as high blood pressure and end-stage kidney disease. Emphasis on early diagnosis in small infants is crucial in order to avoid lifelong kidney disease and its complications. Urine is sterile. This means that there are no bacteria (germs) normally present in urine. Therefore, anything that can introduce microorganisms into the urine can cause infection. Any condition that does not allow urine to completely empty or causes urine to stay within the urinary system can be a setup for bacteria to grow. Bacteria enter from the outside of the body, from the stool or, as in infants, through the bloodstream, seeding the urine. Abnormalities in urinary tract anatomy or function can make some children more prone to infection. Making the diagnosis If the signs and symptoms of a possible urinary tract infection are present, it is important to determine which bacteria are causing the infection. The most efficient and accurate way of collecting urine, especially in the young child, is with the use of a catheter inserted into the bladder. This is definitely not as bad as you may think. The worst part of the procedure is keeping your child still so that the clinician can insert the catheter. With a catheter, the specimen is more likely to be accurate and not contaminated with bacteria from the skin or stool. All specimens should be sent to a lab that can culture for bacteria and provide sensitivity information to the clinician. Knowing this information, definitive treatment can be prescribed. Older children can collect a “clean-catch” midstream urine. Children usually need to be toilet trained in order to collect this kind of specimen. Most hospitals, urgent care centers, emergency rooms and physicians offices will perform a urinalysis on the urinary specimen. However, the test does not identify specific bacteria to treat and may be negative even if infection is present. Treating urine Infections Urine infections are treated with antibiotics. Often, if the urinalysis is suspicious for infection or the physician feels that an infection is likely, antibiotics are started after a specimen for culture is obtained. The most common bacteria for an infection are “e-coli.” The physician will choose an antibiotic that will most likely treat this infection. Usually within 3-5 days, if bacteria are discovered on culture, the lab will run sensitivity tests to determine which antibiotic will best treat the infection. Once this information is available, the physician may need to change antibiotics to better treat the infection. Depending upon age, a child may need to be admitted to the hospital for intravenous antibiotic treatment. This is most likely in the newborn infant as well as the child with severe kidney involvement. Because an anatomical abnormality is often present with a development of a urine infection, the American Academy of Pediatrics recommends evaluation of the urinary tract structure. Although there is some controversy about the value of testing, especially on the first urine infection, most physicians will begin with an ultrasound of the kidneys and a test to evaluate for the potential for urinary tract reflux. Once the tests are done, the physician can determine if any further testing is needed. Occasionally, surgical intervention is required. Therefore, an evaluation by a pediatric urologist may be needed. Points to remember A urinary tract infection in a young child may me a sign of an abnormality in the urinary tract and could lead to repeated problems. Urinary tract infections affect up to 5% of children in the U.S. every year. Symptoms of urinary infection are variable. Younger children may have very non-specific symptoms, such as poor feeding and weight gain or irritability, while older children will have burning with urinating or high fever. Kidney damage can occur with untreated urinary tract infections and is most often avoidable. Ask your doctor questions if you suspect a urinary infection. Dr. Clyde Wesp is a pediatrician with Southern Orange County Pediatric Associates with offices in Lake Forest, Laguna Hills, Rancho Santa Margarita, Ladera Ranch and San Clemente (Talega) and is affiliated with Saddleback Memorial Medical Center, Mission Hospital and Children’s Hospital of Orange County. He is a member of the American Academy of Pediatrics and the MemorialCare Physician Society. If you have any questions or comments for Dr. Wesp, you can email him at askdrwesp@netscape.net |
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