Urinary tract infections in children

Children can suffer renal damage from recurrent urinary tract infection (UTI) that has not been promptly diagnosed or subsequently evaluated. The complications of a UTI include renal (kidney) damage and hypertension (high blood pressure). Infants and young children are at the greatest risk of renal damage. The highest incidence of underlying urinary tract abnormalities, such as vesicoureteral reflux, also occurs in this young age group. By promptly recognizing and appropriately treating the UTI, the physician minimizes the risk of injury to the kidneys.

The American Academy of Pediatrics recently developed a practice guideline for the diagnosis, treatment, and evaluation of UTI in infants and young children from 2 months to 2 years of age. The guideline recommends that any young child with an unexplained fever should be evaluated for a UTI. Infants with a UTI often present with nonspecific signs and symptoms, such as irritability, vomiting, diarrhea, and failure to thrive. Therefore, the physician must maintain a high index of suspicion to diagnose the UTI. Urine for culture should be obtained prior to starting antibiotics.

A reasonable way to collect urine in a child with a suspected UTI is by applying a bag to the perineum. The bag-collected urine, however, frequently contains contamination, and therefore a bag-collected urine specimen is not helpful in diagnosing a UTI. Of course, if the urinalysis is normal, it is unlikely the child has a UTI.

A bag-collected urinalysis suggestive of a UTI requires the performance of a more invasive method of obtaining urine, with the possible exception of circumcised boys over one year of age. Urine obtained by suprapubic bladder aspirate is the least likely to be contaminated. That obtained by transurethral bladder catheterization is next best. A urine culture is required for the diagnosis of a UTI. In a child who appears sufficiently ill to warrant immediate antibiotics, one of the invasive methods of obtaining urine for culture should be performed before starting antibiotics.

The goals of UTI treatment include elimination of the infection, prevention of urosepsis, and reduction of renal damage. Initial treatment with parenteral antibiotics is recommended for those children who appear toxic, dehydrated, or unable to retain oral intake. For children who do not appear as ill, initial oral antibiotics usually include amoxicillin, a sulfonamide-containing antimicrobial, or a cephalosporin. If the expected clinical response is not obtained after two days of antimicrobial therapy, the child should be re-evaluated with another urine culture. Adequate treatment lasts for seven to 14 days. However, continuation of antibiotics in prophylactic dosages should go on until the child undergoes imaging studies.

Imaging of the urinary tract is recommended in every febrile (feverish) infant or young child following the first UTI. Imaging includes a renal and bladder ultrasound and a voiding cystourethrogramn, which is an x-ray examination of the bladder and urethra that is performed while the bladder is emptying. The renal ultrasound may detect hydronephrosis, duplication anomalies, stones, or abnormalities of the bladder wall and should be obtained at the earliest convenient time. A cystogram may be obtained by instillation of contrast with fluoroscopy or by instillation of a radionuclide. Radionuclide cystography has the advantage of decreased radiation, while the contrast-voiding cystourethrogram has the advantage of providing better anatomic detail, which may help detect bladder/urethral abnormalities. Either method should include a voiding phase since reflux is the most likely abnormality to be detected and may only occur with voiding. The cystogram should be obtained once the child is free of infection.

This guideline calls for prompt diagnosis, treatment, and maintenance of prophylactic dose antibiotics until imaging is obtained in all young children following their first UTI. Adherence to the guideline should reduce the incidence of kidney damage from UTIs.

Signs and symptoms of urinary tract infection include:

• Fever
• Tummy aches
• Vomiting (throwing up)
• Poor appetite (not being hungry)
• Pain with voiding (peeing)
• Side or back pain
• Pain with CIC
• Child wet more often between CIC
• Cloudy, smelly urine; blood or mucus in the urine
• Sore skin
• Problems putting in the catheter for CIC
• Low urine output (only peeing a little bit)

If your child has any of these signs or symptoms, their urine should be checked for infection. Your pediatric urologist needs to know about any infections.

A study of the urine under a microscope will show if there are bacteria, white cells or red cells in the urine. White cells and red cells in the urine may mean that an infection is there. A culture of the urine is usually done if the urine looks infected under the microscope. A culture is done by putting some of the urine in a special dish and checked to see if any bacteria grow.

If your child is being catheterized, bacteria in the urine do not always mean there is an infection. Unless the bacteria are causing symptoms, they do not need to be treated. The exception is bacteria in the urine in the child with vesicoureteral reflux (urine goes up backward to the kidneys). If your child has reflux, bacteria in the urine could lead to a serious infection and must be treated.

To prevent urinary tract infections:

• Drink plenty of water. Water is best, but fluids with a lot of water, such as fruit juices, may also be helpful.
• Catheterize frequently using a good clean technique. Keeping the bladder empty of urine will help prevent infections.
• Prevent constipation. A large amount of poop in the rectum keeps the bladder from emptying and allows many bacteria to grow.
• A good bowel program is essential. Keeping the poop off of the privates as much as possible will help keep bacteria from causing an infection. Always wipe from the front to the back.
• Clean up bowel accidents with care and as soon as possible.

Your pediatric urologist needs to know about all infections. Additional testing may be necessary. Changes in your child’s medications or CIC program may be needed.

Last Reviewed: April 2011