Family doctor

Introduction

 Urinary tract infections are common in children- affecting up to 8% of girls and 2% of boys in the first 8 years of life¹. Depending on the age of your child, signs and symptoms may range from fever and irritability to foul-smelling urine and vomiting/ diarrhoea. The treatment requires antibiotics and recovery is usually uncomplicated however some children may need to be followed up with scans to ensure that there are no underlying abnormalities. It is important that urinary tract infections are recognized as most are easily managed but may lead to complications if left untreated.

 The anatomy

 The urinary tract is the set of tubes responsible for eliminating urine from the body- beginning in the kidneys (which filter the waste products from blood to form urine), leading to the bladder (where urine is stored) and ending in the urethra (the opening through which the urine flows). Sometimes, bacteria from the outside (mainly a species called E. Coli) are able to enter and travel upwards to cause an infection at any point in the urinary tract.

 Who gets it?

 Anyone can get a urinary tract infection, adults included. However, it may be more difficult to recognize in children due to the more generalized symptoms and inability to describe discomfort.

 Risk factors

 Most of the time there is no clear cause to why children acquire urinary tract infections. However, some factors which may alter the risk are:

Age- The highest incidence of urinary tract infections in both sexes is during the first year of life¹.

Gender- Over the age of three years, girls tend to get more urinary tract infections compared to boys¹. This is due to the differences in anatomy between girls and boys. As girls have a relatively shorter urethra than boys, it is easier for bacteria to establish an infection in the urinary tract.

Underlying structural abnormalities in the urinary tract- If your child is born with a structural abnormality in the urinary tract such as a condition called vesicoureteric reflux, it may make them more prone to recurrent urinary tract infections.

Urine retention/ incomplete voiding- Constipation may prevent the bladder from emptying completely - therefore retaining urine and increasing the risk of urinary tract infection. Similarly, neurological problems involving bladder control may cause difficulties in voiding. Dehydration also prolongs the time urine remains in the body and increases the risk of developing an infection.

Circumcision- Uncircumcised boys under 3 months have a slightly higher incidence of urinary tract infection compared to circumcised boys of the same age². However, this is quickly overtaken by girls as they get older.

 Signs and symptoms

• Fever of 38˚or higher.

• Irritability

• Lethargy

• Vomiting/ diarrhoea

• Failure to thrive

• Poor feeding/ drinking

• Poor sleep

• Jaundice (in infants)

• Foul-smelling urine

• Burning sensation/ pain on urination

• Blood in the urine

• Increased frequency/ urgency of urination

• Abdominal (tummy) tenderness

As children grow older, they tend to experience more specific or localized symptoms such as pain and discomfort during urination. However, it is important to be aware that general symptoms such as fever, lethargy and irritability can sometimes be the only visible sign- particularly in younger children and infants.

 Diagnosis

 The diagnosis of urine infection is based on the history of symptoms as well as some laboratory tests performed on urine samples to detect bacteria and white blood cells. Ideally, the urine is collected midstream in order to minimize contamination of the sample. If this is not possible, a bag or special pad provided by a hospital or clinic may be used.

 Treatment

 In most cases, a course of oral antibiotics is all that is required for complete resolution. However, more severe cases (young infants, persistently high fever, dehydration and vomiting) may require hospital admission with intravenous antibiotics and fluid replacement.

 Outlook and further investigation

 In the vast majority of cases, urinary tract infections treated with antibiotics result in a complete recovery and return to normal activities within a few days. Most children experience a single episode only.

In certain circumstances, following a urine infection, further investigations including an ultrasound, or other radiological examination may be advised by your doctor. The selection of children who need this can be discussed with your doctor.

Groups who may need scanning include

• Young age –under 6 months

• Boys

• Recurrent infections

• Atypical (unusual bacteria) infections

• Febrile (> 38) Infections

Complications

In some cases, recovery may not be so straightforward due to a number of complications. These include:

Antibiotic resistance: Recently there has been an increase in the rates of resistance to the typical antibiotics used to treat urinary tract infections. If symptoms do not resolve within a few days of treatment, it is possible that the bacteria strain responsible is resistant to that particular antibiotic and will need to be treated with a different kind.

Recurrence: Some 20% of children who suffer a urinary tract infection will have a repeat episode⁴. These children usually have some form of underlying abnormality or illness such as vesicoureteric reflux or a suppressed immune system. It is recommended that you talk to a specialist in these cases regarding management.

Pyelonephritis/ kidney damage: This is when the infection travels up the urinary tract and into the kidneys. This is serious and can lead to permanent damage to the kidneys if not treated promptly. If your child is complaining of back/ loin pain or shivering, consult your doctor immediately.

Sepsis: Sometimes the infection escapes the local area and invades the whole body, resulting in high fevers, shivers/ shakes and drowsiness. It is vital to recognize the signs of current or impending sepsis as if it is not treated promptly with IV antibiotics and fluid replacement, there is a possibility of prolonged hospital admission and even death.

Prevention

Urine that is stagnant or not moving for a long period of time puts you at an increased risk of urinary tract infection. Therefore, effectively managing conditions which predispose to this (such as constipation, incomplete voiding and dehydration) will lower the chances of urinary tract infections.

Long-term antibiotic therapy has been shown to reduce the risk of repeat symptomatic urinary tract infection in susceptible children⁵ but the benefit is small and ultimately not worth the associated side effects and possibility of developing antibiotic resistance in normal children.

Maintaining personal hygiene such as regularly changing soiled nappies and wiping from the top to bottom rather than from the bottom up will help to reduce the risk of urinary tract infection.

Key points for parents

Urinary tract infections in children are common and a rare cause for alarm. However be sure to look for warning signs of severe illness such as persistently high fever, drowsiness, vomiting and shakes/ shivers (see above).

If there is no obvious cause such as a sore throat or cough, a fever can be the only symptom of urinary tract infection in young children.

If your child has a urinary tract infection, frequent drinking will help to prevent dehydration and flush out the bacteria.

Not recognizing and treating urinary tract infections may lead to severe complications downstream.