The urinary tract is one of the most common sites of infection in children, second only to the respiratory tract. Urinary tract infections (UTI) affect nearly 3% of all children every year. They are much more common in little girls, except during infancy, when the number of boys with UTI outnumber girls
What do you mean by the urinary tract?
The urinary tract comprises of the kidneys, the ureters, the bladder and the urethra. Each of us possesses a pair of kidneys that are organs that are located in the upper abdomen. The kidney is the site, where excess fluid, salts and excretory products are filtered out from the blood and the kidney is absolutely essential for survival.
Urine that is formed in the kidneys is transmitted to the bladder by two tubes that are called ureters. They start from the kidney and end where they enter the bladder. The bladder is a muscular receptacle that fills with urine and stores it. When it is convenient, the bladder empties itself by contracting its muscle and then voids the urine out of the body through a tube that is called the urethra. This urethra is fairly short in females and long in males.
How does one get urinary tract infections?
The surface of our body is colonized by innumerable organisms that are looking to enter the body for their own survival. Our body, in general, does an extremely good job of preventing these organisms from entering and causing an infection. Whenever there is a mismatch – either because the organisms are too numerous, too powerful or when the body is relatively weak, the organisms can enter and cause infection.
The opening through which the urinary tract communicates with the exterior is called the urinary meatus. This meatus opens at the tip of the penis in the male, and just above the vaginal opening in the female. The area around the opening is heavily colonized by organisms from the rectum and the feces. Bacteria, viruses, fungi or other organisms can enter the urinary tract when conditions are favorable and lead to urinary tract infection. Uncommonly, especially in very young infants, they may invade the urinary tract from the bloodstream.
Why are some children prone to developing UTI?
Firstly, in general, females are prone to UTI than boys because their shorter urethra is more likely to allow, organisms to travel up from the meatus to the bladder. However, certain predisposing factors do cause some children to be more prone to developing UTIs repeatedly:
- Age: Boys younger than one year of age and girls less than four years of age are more likely to get UTIs.
- Uncircumcised infants almost always have phimosis, and the closed preputial sac acts as a large reservoir for organisms. However, this by itself is not a reason to recommend circumcision since it has been estimated that 111 circumcisions would need to be performed to prevent one UTI!
- Race: UTIs are more common (x2-3 times)in whites as compared to other races.
- Improperly developed urinary tracts or poorly functioning bladder: Any abnormality whether structural or functional that results in stagnant urine makes it more likely to have a UTI. Flowing water like a stream is clean while stagnant water like a pond, tends to be dirty.
- Indwelling catheter: Some children require a catheter or a tube to be kept in their urinary tracts for a prolonged period. This predisposes them to developing UTIs.
- Previous urinary tract infection: If a child has had one UTI, it is more likely that the child will have another UTI.
How will I know if or when my child develops UTI?
Well, symptoms are different depending on the age of the child. Unlike adults, young children may have very generalized constitutional symptoms and really have no symptoms that point to urinary tract as a source of infection at all.
Young infants and children less than two years of age:
- Fever: This may be the only symptom that the child suffers from.
- Generalized listlessness and the ‘something is not well’ look
- Poor intake and in chronic cases, poor weight gain
You need to consult your doctor who will examine the child and rule out UTI as one of the causative factors of these non-specific symptoms. Do inform your doctor about foul-smelling urine as this is a good pointer to a potential UTI in this age group.
Children older than two years of age:
- Fever: The height of fever may vary depending on the severity of infection and whether the kidneys are involved or not.
- Painful urination or burning while passing urine
- Frequency of urination: The child will frequently go to the toilet to pass urine
- Pain: The child may complain of pain in the lower back or in the lower abdomen.
Doctor, is there any test that confirms UTI?
Well, your doctor will definitely order some tests to confirm urinary tract infection. The gold standard in diagnosing UTI is urine culture along with routine urinalysis done on a properly collected sample of urine. He or she may order other tests depending on the clinical condition of the child.
You mentioned a properly collected sample. But is it not as simple as giving a sample of urine in a bottle?
While this method is OK for routine examination of urine, it certainly is unacceptable for a urine culture examination. In a urine culture test, the lab is trying to ‘grow’ organisms that may be causing your child’s UTI. You should remember that there are literally innumerable bacteria that live on the surface of our body especially near the genitals, being so close as it is to the anus.
While collecting the specimen of urine, if there is contamination with these organisms, then the result is meaningless, since it will show some organisms even if the original urine of the child is clean, Your doctor now has to treat as if the child has confirmed UTI, instead of looking for another cause for the child’s fever.
How should I collect the urine sample then?
Toilet trained children: If your child is toilet trained and can initiate urinary stream at will, then it is relatively simple. If a boy, then retract the foreskin of the penis (if a girl, separate the labia), clean the glans with soft soapy solution and ask the child to pass urine. Do not collect the first portion of urine, and collect the next portion while he continues to pass urine in a continuous stream, into a special urine culture bottle (obtained from the lab earlier) and immediately cap it. Do remember that, you should not be touching the inside of the bottle or the cap while collecting the specimen, and that this should be submitted to the lab within half an hour of collecting it.
Non-toilet trained children: Any attempt to collect urine by the above method, is doomed to be contaminated. The only reliable ways of collecting a good urine sample is either by catheterizing the child or by drawing some urine directly from the bladder with a syringe and needle. Please remember, that an incorrect diagnosis can result in far greater harm to your child rather than the slight discomfort associated with these procedures.
What next, Doctor?
Based on the dipstick test, your doctor may decide to start with an antibiotic. The results of the urine culture test come in after 48 hours and by then we can decide whether the antibiotic that has already been given is effective. If the child does not respond, your doctor will change the antibiotic depending on the result of the urine culture test. The antibiotics are given for a minimum of a week and hospitalization is rarely required and only when the child either does not tolerate oral feeds (more with younger children) or does not respond to medication.
How long are the antibiotics to be continued?
Antibiotics are to be given for a total of 5-10 days depending on the child’s condition. She should start feeling better in 48 hours and if the child is still not feeling better, then we may need to change the antibiotics or even consider hospitalization.
Doctor, somebody I know was advised an ultrasound examination, Will my child also need an ultrasound?
Yes, all children who have a UTI require to undergo USG of the urinary tract. This should be done about a week after the illnesss subsides, since the UTI itself can show as some abnormalities on the USG. USG is advised earlier in case the child does not respond to antibiotics as one would expect. USG is done to rule out any congenital abnormality in the urinary tract. Children with congenital abnormalities are more likely to develop UTI and it is important to pick these up so that therapy (if required) can arrest any further deterioration in kidney function and to prevent recurrent UTI.
Are any more tests necessary, Doctor?
Further testing primarily depends on whether there is any abnormality on the USG and whether your child has a first UTI or is it a recurrent UTI.
Doctor, will my child get another infection and what can I do to prevent a second infection?
UTI can recur in as many as 8-30% of all children, especially in girls. This usually happens in the first 6 months after the first infection though girls are at a higher risk of developing UTI all through their life because of a shorter urethra. There are certain measures that you can take that can decrease the incidence of UTI:
- Give your child plenty of fluids to drink.
- Make sure she voids every few hours. Children especially girls, tend to hold back on urine when they are in public places like school, because of the relatively unhygienic toilets. Do speak to the school authorities about this and ensure that your child visits the toilet at least every few hours.
- Avoid constipation at all costs. Constipation is the leading cause of recurrent UTIs in children. The loaded rectum tends to prevent effective urinary voiding and acts as a rich source of bacteria to colonize the perineum.
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