URINARY TRACT INFECTIONS IN CHILDREN
Last week, I went to see a friend and her ten month old son whom I had seen last at the hospital at the time of his birth. I was surprised to see what I found there. I could not relate that little one to the healthy newborn I had seen earlier. He looked like an undernourished, totally withdrawn child who did not even seem to be doing the normal things that a child of his age would be expected to do like walking with support, giving social smile etc. I learned the answer to the unspoken questions wrong. when my friend, almost in tears, told me that the little boy was suffering from UTI (urinary tract infection) and that too not for the first time. It had happened four times before and she blamed herself for that because she left her son in the day care center during her work hours. On asking her further I was surprised to know that she was still unaware of many aspects of UTI and that there could be more to it than just lack of care.
This made me think if the parents are really aware of the facts related to urinary tract infections in children or does their knowledge consist of only what they have been hearing from here and there and which is not the complete picture.
Urinary tract infection is something we hear about every now and then, but have we ever thought what actually it is. It may have very little to do with the unhygienic conditions that parents mostly believe to be a reason for the UTI in children and henceforth not take them seriously. It might rather be due to some problem with the urinary tract anatomy itself or many other such reasons of which the parents actually have no knowledge at all. I have hereby tried to bring to the knowledge of parents some simple and basic facts about urinary tract infections in children.
WHAT IS UTI?
UTI is the presence of a significant number of pathogenic (disease producing) microorganisms in the urine or anywhere in the urinary tract i.e. urethra, bladder, kidney etc and may or may not produce symptoms.
MYTHS AND FACTS
UTI is not caused by the organisms normally found in urine, rather by the organisms from the external environment or even patient’s own skin. A bacteria called E.Coli has been commonly held responsible for causing UTI. There are many other such bacteria which can also cause infection. These bacteria can enter the urinary tract of an infant only when the natural defenses of the body are tampered with. And this happens when people are unaware of the true facts and believe the commonly prevalent myths about the causes. Here are a few examples:
Circumcision: It’s a common understanding that uncircumcised boys are at higher risk of getting UTI. The vast research done in this field does show some relation but a very minor one. Rather the latest researches have brought to light facts absolutely contrary in nature. Firstly, UTI is more common in girls. Had foreskin been the cause, this would not be true. Secondly, even though E.Coli is commonly found on human skin, its dangerous form is more commonly found in the setting of a medical centre. So, when a child is taken there for circumcision, he comes in contact with that dangerous form and the raw area formed by the circumcision provides the easy route of entry to organism. Not only this, but by removing the foreskin, the child is losing the protective covering of his urinary meatus and also the sphincter which keeps the opening closed and thus denies entry to foreign organisms. All this predisposes a circumcised child to UTI more than an uncircumcised child.
Wiping techniques in infants: We have often have heard doctors advising the parents to wipe their child from front to back to prevent UTI. As is said prevention is always better than cure and all measures should be taken to prevent infection but had improper wiping been the cause of UTI, most of the children who have not yet achieved bowel and bladder control would have had UTI at least once and the common use of diapers (exposure of the child to soiled diapers) would have made UTI much more prevalent and a major cause of it but this is far from truth. So this alone has nothing to do with causing UTI.
Bubble bath: These are no doubt a cause of urethral irritation and their frequent use can cause local infections but their association with the upper urinary tract infection has not been proved nor has their role in causing cystitis (bladder infection) been established.
Narrow urethral caliber in girls: A narrow urethra can be a cause of voiding dysfunction in children but this as an actual cause of UTI has not been found to be true. Instead, the urethral dilation procedures that are performed to treat this condition are a common cause of UTI. The instruments used for dilation may provide entrance to the pathogenic organisms which reach the bladder and even the upper urinary tract.
Day care centers: Many people think that day care centers do not provide a hygienic and healthy environment to the children. It might be possible that sometimes these bacteria and even their drug resistant forms may be found at these centers but this is a very uncommon occurrence.
What I have been trying to convey here is that all these above mentioned factors are just sources of infection, not the real causes. The parents should be aware of the fact that if their child is getting UTI, there has to some predisposing factor. I am hereby mentioning the most common predisposing factors, important clinical symptoms, and their management in brief.
PREDISPOSING FACTORS:
Obstruction: Obstruction is more common in boys. Any impediment to the free flow of urine can lead to UTI. This can be due to a congenital tumor, stones in the urinary tract or even a stricture. The retention of urine predisposes to superimposed infections. The presence of excessive crying or straining during voiding, dribbling, and a weak or abnormal urine stream suggests urinary obstruction. The importance of recognizing this condition lies in the fact that sometimes the obstruction is minor with no superimposed infection. In such cases, great caution should be exercised in attempting surgical correction which might itself introduce infection and cause more damage.
Vesicoureteric reflux (VUR): This is the retrograde flow of urine from the bladder cavity to the upper urinary tract like ureters and sometimes even kidneys. This occurs during voiding or with elevation of pressure in bladder. VUR is commonly associated with urinary tract anomalies in children. Boys have a higher incidence of congenital anomalies of urinary tract and so UTI is more common in boys during first six months of life. VUR is also found in children with normal anatomy but infected urinary tracts. The research on children with UTI who have reflux has led to the conclusion that marked reflux and not infection is responsible for the renal damage. This is what makes the diagnosis of this condition very important in children.
Neurogenic bladder: This means that nerve supply to the bladder is impaired. It may be associated with some congenital conditions of the spinal cord or may follow neoplasm or trauma to the lumbosacral region. In this case, urine is retained in the bladder. Here, the infection may be introduced by the use of catheters to drain the bladder.
These are some of the most important conditions affecting the pathogenesis of a urinary tract infection in an infant. If a child under the age of 5 years develops UTI, then all the investigations should be made to rule out some anatomical cause. Especially in an infant with recurrent UTI, the cause is mostly an anatomical abnormality.
SYMPTOMS OF UTI
The presentation of UTI depends upon the age of patient and the severity of infection. It is often difficult to recognize UTI in children as the classic symptoms found in adults are absent here.
An infant with mild to moderate UTI may not present with any symptom except fever. Therefore, UTI should be ruled out in any case of fever of more than three days duration in an infant. The common presentation of severe or recurrent UTI in an infant is unexplained fever, failure to thrive, weight loss, vomiting and diarrhea.
Older children may have fever, abdominal pain, enuresis (the uncontrolled discharge of urine), hematuria (blood in urine).
MANAGEMENT
Proper diagnosis and treatment of UTI is a must. The complications associated with UTI can be life long and even life threatening. Hospitalization and medication are important in an acute attack.
But that is not the end of the story. As much important is a follow up and finding the underlying cause if any, especially in children. If the UTI has been recurrent, then a monthly follow up for up to 3 months, then a 3 monthly follow up for a year and then yearly follow up is required.
CONCLUSION
There is more to urinary tract infection occurring in children than sees the eye. Even more so if an infant is getting recurrent UTI. Management should not be directed towards treating the acute condition and eliminating the source of infection only. A complete work up should be done in such cases to rule out all the possible underlying causes leading to UTI in a particular age group. Preventing exposure to the infection is no doubt the most important step towards a healthy living but if your child does get UTI, then remember that there could be more to it than just soiled diaper or infection from day care center.