What is Urinary Tract Infections In Children (UTI in children)?
Urinary tract infections (UTIs) are a common type of bacterial infection in children. These infections happen when bacteria moves up the urethra and into the urinary tract. The infection can occur anywhere from the urethra to the kidneys. A UTI in the kidneys and ureters is called an upper tract UTI, while a UTI in the bladder and urethra is known as a lower tract UTI. Depending on where the infection is, it may be called urethritis (in the urethra), cystitis (in the bladder), or pyelonephritis (in the kidneys).
Sometimes, bacteria can be present in the urinary tract without causing any inflammation or symptoms. This is known as asymptomatic bacteriuria. There can also be a condition called sterile pyuria, where there are more white blood cells in the urine, but no bacteria shown on a urine test.
Complicated UTIs are more serious infections that may occur in newborns, cause sepsis, create a bladder or abdominal mass, or be linked with congenital kidney and urinary tract anomalies. These infections could also be caused by bacteria other than E. coli, show atypical symptoms, result in a kidney abscess, or not respond to antibiotics within three days.
What Causes Urinary Tract Infections In Children (UTI in children)?
Urinary tract infections, or UTIs, are usually caused by bacteria that naturally live in the colon. The most common type of bacteria causing UTIs is Escherichia coli, which is responsible for around 85% to 90% of these infections. Other bacteria that often cause UTIs include Klebsiella, Proteus, Enterococcus, and Enterobacter.
One interesting fact is that Proteus bacteria can cause kidney stones. Bacteria such as Pseudomonas, Staphylococcus aureus, and group B Strep often cause UTIs in people who have had urinary surgery, use a urinary catheter, or have recently used antibiotics. Enterococci bacteria are especially known for causing UTIs related to catheter use.
Newborns and children whose immune system is not working well can get UTIs through what’s known as the hematogenous route – this is when the bacteria spread through the bloodstream to the urinary system. Group B Streptococcus, Candida, Staphylococcus aureus, and salmonellae are examples of bacteria that can cause UTIs this way, leading to a kidney infection known as pyelonephritis.
Risk Factors and Frequency for Urinary Tract Infections In Children (UTI in children)
Urinary Tract Infections (UTIs) are common and the rates of occurrence are influenced by several factors like gender, age, race, and whether a male child is circumcised or not. About 8.4% of girls and 1.7% of boys get a UTI before they turn 7 years old. UTIs most often occur in infancy, during toilet training, and when girls begin to be sexually active.
A number of risk factors increase the likelihood of UTIs in children. These include being female, being younger, being of white race, being an uncircumcised boy, having a fever for a longer period, having a condition known as high-grade vesicoureteral reflux (VUR), having had a UTI before, having conditions related to the bladder and bowel, spinal malformation and having a catheter inserted into the bladder. For older children and teenagers, additional risk factors include being sexually active, being pregnant, having kidney stones, having a weakened immune system, and having diabetes. Taking antibiotics such as penicillin or ampicillin also increases the risk of UTI.
- About 7% of infants with a fever may actually have a UTI.
- Girls younger than 1 year old and uncircumcised boys younger than 3 months old have the highest rates of UTI.
- Circumcision in boys can significantly affect their likelihood of getting a UTI. For instance, uncircumcised boys under 3 months old with a fever have a 20% chance of having a UTI, while circumcised boys of the same age only have a 2.4% chance.
The University of Pittsburgh has created a UTI calculator to support doctors in estimating the likelihood of a UTI in young children (2 to 23 months old) with a fever. The calculator uses several key factors, including being younger than 12 months old, being female or a uncircumcised male, the absence of other potential causes for the fever, having a fever for more than 48 hours, having a history of UTI, and having a temperature above 39 degrees Celsius. This tool has proven to be beneficial in reducing unnecessary tests, missed diagnoses, and treatment delays, thereby improving treatment and patient outcomes.
VUR and bladder and bowel dysfunction (BBD) are the two risk factors linked to the highest rates of recurring UTIs within 2 years, especially if a child has both. Lastly, there is no evidence to prove that the way how children clean themselves after using the toilet or the use of bubble baths without constipation causes UTIs.
Signs and Symptoms of Urinary Tract Infections In Children (UTI in children)
Urinary tract infections (UTIs) can affect people of all ages and may cause different symptoms based on the individual’s age and where the infection is in the urinary tract.
For instance, in the first three months of a baby’s life, a UTI might cause symptoms like fever, vomiting, lower-than-normal body temperature, yellowing of the skin (jaundice), difficulty feeding, poor weight gain, or fussiness. For children under 2 years old, the symptoms tend to be more general and harder to identify because the child might not be able to explain what they’re feeling or point to where it hurts. In this age group, the most common sign of a UTI is a fever that doesn’t seem to be linked to any other illness. Kids who are older might be able to explain their symptoms better or point to where the pain is.
- Urethritis (infection of the urethra) causes pain during urination, itching, or discharge from the urethra.
- Acute cystitis (bladder infection) can present with painful urination, blood in the urine, a frequent need or feeling of needing to urinate, cloudy or unusually smelly urine, and lower abdominal pain.
- Acute pyelonephritis (kidney infection) can cause symptoms like fever, pain in the side of the back, abdominal pain, vomiting, or other general illness symptoms.
A doctor will also take into account medical history details such as a history of constipation, symptoms of urinary function issues, previous UTIs, and recent antibiotic treatments. During a physical examination, the doctor will look for signs of a distended (swollen) abdomen or bladder, flank mass (a lump on the side of the back where the kidneys are located), a palpable stool (feeling stool in the abdomen during a physical examination), tenderness over the kidney or lower abdomen area.
Testing for Urinary Tract Infections In Children (UTI in children)
Diagnosing a urinary tract infection (UTI) in young children can be difficult due to nonspecific symptoms. To definitely diagnose a UTI, an uncontaminated urine sample is needed. This can be difficult to obtain in children who haven’t been toilet-trained. There are a few different ways to collect a sample, for example, using a bag, catching it midstream, or through catheterization. There is also a method called the “Quick-Wee” where cold saline-soaked gauze is rubbed onto the child’s lower abdomen to stimulate urination.
A urine test strip or dipstick analysis can help determine if there is an infection. It tests for nitrate (evidence of certain types of bacteria) and an enzyme from white blood cells (WBCs). The presence of blood or protein in the urine doesn’t necessarily mean there’s a UTI.
When it comes to collecting urine, samples collected with a bag should only be used for testing (urinalysis) not for growing cultures, as there could be bacteria on the skin that isn’t actually in the urinary tract. In younger children, doctors weigh the pros and cons of using a bag or catheter. Urine collected with a bag is painless but may take time, and if abnormal, it may need to be confirmed with catheterization. Catheterization might be painful, but it’s faster, has less risk of contamination, and can be cultured.
In older children who are toilet-trained, urine samples can be obtained midstream in a sterile cup after cleaning the surrounding area. Gathering urine with a needle from the bladder is less common as it’s quite painful and not always successful.
A urine test will look for an enzyme produced by WBCs, as its presence indicates activity in white blood cells (pyuria). This result can be false in neutropenic patients and young children who frequently pee. Various bacteria have been tied to different levels of pyuria. It’s worth noting that nitrites, which are produced by gram-negative bacteria, can also indicate a UTI. The bacteria convert dietary nitrate in the bladder to nitrite. Certain bacteria do not participate in this conversion.Therefore, the urinalysis results for this enzyme and nitrites differ in terms of sensitivity and specificity in diagnosing UTI.
In most labs, if nitrites or the enzyme are detected, a microscopic examination is undertaken to look for bacteria, WBCs, and red blood cells (RBCs). In uninfected urine, bacteria shouldn’t be visible under a microscope. So, the presence of bacteria could suggest a UTI. Also, more than 5 WBCs per high-power field or 25 WBCs per microliter in a urine sample is seen as abnormal and suggests a UTI in symptomatic patients.
Some conditions might show white cells in urine but no bacteria on a urine culture. This could be due to different causes, for example, strenuous exercise, partially treated UTI, various infections, inflammatory diseases, kidney stones, nephropathy, or necrosis among others.
In terms of urine cultures, having clinical symptoms alongside evidence of inflammation in the urinalysis and urine culture results with at least 50,000 CFU/mL of a single uropathogenic organism, would allow a UTI diagnosis according to the AAP. The threshold for a positive urine culture result depends on the method of urine sample collection. Asymptomatic bacteriuria is the growth of a single type of bacteria in a correctly collected urine sample without inflammation, pyuria, or UTI symptoms. This is often present in children with neurogenic bladder dysfunction and those using clean intermittent catheterization.
It is important to say that negative urinalysis results do not entirely rule out a UTI. Neonates with UTI who appear well, alongside a procalcitonin value below 0.35 ng/mL, are at a low risk for bacterial meningitis. In these cases, avoiding routine lumbar puncture may be worth considering.
A renal ultrasound is recommended after a first febrile UTI in young children and in older children with recurrent UTI. This would help detect any structural abnormalities. Very ill children or those not improving as expected should undergo ultrasonography within a few days. Those with less severe infections can pursue it after the acute phase to decrease false-positive results.
A voiding cystourethrogram (VCUG) is useful to confirm vesicoureteral reflux (VUR) and assess its severity. Yet, routine VCUG is not recommended after the first UTI only when certain conditions are present or in cases of recurrent febrile UTI.
To limit radiation exposure in children needing VCUG, a contrast-enhanced voiding urosonogram (ceVUS) can be offered as an alternative. Also, a DMSA scan may be considered in children with renal parenchymal abnormalities on ultrasound or recurrent febrile UTIs. A DMSA scan is the gold standard for diagnosing acute pyelonephritis and renal scarring, but it’s not universally used. This test should be performed 6 months after acute infection to help diagnose renal scarring following acute pyelonephritis. In summary, diagnosing UTIs requires careful and thorough analysis using multiple diagnostic methods and considering patient-specific factors. It’s essential to choose the most accurate and least disruptive methods, especially for younger patients.
Treatment Options for Urinary Tract Infections In Children (UTI in children)
It usually takes 12 to 24 hours to get results from a urine culture test that checks for bacteria that causes urinary tract infections (UTIs). After identifying the specific bacteria, it takes another 2 to 3 days to find out which antibiotics the bacteria are susceptible to. Meanwhile, doctors often prescribe antibiotics based on their best guess, even before getting these detailed results, to quickly help fight off the infection.
The preferred treatment for simple UTIs generally involves certain types of antibiotics like cephalosporins or amoxicillin-clavulanate. For very young babies or children who look very sick, have a weak immune system, or can’t take oral medicine, doctors advise giving antibiotics by injection or intravenous drip (IV).
For UTIs that have spread to the kidney (known as pyelonephritis), oral antibiotics work as well as IV antibiotics, as long as the patient is not severely ill. Once the patient starts getting better, doctors switch them from IV to oral antibiotics.
Doctors choose the length of antibiotic treatment depending on the child’s age and how severe the UTI is. Infants or toddlers, and older kids with a kidney infection, often need antibiotics for 1 to 2 weeks. Older kids with bladder infections may need antibiotics for 3 to 7 days. This can be reduced to 2 to 4 days for some children with bladder infections.
Bacteria present in the urine but not causing any symptoms (asymptomatic bacteriuria) usually don’t need treatment. The exception is during pregnancy because an infection can develop, leading to kidney infection. Treating asymptomatic bacteriuria in pregnant women with a 3 to 7-day course of antibiotics can prevent problems such as preterm birth or low birth weight.
In terms of repeat UTIs, the care plan includes checking for risk factors and managing them. These factors could include structural problems in the urinary tract and issues with bowel or bladder function. Additionally, developing healthier bathroom habits such as regular voiding and drinking plenty of water can be beneficial.
For kids who keep getting UTIs despite treatment, doctors may recommend antibiotics to prevent future infections. Surgical treatment is considered for kids who continuously get infections that could lead to kidney damage, despite taking antibiotics. This usually involves procedures designed to prevent urine from flowing backward from the bladder to the kidneys.
Lastly, circumcision has been shown to reduce the risk of UTIs in boys with a history of hydronephrosis during the first year of life.
What else can Urinary Tract Infections In Children (UTI in children) be?
Different urine infections show different symptoms based on where the inflammation is in the urinary tract. This includes conditions like urethritis, cystitis, and acute pyelonephritis.
To help differentiate, consider this information:
– Acute pyelonephritis is more commonly seen in younger children while cystitis is often found in children older than 2.
– A fever higher than 38°C may indicate acute pyelonephritis. However, cystitis usually doesn’t show a high fever.
– Systemic symptoms like vomiting are common with acute pyelonephritis. For cystitis, these are uncommon.
– The source of the problem can be bacteria (E. coli being the most common), viral infections, chemical reactions, and fungi.
– The patient’s urine may contain blood or clots in the case of cystitis, but this is not common with acute pyelonephritis.
– Positive urine culture for bacteria is found in both acute pyelonephritis and bacterial cystitis. However, if the cystitis is due to viral, chemical, or fungal reasons, the result will be negative.
– A kidney scan can reveal swelling or increased blood flow in the case of acute pyelonephritis, but for cystitis, it can show a thickened bladder wall.
– Acute pyelonephritis may lead to kidney scarring, while cystitis doesn’t result in complications for the kidneys.
Additionally, other conditions that may have similar symptoms include viral infections, kidney stones, certain male reproductive system conditions like orchitis and epididymitis, sexually transmitted infections, appendicitis, and pelvic infections.
What to expect with Urinary Tract Infections In Children (UTI in children)
Most children who get urinary tract infections (UTIs) typically have a good outcome and usually don’t encounter long-term damage to their urinary system due to the infection. It’s not always necessary to perform routine urine tests or culture after UTI symptoms have disappeared, unless there’s a specific clinical need.
However, when bacteria from the urinary tract make their way into the bloodstream, it could cause urosepsis (a severe infection) and meningitis (an infection of the brain and spinal cord). Newborns and children with weak immune systems are especially at risk of these serious system-wide infections.
Possible Complications When Diagnosed with Urinary Tract Infections In Children (UTI in children)
Short-term complications from a urinary tract infection, or UTI, are much like those of any fever-causing illness. These can include dehydration and abnormalities in the body’s balance of electrolytes, which are minerals that help your body carry out vital functions.
In the long run, severe kidney infection (known as acute pyelonephritis) and persistent backflow of urine into the kidneys (known as vesicoureteral reflux, or VUR) can cause kidney scarring and reflux nephropathy (or kidney damage due to the backflow of urine). About 15% of people with a fever-causing UTI develop kidney scarring.
Children who suffer from reflux nephropathy may go on to develop a range of kidney problems later in life. These can include the presence of tiny amounts of a protein called albumin in the urine (microalbuminuria), excessive amounts of proteins in the urine (proteinuria), high blood pressure, or enduring kidney disease.
If both kidneys are damaged by reflux nephropathy, this can progress to chronic kidney disease, which is a long-term condition where the kidneys do not work as well as they should. This can sometimes progress to a serious condition called end-stage renal disease, which is when the kidneys stop working altogether and the person requires dialysis or a kidney transplant.
Preventing Urinary Tract Infections In Children (UTI in children)
Parents need to be aware if their child was born with a condition called antenatal hydronephrosis. This condition increases a child’s risk of developing urinary tract infections (UTIs). Therefore, it’s important for parents to know the signs of a UTI. If the child shows any symptoms, parents should seek medical help and get a urine test for the child.
Parents of newborn boys diagnosed with antenatal hydronephrosis should also be aware of the benefits of circumcision. This procedure can help reduce the child’s chances of developing UTIs.
In cases where boys have a condition called phimosis, circumcision may be required to stop UTIs from happening again. If a boy has not been circumcised, parents should gently pull back and clean the area every day.
It’s important to inform both children and those who care for them about the role of a healthy diet and regular bathroom breaks in preventing UTIs, especially for those with bladder and bowel dysfunction (BBD). Doctors should actively look for and manage BBD in older children. This proactive approach significantly lowers the risk of UTIs, as BBD often contributes to recurring UTIs, but is not always recognized.
People with UTIs should make sure to take their antibiotics exactly as their doctor has prescribed, even if they start to feel better before the medication is finished.
Parents of children with multiple UTIs should immediately seek medical help if the child becomes sick with a fever. Early detection and treatment (within 48 hours) will prevent damage to the kidneys.
Children who have repeatedly had UTIs and also have a severe form of a condition called vesicoureteral reflux (VUR) should be told to take preventative antibiotics exactly as their doctor has directed.
Lastly, sexually active teenage girls should be told to use the bathroom straight after sexual activity, as this can help clear any bacteria from the bladder.
