UTI is an infection of the urinary tract, which includes the urinary bladder, kidneys, ureters (the tubes that carry urine from each kidney to the bladder), and urethra (the tube that empties urine from the bladder to the outside). UTI is a common bacterial infection in infants and children. The risk of having a UTI before the age of 14 years is approximately one to three per cent in boys and three to 10 per cent in girls.
UTI can occur when bacteria find their way into the bladder or kidneys. These bacteria are normally found on the skin around the anus or sometimes around the vagina. Normally, there are no bacteria in the urinary tract. However, some conditions can make it easier for bacteria to enter or stay in the urinary tract. These include:
- VUR (vesicoureteral reflux), which is usually present at birth. This condition allows urine to flow back up into the ureters and kidneys.
- Brain or nervous system illnesses (such as myelomeningocele, spinal cord injury, and hydrocephalus) that make it harder to empty the bladder.
- Changes or birth defects in the structure of the urinary tract.
- Not urinating often enough during the day.
- An obstruction, such as a kidney stone, that blocks or slows the normal flow of urine through the urinary tract.
Young children with UTI may only have fever, poor appetite, vomiting, or no symptoms at all. Symptoms of a bladder infection in children include:
- Foul smelling or cloudy urine
- Blood in the urine
- Frequent or urgent need to pass urine
- Pain or burning with urination
- Pressure or pain in the lower pelvis or lower back
- Wetting problems after the child has been toilet trained
- General ill feeling (malaise)
Symptoms of infection that may have spread to the kidneys (pyelonephritis) include:
- High fever with chills
- Pain in side of abdomen
The diagnosis of UTI is based on positive culture of a properly collected specimen of urine. If this is your child’s first UTI, special imaging tests may be done to find out why the infection happened, or to see if there is any kidney damage.
Tests may include imaging tests whose aim is to identify patients at high risk of renal damage, chiefly those below the age of one year, and those with VUR or urinary tract obstruction. Evaluation includes ultrasonography, dimercaptosuccinic acid (DMSA) renal scan and voiding cystourethrography (VCU).
Kidney ultrasound (USG): Febrile infants aged two to 24 months with UTI should undergo renal and bladder USG. In addition, the following paediatric patients should also undergo sonography of the urinary tract after a febrile UTI:
- Children with a delayed or unsatisfactory response to treatment of the first febrile UTI
- Children with an abdominal mass or abnormal voiding (dribbling of urine)
- Children with a first febrile UTI caused by an organism other than E coli
- Children with recurrence of a febrile UTI after they have had a satisfactory response to treatment of the initial febrile UTI
Renal USG should also be considered for any child with a first febrile UTI in whom good follow-up cannot be ensured.
Voiding cystourethrogram (VCUG): This is an X-ray taken while the child is urinating, and is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that suggest either high-grade VUR or obstructive uropathy. It should be performed if there is a recurrence of a febrile UTI, even if previous ultrasonographic examination findings were unremarkable. The following types of paediatric patients should undergo VCUG after a first febrile UTI:
- Those in whom treatment fails after 48 to 72 hours
- Patients with an abnormal voiding pattern (dribbling of urine)
- Infants and children in whom good follow-up is not assured
- Those with an abdominal mass
- Infants and children with recurrence of a febrile UTI
DMSA scintigraphy: This is a sensitive technique for detecting renal parenchymal infection and cortical scarring.
Antibiotics: Younger infants are usually given antibiotics through vein. Older infants and children are treated with antibiotics by mouth. If this is not possible, they are admitted to the hospital for intravenous antibiotics.
Some children may be treated with antibiotics for long periods of time (as long as six months to two years). This treatment is more likely when the child has had repeated infections or a condition called vesicoureteral reflux, which causes urine to flow back up into the uterus and kidneys. Antibiotics commonly used in children include:
- Amoxicillin or amoxicillin and clavulanic acid (augmentin)
- Cephalosporins – cefixime, cefpodoxime, ceftriaxone, cefotaxime
Analgesics: Ibuprofen is used to provide symptomatic pain relief for dysuria.
- Plenty of oral fluids.
- High blood pressure
- Kidney abscess
- Kidney infection (pyelonephritis)
- Renal insufficiency or kidney failure
- Swelling of the kidneys (hydronephrosis)
Visit your paediatrician if the child’s symptoms get worse, or new symptoms develop, especially:
- Back pain or flank pain
- Bad-smelling, bloody, or discoloured urine
- Fever of 100.4°F (38°C) rectally in infants, or over 101°F (38.3°C) in children
- Low back pain or abdominal pain (especially below the belly button)
- Persistent fever
- Increase in frequency of urination
What else to do
- Increase your child’s intake of fluids
- Avoid giving bubble baths.
- Keep your child’s genital area clean to prevent bacteria from entering through the urethra.
- Teach your child to go to the bathroom several times every day.
- Teach your child to wipe the genital area from front to back to reduce the chance of spreading bacteria from the anus to the urethra.
- Treat constipation.
You need to consult a paediatric nephrologist when…
UTI can be effectively managed by the primary care paediatrician. However, because of their potential for renal parenchymal damage, scarring and subsequent chronic kidney disease, patients having risk factors that increase the likelihood of complications should be managed in collaboration with a paediatric nephrologist. These include:
- Recurrent UTI
- UTI in association with bowel bladder dysfunction
- Patients with vesicoureteral reflux, underlying urologic or renal abnormalities
- Children with renal scar, deranged renal functions, or hypertension