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Urinary Tract Infections in Children

You may think urinary tract infections are only for adults but 1 to 2 percent of children can suffer this painful nuisance too. Furthermore, young children have a greater risk of kidney damage linked to urinary tract infection than older children or adults. The information below should help you recognize a urinary tract infection in children before it causes serious damage.

What happens under normal conditions?

The urinary tract controls the outflow of urine, one of the body's liquid waste products. The kidneys produce about 1½ to two quarts a day in an adult, and less in children, depending on their age. Urine travels from the kidneys down two tubes, the ureters, into a balloon-like container called the bladder. In children, the bladder can hold 1 to1½ ounces of urine for every year of age (e.g., four to six ounces, or a little less than a cup, in a four-year-old). When the bladder empties, it pushes the urine out of the body through a tube at the bottom of the bladder called the urethra. The opening of the urethra is at the end of the penis in boys and in front of the vagina in girls.

What causes urinary tract infections in children?

Normal urine is sterile and contains no bacteria, but under normal circumstances bacteria cover the skin and are present in large numbers in the rectal area and within bowel movements. Bacteria may, at times, get into the urinary tract and travel up the urethra into the bladder. When this happens, the bacteria multiply and cause infection and redness, swelling and pain (inflammation) of the bladder. When bacteria infect the bladder alone, this is called cystitis. If the bacteria travel upward from the bladder through the ureters and reach and infect the kidneys, the kidney infection is called pyelonephritis. Kidney infections are more serious than bladder infections, and can cause kidney damage especially in children.

What are the symptoms of urinary tract infections in children?

Most often when there is a urinary tract infection, the linings of the bladder, urethra, ureters, and kidneys become red and irritated. This usually causes pain and irritation so that a child complains of pain with urination and the irritation may cause frequent urination or urinary accidents and bloody urine. If the kidneys become infected, these signs are usually accompanied by a fever.

If your child is an infant or too young to tell you how he or she feels, the signs may appear vague and unrelated to the urinary tract. Your child may have a high fever, be irritable, and not eat or sometimes have only a low-grade fever, loose bowel movements or just not seem healthy. You may notice that the diaper urine smells ‘bad.' If your child has a high temperature and appears sick without another obvious source for his/her discomfort (such as runny nose or ear ache) for more than a day or two, they may need to see a doctor. If a kidney infection is not treated promptly, the bacteria may spread to the bloodstream and cause a life-threatening infection.

Older children may complain of pain in the low stomach area or back as well as the need to urinate frequently. Your child may cry when he or she urinates or complain that it hurts to urinate and produce only a few drops of urine. It may be hard for them to control their urine so they may have urinary accidents or bed-wetting. They may also produce urine that smells bad or looks cloudy.

How are urinary tract infections diagnosed in children?

If you think your child has a urinary tract infection, call your doctor. After an examination, the doctor will probably collect a urine sample for microscopic evaluation. The method your physician uses will depend on your child's age. For instance, if your toddler is not toilet-trained, your doctor may simply attach a plastic bag to the skin to collect the sample. If your child is older, you may be asked to help catch the specimen as your child empties his or her bladder. Since it is important that the collected urine be free from surrounding skin and rectal bacteria, it is sometimes necessary to pass a small tube into the urethra or a needle into the low abdomen to the bladder directly to collect a good sample.

This sample of urine is then examined under a microscope. If an infection is present, your doctor may be able to see bacteria and pus. The doctor may also perform a urine culture, a process in which bacteria from infected urine are grown in a laboratory. The bacteria can then be identified and tested to see which drugs will most effectively treat the infection. There are many different kinds of bacteria that can infect the urine. It may take a day or more to complete this testing.

How are urinary tract infections treated in children?

Urinary tract infections are treated with antibiotics. If your doctor thinks your child has a urine infection, they will choose a drug that treats the bacteria most likely to be causing the problem. Sometimes a few days later, after the culture results are finished, the antibiotic drug might be changed to one that is more effective against the particular bacteria found in your child's urine.

The specific antibiotic drug, way it is given and number of days that it must be taken may depend, in part, on the type and severity of infection. If your child is very sick and unable to take fluids, the antibiotic may need to be given as shots (injected directly into the bloodstream or muscle) with your child in the hospital; otherwise, oral medicine may be given. The daily treatment schedule your child's doctor recommends will depend upon the specific drug prescribed: it may call for a single dose each day or up to four daily doses. In some cases you will be asked to give your child medicine until further tests are finished.

After a few doses of the antibiotic, your child may appear much improved or even have returned to their normal activities, but often it may take weeks before all symptoms are gone. Even if they are improved, it is important that they take the antibiotic medicines as prescribed by your doctor and not stop them because the symptoms have gone away. Unless urinary tract infections are fully treated, they may return, or your child may get another infection.

What can be expected after treatment for urinary tract infections in children?

Once the infection has cleared, your child's doctor may recommend additional tests. The tests are performed to assure that there are no abnormalities in the urinary tract that might result in kidney damage from urinary tract infections. The kinds of tests ordered will depend on your child and the kind of urinary infection they had. Unfortunately no single test can tell everything about the urinary tract that might be important to know after having a urinary tract infection. For that reason several tests are usually recommended. If these studies show a urinary tract abnormality, your doctor may want you to see a urologist.

Additional tests may include:

Kidney and/or bladder ultrasonography: This test images the kidney and bladder using sound waves. This test may show shadows that indicate some kinds of abnormalities, but cannot show all important urinary tract abnormalities. It also cannot tell how well the kidney works.

Voiding cystourethrogram (VCUG): This important test can show abnormalities of the inside of the urethra and bladder, and if urinary flow is normal during bladder emptying. It also tells your doctor if urine from the bladder can back up into the ureters (vesicoureteral reflux) and reach the kidney. In this test a small soft tube (catheter) is placed into the urethra. A liquid that can be seen on X-rays is then placed into the bladder through the tube until your child empties their bladder.

Nuclear scans: There are different kinds of nuclear scans of the bladder and kidneys and these give different kinds of information. These scans use liquids that have different radioactive materials in them. From these tests a doctor can sometimes tell how well the kidneys work, the shape of the kidneys, and if the urine empties from the bladder in a normal way. Although the liquids that are used may have special radioactive materials in them, this does not mean they give more radiation than other kinds of X-rays. Sometimes they give your child less radiation exposure.

CT scan or MRI: These are imaging tests examine the bladder and kidneys in three dimensions. They are sometimes used for complicated infections when the other studies are unclear and more detail of these organs may be needed.

Frequently asked questions:

I have heard of urinary tract infections in adults but how did my child get one?

In some children a urinary tract infection may be a sign of an abnormal urinary tract. For this reason, when a child is found to have a urinary tract infection, it may be recommended that they get additional tests and X-rays. However, other children develop urinary tract infections because they are prone to such infections the way other children are prone to getting coughs, colds or ear infections. In other instances, children may get an infection with a bacteria that has a special capability of causing urinary tract infections or because they develop poor habits when it comes to the amount of water they drink, holding their urine for long periods of time and improper diet leading to constipation.

Do urinary tract infections have long-term effects?

Young children have the greatest risk for kidney damage from urinary tract infections, especially if they have some unknown urinary tract abnormality. The damage can cause scarring, poor growth and function of the kidney as well as high blood pressure and other problems. For those reasons, it is imperative that your child be evaluated carefully and treated promptly.

What kinds of abnormalities of the urinary tract could a child have if he/she has a urinary infection?

Many children who get urinary infections have normal kidneys and bladders, but the children who have abnormalities should be detected as early as possible in life to try to protect their kidneys against damage. Some of the more common abnormalities that may be present are:

Vesicoureteral reflux: Normally urine flows from the kidney down the ureters and into the bladder. This one-way flow is usually maintained because of a ‘valve' mechanism at the junction of the ureter and bladder. When vesicoureteral reflux is present, the urine may also flow backwards from the bladder up the ureters to the kidneys. This refluxing urine may carry with it bacteria that is present in the bladder, up to the kidneys and cause a more serious kidney infection (pyelonephritis).

Urinary Obstruction: Blockages to urinary flow may occur at many locations in the urinary tract, and in children commonly represent birth abnormalities. These blockages are usually caused by abnormal narrow areas in the urinary tract that prevent normal flow of urine out of the body.

Can urinary tract infections be prevented?

If your child, who had a urinary tract infection, has been found to have a normal urinary tract, certain habits may be useful to prevent future urinary infections. These children should be encouraged to empty their bladder frequently (every three hours during the day), and completely. Constipation should be avoided. Increased fluid intake in children who urinate infrequently may encourage more frequent bladder emptying. Proper cleanliness of the child's bottom area may decrease the amount of bacteria that enter the bladder. In some children who are very prone to getting urinary infections, it may be difficult to prevent recurrent infections.

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