How to Identify and Manage Urinary Tract Infections in Children
Table of Content
Understanding UTIs in children
A urinary tract infection (UTI) is an inflammation of any part of the urinary system caused by bacteria that enter the urinary tract via the urethra (allows urine to leave the body). It is a common infection found in children, with 2% of boys and 8% of girls having had UTI by 7 years of age.
The most common cause of UTI is Escherichia coli, which is present in the colon and responsible for 85%-90% of UTIs. UTI is more common in girls than boys as girls have a shorter urethra. Symptoms of UTI depend on the age of the child. In young children, symptoms are vague and non-specific. UTI should be considered in children (2-24 months) who present with fever and no infection source. Early diagnosis and treatment are crucial for a full recovery; if left untreated, it can cause serious complications.
Causes of UTI
Urine does not contain bacteria. Bacteria are found on the skin, rectal area and stools. Sometimes, owing to poor hygiene practices, bacteria can gain entry through the urethra into the bladder where they grow and cause an infection. Infection of the bladder causes swelling and pain and is called cystitis. If the bacteria reach the kidneys, it is called pyelonephritis. The most common bacteria responsible for UTI is E. coli.
Structural abnormalities, such as vesicoureteral reflux (VUR; backward flow of urine from the bladder through the ureters to the kidneys) can cause serious kidney infection. Several blockages along the urinary tract can prevent the passage of urine from the body (urinary obstruction).
Symptoms of UTI
Symptoms vary among children. Babies can present with fever, foul-smelling urine, fussiness, crying, irritability, vomiting, diarrhoea and poor feeding. Children may present with frequent urination, burning sensation while urinating, urinary incontinence, painful urination, urgency to urinate, foul-smelling urine, trouble while urinating, blood in urine, fever, nausea, vomiting, tiredness and pain in the back or on the sides below the ribs.
Risk factors for UTIs in children
- Female sex (due to shorter urethra than males)
- White race
- Young age
- Lack of circumcision in boys
- History of UTIs
- Bowel and bladder dysfunction
- An indwelling catheter
- High-grade VUR
- Congenital anomalies of kidneys and the urinary tract
- Duration of fever (longer than 48 hours with no identifiable source)
Risk factors in older children and adolescents include sexual activity, diabetes, immune deficiency, kidney stones and antibiotic use.
Diagnosis of UTIs
Reviewing medical history and symptoms
The healthcare provider will obtain your child’s medical history, such as history of constipation, voiding dysfunction, history of UTI and recent antibiotic treatment. A physical examination will check for abdominal distention, palpable stool, costovertebral angle (ribs meet the spine)/suprapubic (area above the pubic bone) tenderness or a distended bladder. In children <2 years of age, symptoms are nonspecific, and fever with no obvious source is the most common presentation of UTI. Older children can specifically explain their symptoms, making diagnosis easier.
Urinalysis and urine culture
A urinalysis and urine culture must be performed if UTI is suspected in children <3 years of age with unexplained fever and in children >3 years of age with dysuria (painful urination), suprapubic pain, urinary frequency and urgency, foul-smelling urine and new-onset daytime wetting.
Urine collection
The method of urine collection depends on the child’s age. In infants, a sterile bag is attached to the perineum to obtain the urine specimen. For toilet-trained children, a clean-catch urine sample can be obtained while your child urinates in a sterile container. Care should be taken to avoid contamination from skin bacteria by instructing girls to gently spread the labia and uncircumcised boys to retract the foreskin.
Urinary bladder catheterisation is not recommended as it causes discomfort to the child, emotional distress to the child and parents, considerable trauma resulting in haematuria (blood in urine) and dysuria and the possibility of bladder infection.
Suprapubic aspiration is a method to obtain a clean sample from infants and acutely ill or incontinent children. As the main cause of this method’s failure is the absence of urine in the bladder, it is recommended to perform this method with ultrasonography to ensure the bladder is sufficiently full to improve the success rates. If the urine sample cannot be examined or cultured immediately, it can be kept at 4°C for up to 4 hours.
Urinalysis
Dipstick tests
Leucocyte esterase is an enzyme produced by WBCs and a positive result demonstrates the presence of pyuria. The nitrite test is based on the principle that dietary nitrate is reduced nitrite if nitrate-reducing bacteria (E. coli, Proteus species and Klebsiella species) are present and sufficient time is there (approximately 4 hours) to complete the reaction.
Dipstick tests, such as the leukocyte esterase and nitrite tests are rapid, convenient and inexpensive; however, they are not diagnostic of UTI and cannot replace urine culture but can be used alongside it to improve diagnostic accuracy.
Microscopy
A microscopic examination of the urine sample is performed to detect pyuria or bacteriuria. The presence of ≥5 white blood cells (WBCs; pus cells) per high-power field and ≥10 WBCs/microlitre indicates UTI. The presence of bacteria in a Gram-stained sample is more accurate for UTI diagnosis than the presence of pus cells.
Urine culture
Urine culture is the mainstay in UTI diagnosis and is used to check for bacteria or other microorganisms in the urine sample. The presence of bacteria is evident in approximately 24 hours and the sensitivity tests (to determine the antibiotics that prevent microbial growth, which helps to assess treatment course) take approximately 48 hours. If the culture test is negative but the child exhibits UTI symptoms and the Gram stain shows the presence of bacteria, an anaerobic culture should be performed.
The method of urine sample collection defines the diagnostic bacterial count for UTI: mid-stream urine specimens, >100,000 colony forming units (CFU; a measure of viable bacteria in a sample)/mL; catheterisation, >50,000 CFU/mL and suprapubic aspiration, >1000 CFU/mL.
Serum creatinine
Serum creatinine is considered for children receiving aminoglycoside treatment for more than 48 hours, renal scarring suspicion and recurrent or complicated UTI.
Imaging tests
Imaging tests must be used judiciously to avoid unnecessary radiation exposure to children.
Ultrasonography
Bladder or renal ultrasonography is safe, radiation-free, non-invasive and easy to perform, making it the method of choice for urinary tract imaging. It helps to determine the kidney shape, size and position, renal parenchyma echotexture, ureter dilatation or duplication, structural abnormalities of the bladder and obstructive uropathy (blocked urine flow).
Hydration is important as the bladder must be adequately filled before the test, and a post-void measurement is essential in toilet-trained children. Pyonephrosis (pus in the renal pelvis) or renal/peri-renal abscess can be identified via renal ultrasonography. This technique is considered for children <2 years old with febrile (fever) UTI, those (any age) with recurrent UTI and those with abnormal voiding, haematuria, palpable abdominal mass, irresponsive to anti-microbial treatment and family history or urological or renal disease.
99mTc-dimercaptosuccinic acid (DMSA) renal uptake
If renal imaging with the isotope DMSA shows decreased renal uptake of DMSA, it is suggestive of renal scarring or pyelonephritis. DMSA renal scan can detect moderate to severe VUR in >70% of children. This technique is not routinely used as it is costly and involves radiation exposure. Thus, this method is recommended in children with recurrent UTI or 4-6 months after atypical UTI (does not present typical symptoms of UTI) in children <3 years old.
Voiding cystourethrogram (VCUG)
This is an X-ray procedure in which a catheter is inserted into the urethra. The bladder is filled with a liquid dye and images are collected while urinating (as the bladder gets filled and emptied). The reverse flow of urine from the bladder to the ureters or kidneys can be seen. This procedure is costly and involves radiation exposure. Thus, it should be performed only in children with ≥2 febrile UTIs.
Nuclear cystogram
It is a sensitive method for detecting VUR; however, it fails to detect the degree of reflux, intra-renal reflux and detailed images of ureters and urethra. The radiation exposure is low in this technique. A catheter is inserted into the urethra into the bladder. Subsequently, water containing radioactive tracer is passed through the catheter to fill the bladder. Images are collected while the patient is urinating.
Treatment of UTIs in children
- Encourage your child to drink plenty of fluids and urinate frequently.
- You can use a heating pad or medicines for pain relief.
- Antibiotic therapy should be initiated immediately for symptomatic UTI based on positive urinalysis and clinical findings. This will eliminate the infection and improve clinical outcomes while waiting for the culture results. The selected antibiotic should cover gram-negative rods ( coli) and gram-positive cocci. The antibiotic should have the following characteristics:
- Easy administration
- Achieves high concentration in urine
- reduced or no effect on faecal or vaginal flora
- Low incidence of bacterial resistance
- Cost-effective
- Low or no toxicity
Amoxicillin used to be the antibiotic or choice, but increased rates of E. coli resistance have limited its use. Trimethoprim/sulfamethoxazole, amoxicillin/clavulanate or cephalosporins are more effective. Fluoroquinolones are only recommended for UTIs caused by Pseudomonas aeruginosa and multi-drug-resistant gram-negative bacteria.
Once the culture results are obtained, the paediatric urologist may change the antibiotic that works well with the bacteria found in the urine. Antibiotics can be given orally or intravenously. Your child may be given a single dose or four doses per day.
Most UTIs are cured within a week and your child may feel better. However, it may take a few weeks for all the symptoms to disappear. You must complete the antibiotic course specified by your paediatric urologist even if your child exhibits no symptoms. UTIs can recur if the infection is not completely treated. If the symptoms worsen and your child does not feel better after 3 days, you may need to take your child to the hospital.
Complications
- Renal insufficiency (kidney failure) due to pyelonephritis or nephrotoxic antibiotics
- Electrolyte and acid/base disturbances
- Renal scarring (kidney tissue is damaged) caused due to pyelonephritis in infancy, urinary tract abnormalities and delay in treatment. Hypertension is commonly seen during adolescence or early adulthood in 10% of children with renal scarring.
Prognosis
Most children have good outcomes and do not have long-term urinary tract damage if VUR and renal scarring are absent. Delay in treating febrile UTI or recurrent febrile UTI has been associated with renal scarring. Children who have anatomic or functional urinary tract abnormalities are prone to UTIs.
Preventing UTIs in children
- Children should be educated on good hygiene practices, such as regular handwashing after urination, thorough cleaning of genital areas, and teaching girls to wipe from front to back after using the restroom.
- Children should be encouraged to frequently and fully empty their bladders and not hold the urine for too long.
- Children should be encouraged to drink plenty of fluids
- Children should be encouraged to have fibre-rich foods to avoid constipation that can lead to urinary retention
- Frequent diaper changes in babies
- Do not give bubble baths as bacteria can enter the urethra
- Avoid tight-fitting clothes and undergarments
Conclusion
UTIs are caused due to inflammation of any part of the urinary system. The most common cause is E. coli. UTIs are more common in girls than boys. As symptoms can be vague and nonspecific, doctors should consider an unexplained fever in children < 2 years as a UTI and start treatment immediately. Delay in treatment can lead to complications such as kidney failure. Thus, prompt and accurate diagnosis and appropriate treatment are crucial. Overall, children make a good recovery with only a few cases reporting high blood pressure or kidney problems, which require long-term monitoring. Parents should encourage measures, such as good hygiene practices, adequate fluid intake and frequent bladder emptying, to keep UTIs at bay.
Frequently Asked Questions
What are the first signs of a urinary tract infection in a child?
The first signs often include fever, irritability, foul-smelling urine, and pain or burning during urination. Babies may show non-specific symptoms like poor feeding and vomiting.
Can a child have a UTI without symptoms?
Yes, especially in infants and toddlers. A fever with no obvious cause may be the only sign, which is why UTIs should be considered in such cases.
How is UTI diagnosed in children?
UTIs are diagnosed using urine tests like urinalysis and urine culture. The method of urine collection varies by age, and imaging may be recommended in some cases.
What causes UTIs in children?
The main cause is bacteria (usually E. coli) entering the urinary tract. Risk factors include poor hygiene, constipation, holding in urine, and structural abnormalities.
How long does it take for a UTI to go away in kids?
Most children start feeling better within 1–2 days of treatment, but the full antibiotic course (usually 7–10 days) must be completed to avoid recurrence.
How can I prevent UTIs in my child?
Encourage frequent urination, good hygiene, proper wiping techniques, adequate water intake, and regular bowel movements to reduce the risk.
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