Urinary tract infection - children

Definition

A urinary tract infection (UTI) is a bacterial infection of the urinary tract. This article discusses UTIs in children.

The urinary tract includes the:

• Bladder
• Kidneys
• Ureters -- the tubes that take urine from each kidney to the bladder
• Urethra -- the tube that empties urine from the bladder to the outside

See also:

• Catheter-associated UTI
• Urinary tract infection - adults

Alternative Names

UTI - children; Cystitis - children; Bladder infection - children; Kidney infection - children; Pyelonephritis - children

Causes, incidence, and risk factors

Urinary tract infections (UTIs) can occur when bacteria find their way into the bladder or the 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 itself. However, certain things can make it easier for bacteria to enter or stay in the urinary tract. These include:

• A problem in the urinary tract, called 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, hyrocephalus) that make it harder to completely empty the bladder
• Bubble baths or tight fitting clothes (girls)
• Changes or birth defects in the structure of the urinary tract
• Not urinating (peeing) often enough during the day
• Wiping from back (near the anus) to front after going to the bathroom. In girls, this can bring bacteria to the opening where the urine comes out

UTIs are more common in girls, especially around age 3 when they first begin toilet training. In boys who are not circumcised, the risk for UTIs is slightly higher before the first birthday.

Symptoms

Young children with UTIs may only have a fever, poor appetite, vomiting, or no symptoms at all.

Most urinary tract infections in children only involve the bladder. If the infection spreads to the kidneys, it is called pyelonephritis and may be more serious.

Symptoms of a bladder infection in children include:

• Blood in the urine
• Cloudy urine
• Foul or strong urine odor
• Frequent or urgent need to urinate
• General ill feeling (malaise)
• Pain or burning with urination
• Pressure or pain in the lower pelvis or lower back
• Wetting problems after the child has been toilet trained

Symptoms that the infection may have spread to the kidneys include:

• Chills with shaking
• Fever
• Flushed, warm, or reddened skin
• Nausea
• Pain in the side (flank) or back
• Severe pain in the belly area
• Vomiting

Signs and tests

A urine sample is needed to diagnose a UTI in children. The sample is examined under a microscope and sent to a lab for a urine culture.

In children who are not toilet trained, getting a urine sample can be difficult. The test cannot be done using a wet diaper. Possible ways to collect a urine sample in very young children include:

• Urine collection bag -- A special plastic bag is placed over the child's penis or vaginal area to catch the urine; this is not the best method because the sample may become contaminated.
• Catheterized specimen urine culture -- A plastic tube (catheter) placed into the tip of the penis in boys, or directly into the urethra in girls, collects urine directly from the bladder.
• Suprapubic urine collection -- A needle is placed through the skin of the lower abdomen and muscles, into the bladder, and used to collect urine.

If this is your child's first UTI, special imaging tests may be done to determine why the infection happened, or to see if there is any kidney damage. Tests may include:

• Kidney ultrasound
• X-ray taken while the child is urinating (voiding cystourethrogram)

These studies may be done while the child has an infection, but most often it's done weeks to several months afterward.

Your doctor will consider many things when deciding if and when a special study is needed, including:

• Is the child younger than 6 months?
• Has the child had infections in the past?
• Is the infection severe?
• Does the child have other medical illnesses?
• Does the child have a problem with the spinal cord or defects of the urinary tract?
• Has the child responded quickly to antibiotics?

Treatment

In children, UTIs should be treated quickly with antibiotics to protect the developing kidneys. Any child under 6 months old or who has other complications should see a specialist immediately.

Younger infants will usually stay in the hospital and be given antibiotics through a vein. Older infants and children are treated with antibiotics by mouth. If this is not possible, they are admitted to the hospital where they are given antibiotics through a vein.

It is important that your child drink plenty of fluids during the time they have a urinary tract infection.

Some children may be treated with antibiotics for long periods of time (as long as 6 months - 2 years), or they may be prescribed stronger antibiotics.

The health care provider may also recommend low-dose antibiotics after the first symptoms have gone away. This type of treatment is less common now than it once was.

Antibiotics commonly used in children include:

• Amoxicillin or amoxicillin/clavulanic acid (Augmentin)
• Cephalosporins
• Doxycycline (should not be used in children under age 8)
• Nitrofurantoin
• Trimethoprim-sulfamethoxazole

Follow-up urine cultures may be needed to make sure that bacteria are no longer in the bladder.

Expectations (prognosis)

Most children are cured with proper treatment. The treatment may continue over a long period of time.

The long-term consequences of repeated UTIs in children can be serious. However, these infections can usually be prevented.

Complications

• High blood pressure
• Kidney abscess
• Kidney infection (pyelonephritis)
• Renal insufficiency or kidney failure
• Swelling of the kidneys (hydronephrosis)

Calling your health care provider

Call for an appointment with your health care provider if your child's UTI symptoms continue after treatment or come back more than twice in 6 months.

Call your health care provider if the child's symptoms get worse, or new symptoms develop, especially:

• Back pain or flank pain
• Bad-smelling, bloody, or discolored urine
• Fever of 100.4°Fahrenheit (38°Celcius) rectally in infants, or over 101°Fahrenheit (38.3°Celcius) in children
• Low-back pain or abdominal pain (especially below the belly button)
• Persistent fever
• Unusually frequent urination or frequent urination during the night
• Vomiting

Prevention

• Avoid giving your child bubble baths
• Have your child wear loose-fitting underpants and clothing
• Increase your child's intake of fluids
• Keep your child's genital area clean to prevent bacteria from entering through the urethra
• Teach your child to go 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

Long-term use of preventive (prophylactic) antibiotics may be recommended for some children who are prone to chronic UTIs.

References

Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008;122(5):1064-71.

Mori R. Kakhanpaul M, Verrier-Jones K. Diagnosis and management of urinary tract infection in children: summary of NICE guidelines. BMJ. 2007; 335:395-397

Roussey-Kesler G, Gadjos V, Idres N, Horen B, Ichay L, Leclair MD, et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. J Urol. 2008;179:674-679; discussion 679. Epub 2007, Dec 20.

Shaikh N, Morone NE, Lopez J, Chianese J, Sangvai S, D'Amico F, Hoberman A, Wald ER. Does this child have a urinary tract infection? JAMA. 2007; 298:2895-2904.