Urinary Tract Infections in Children

The urinary tract, or urinary system, is the pathway through which waste fluid filtered from the blood by both kidneys is excreted as urine. The two narrow tube-like structures that run down from the kidneys and connect to the bladder are called ureters. The bladder passes the urine into a shorter tube called the urethra, and in this way urine is expelled. In short, the kidneys, ureters, bladder and urethra make up the urinary system. An infection in any of these is called a urinary tract infection.

WHO GETS IT?

Urinary tract infections (UTIs) occur in 3–5% of children. In the newborn period and the first year of life, they are more common in boys because underlying urinary tract anomalies are more frequent in boys; otherwise, they are generally more common in girls because of their anatomy. This is because girls have a shorter urethra than boys, and the anal area and the vaginal area and urethra are very close to each other. For various reasons, this creates a greater predisposition to infection. In boys, they are also more common in uncircumcised boys than in circumcised boys. Children with any blockage in the urinary tract, whether anatomical or due to other causes, are also more likely to develop an infection.

WHAT CAUSES A URINARY TRACT INFECTION?

Urine is normally sterile and contains fluid, salts and waste products. It does not normally contain bacteria, viruses or fungi. If for any reason microorganisms manage to enter through the urethra (most often bacteria spread from stool and the anal area), they can travel to the bladder and from there spread to the kidneys. However, the kidneys are not always involved. Sometimes the infection is only in the bladder; this is called ‘cystitis’. An infection that spreads to the kidneys is more serious, however, and is called ‘pyelonephritis’. Acute pyelonephritis can cause severe findings such as fever, elevated infection markers in the blood, severe flank pain, severe vomiting and fluid loss, and deterioration in general condition. These patients may need to be admitted to the hospital and treated with intravenous antibiotics.

Most commonly (70–90%), urinary tract infections are caused by a bacterium called Escherichia coli (E. coli), which normally lives in our large intestine.

WHAT ARE THE SYMPTOMS OF A URINARY TRACT INFECTION?

Each child may have different symptoms, but the ones listed below are the most common:

In babies (< 1 year):

• Fever
• Abdominal pain
• Abdominal swelling
• Foul-smelling urine
• Slowed growth
• Weight loss or poor weight gain
• Irritability
• Vomiting
• Feeding difficulties and loss of appetite
• Diarrhea

In older children:

• Frequent urination
• An urgent need to urinate
• Urinary incontinence (during the day or at night)
• Burning during urination
• Pain in the bladder area
• Blood in the urine
• Foul-smelling urine
• Nausea and vomiting
• Fever
• Chills
• Flank pain
• Weakness
• Passing very small amounts of urine despite an urgent need to urinate

Since these findings can also be seen in other diseases, you must consult your pediatrician for a differential diagnosis.

HOW IS A URINARY TRACT INFECTION DIAGNOSED?

After taking a detailed history from you, your pediatrician will confirm the diagnosis with a physical examination, a complete urinalysis and a urine culture. Blood tests are not routinely requested for every child, but they must be done when necessary. A kidney ultrasound is always requested for every child who has had a urinary tract infection, if one has not been done before, because an anatomical problem that may be an underlying risk factor can be identified this way. Further investigation may be needed in children with recurrent urinary tract infections. In that case, a test called a voiding cystourethrogram (VCUG) is performed, in which a catheter is inserted into the urethra to check whether urine flows back into the kidneys and ureters during urination. Sometimes scintigraphic imaging (DMSA, DTPA) may also be requested. Your doctor will decide which imaging methods will be used and whether further investigation is needed.

HOW IS A URINARY TRACT INFECTION TREATED?

This varies depending on several factors and will be decided by your doctor. These factors are:

• Your child's age, general health and any underlying diseases
• The severity and course of the disease
• How well your child tolerates the treatment
• Your opinion or preferences

Treatment may include:

• Antibiotics
• Increased fluid intake
• Fever reducers.
• Severe cases require hospitalization: admission needs to be considered if there is deterioration in general condition, severe vomiting or inability to feed, elevated infection markers in the blood, or if the child is very young. Your doctor will decide on this according to your child's condition.

Some time after treatment, your doctor will ask you to bring your child back for a follow-up visit and will re-evaluate your child. Urine tests are repeated after treatment to check whether the infection has cleared. If blood tests were taken, your doctor will decide whether to repeat them according to your child's condition.

WHAT SHOULD BE DONE TO PREVENT THE INFECTION FROM RECURRING?

If an underlying anatomical abnormality has been found in your child, treating it may prevent recurrence. Genital hygiene is very important in girls. When cleaning the genital area, wipe ‘from front to back’, and a tissue, cotton pad, etc. that has touched the anal area should not be brought back into contact with the front, that is, the vaginal and urethral area. The diaper must be changed immediately after a bowel movement. Tight, narrow synthetic underwear that is not cotton should be avoided. If your child has a pinworm infection, it must be treated. If toilet training is being enforced strictly, the predisposition to urinary tract infections also increases during this period. Care should be taken in this regard. Toilet training should begin whenever the child is ready. The child's psychological state and the stress they experience about this should always be taken into account. Children may put off urinating when they are busy with something for long hours, especially while playing or watching TV. Holding urine is more common in girls than in boys. Children with constipation also have a strong tendency to hold their urine. To prevent urinary tract infections from recurring, it is very important to go to the toilet regularly and empty the bladder. For this reason, you can make sure that your child goes to the toilet and urinates at regular intervals, for example every 2–3 hours. You should also increase their water intake. However, this does not mean fruit juices, packaged drinks, etc. If your child has recurrent urinary tract infections, close follow-up is essential to prevent permanent damage to the kidneys. Since infections are more common in uncircumcised boys than in circumcised boys, your doctor may recommend circumcision for boys with recurrent urinary tract infections if it is considered appropriate after evaluation.