Difficult to identify but potentially sinister

Illness in children is usually subtle as they do not express symptoms like adults. The only signs may be a slight change in behaviour, feeding habits and even abnormal crying. Not paying attention to these trivial warning signs could result in irremediable problems with lasting consequences.

Urinary tract infections in childhood are one such problem, difficult to identify but potentially sinister. This week MediScene spoke to Dr. Pujitha Wickramasinghe, a Consultant Paediatrician at Lady Ridgeway Hospital, Colombo to find out more about urinary tract infections in childhood.

Urinary tract infections are quite common in childhood and may also point to an underlying problem in the urinary passage of the child. But it does not present with typical symptoms as in adults.

"An older child would complain of pain or burning sensation when passing urine, but a smaller one would only cry while passing urine to indicate that there is pain," says Dr. Wickramasinghe.

Therefore, if your child keeps on crying while passing urine and for some time thereafter, or touches the urinary passage, it could be a warning sign. Fever, although not very prominent, can be a manifestation of urinary tract infection.

Usually a child passes urine 5 to 6 times a day. Passing urine every hour, an increase in frequency, poor sucking, irritability, reduced activity and even failure to gain weight could also occur due to an infection in the urinary tract.

These are not the only symptoms of urinary tract infection. If the child has a poor stream of urination (especially in a baby boy), or passes urine as drops, it could be due to an underlying abnormality in the urinary tract which needs urgent attention.

Childhood urinary tract infections can have more serious consequences than the adult illness. One reason is that the kidneys of children are not fully mature and continue to grow till about 5 years of age. Thus, if a problem occurs at an early age it could damage the kidney and cause kidney failure at an early age. Also, for the children to have a urinary infection, usually there is an underlying malformation in the urinary tract, which predisposes the child to infection. Unless this problem is picked up and corrected, the child will have recurrent episodes of urinary infections, which worsen the problem and lead to further damage to the kidneys. Most of these problems can be avoided by early detection and proper management," explained Dr. Wickramasinghe.

Therefore, any problem regarding your child's urinary habits should prompt you to seek medical advice at least from the family doctor. It is necessary to do a urine full report and a urine culture, when there is a suspicion of urinary tract infection. If your child's urine full report is abnormal, treatment with a course of antibiotics should be preceded by a urine culture which is the most valid test in diagnosing urinary tract infection in children. A course of antibiotics will usually eradicate the infection, but it is very important to complete a seven-day course of antibiotics even if symptoms improve midway. If the child has high fever, doctors may decide even to start antibiotics in the form of injections for which the child will need hospitalization.

Following the seven-day course of antibiotics, your child will be started on a lower dose of antibiotics, to be given every night before going to bed, to prevent further episodes of infections. After 3-5 days of starting the preventive regimen, you need to repeat the urine culture, to confirm that the infection has been cured successfully.

But getting a negative culture report does not conclude the story. The child has to continue the preventive regimen of antibiotics until he is about 5 years of age or even longer, as advised by your doctor. It is important that you do not miss doses, or stop treatment on your own.

"Parents are anxious about continuing antibiotics for a long time. But we prescribe it because preventing another episode is crucial," Dr. Wickramasinghe explains, highlighting the importance of drug compliance.

This is because your baby may have some underlying abnormality that could predispose the child to more urinary infections. Just addressing this episode and forgetting the future, can lead to further episodes of infections, and as time passes by kidney damage. But the situation may change in a child older than 5 years, because the growth of the kidney is almost complete by then and the damage that occurs with urinary tract infections is negligible.

Any child under five years of age has to undergo an ultrasound scan of the abdomen, when diagnosed as having urinary tract infection to look for an underlying cause. Depending on the scan and the other risk factors, the baby may need to undergo special types of X'rays and other radiological investigations.

If a serious problem is identified, the child may need surgical correction, but this is rare. If a child develops symptoms again while on the preventive antibiotic regimen, a urine culture is necessary. But, routinely doing cultures, on a monthly basis is not essential.

In addition to medication, there are things that you have to do at home to prevent urinary tract infections. These are: