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The Diagnosis Your Pediatrician May Miss

Childhood urinary tract infections are more common than parents -- or doctors -- realize

FRIDAY, May 11 (HealthScout) -- You wake up to find your two-year-old is feverish and doesn't want breakfast. The rest of the day, she's also cranky -- fussing about eating and crying periodically for what seems like no apparent reason. And her fever continues.

If you're like most parents you probably think "ear infection" or maybe "teething." But according to the American Academy of Pediatrics (AAP), a child with an unexplained fever -- and no other obvious symptoms -- could have a urinary tract infection, or UTI. And while it's generally not a diagnosis that crosses a parent's mind, studies show it's an option no mom or dad can afford to ignore.

"Up to 1 percent of all boys and 3 percent of girls -- tens of thousands of children -- have at least one symptomatic urinary infection during the first 10 years of their life. If left undiagnosed, it can lead to some serious complications," says Dr. Fernando Ferrer, a pediatric urologist at the Brady Urological Institute at Johns Hopkins Medical Center in Baltimore. Those complications, he says, can include a potentially life-threatening kidney infection or a serious urological impairment requiring immediate care.

Despite the seriousness of the problem, experts report that pediatric urinary tract infections are often overlooked -- not only by parents, but also by doctors.

Indeed, the AAP became so concerned about the potential for undiagnosed UTIs, it issued a set of guidelines in 1999 covering diagnosis, treatment and follow-up care, particularly for children between the ages of two months and two years.

"We needed to remind people that the diagnosis needs to be considered. Because if you don't think of it, you don't make it . . . it's not a diagnosis that finds you," says Dr. Kenneth Roberts, professor of pediatrics at the University of North Carolina and co-author of the AAP guidelines.

How an infection occurs

Urinary tract infections are often caused by the bacterium escherichia coli or E. coli -- a germ commonly present in the colon. Due to poor bathroom hygiene or sometimes during a diaper change, the germ can make its way to the urethra -- the tube that carries urine out of the bladder. Once there, an infection known as urethritis can occur. If the germ ascends to the bladder, cystitis is the diagnosis.

And infections that go all the way to the kidney are called pyelonephritis.

In general, a girl is far more likely to develop a UTI, since her urethra is short, and the passage to her urinary tract unprotected.

Interestingly, however, if you look at just the first year of life, a boy is more vulnerable, particularly if he is uncircumcised. The reason: the extra foreskin can harbor germs, a problem that sometimes diminishes as the genitals grow, experts say.

When diagnosed in the early stages, both urethritis and cystitis respond well to antibiotics -- usually a week or less of treatment can do the trick.

Delay the diagnosis, however, and pyelonephritis sets in, often causing high fever, pain and the potential for serious kidney damage.

"If the infection escapes the tract and gets up to the kidney, that infection causes a scar and a scar in the kidney is dead renal tissue that won't work," says Ferrer. According to the National Institutes of Health, children who experience kidney damage can grow up with a 23 percent increased risk of high blood pressure and 10 percent greater risk of fatal kidney failure.

Check for anatomical problems

Recurring infections in children can often be the first sign of a potentially serious urinary tract malfunction -- an anatomical problem that requires immediate attention.

"Kids should not get recurring urinary tract infections, and if they do, the chances of them having a urinary tract abnormality are high -- up to one in 10 children with a UTI will have a more serious problem," says Ferrer.

Among the most common problems is a condition called vesico-ureteral reflux, a backward flow of urine caused by a faulty valve in the tubing that connects the bladder to the kidneys. Studies show this can be the case with up to 50 percent of children with recurring UTIs.

"We pick it up because the child develops a urinary infection -- it's silent until they do have a UTI," says Dr. Russell Steele, a pediatric urologist at the Louisiana State University School of Medicine and Children's Hospital in New Orleans.

Additionally, says Steele, "It's not uncommon to pick it up in one child who has a UTI, and then examine their brothers and sisters and discover they have it, too."

Left undiagnosed, a faulty valve can lead not only to chronic infections, but also to serious kidney damage. The good news: For some children, all that's necessary is a regimen of continuous, low-dose antibiotic therapy and time for a natural growth spurt.

"As these children grow, their bladder increases in size and the seal closes on its own," says Ferrer. The antibiotic controls the recurring UTIs and helps guard against subsequent kidney infection.

If growth doesn't solve the problem, or if breakthrough infections continue while waiting, a simple surgery to seal the valve can help.

Other abnormalities linked to UTIs include blockages or defects somewhere in the system between the urethra and the kidney.

"Anywhere from 5 to 10 percent of kids with a UTI will have some obstructive lesion in their urinary tract," says Ferrer, adding that most respond well to surgery, particularly when they are treated early on.

What To Do

Experts say if your child is running a fever, be on the lookout for subtle signs of a urinary tract infection, including grunting or groaning right before or right after urination; a stronger-than-normal urine odor on the diaper; and, in a toddler who is toilet trained, a reluctance to go to the bathroom, or wetting accidents. Another clue: If your child urinates and then wets himself a short time afterward, it may indicate he is holding back urine because of pain.

Other symptoms can include abdominal tenderness or pain around the pubic bone, as well as general lethargy, vomiting, diarrhea and a lack of appetite.

Visit the American Academy of Pediatrics for its revised guidelines on treating UTIs in children.

To read more about treatments for UTIs in children, visit The National Kidney and Urologic Diseases Information Clearinghouse.

For more HealthScout stories on children's health, click here.

SOURCES: Interviews with Fernando Ferrer, M.D., pediatric urologist at Brady Urological Institute, Johns Hopkins Medical Center, Baltimore, Md.; Russell Steele, M.D., pediatric urologist, Louisiana State University School of Medicine and Children's Hospital, New Orleans, also spokesman for the American Academy of Pediatrics; Kenneth Roberts, M.D., director, pediatric teaching program, Moses Cone Health System, Greensboro, N.C., and professor of pediatrics, University of North Carolina, and co-author of American Academy of Pediatrics guidelines on the treatment of urinary tract infections in children
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