“My child has frequent UTIs -- What's wrong?”
My child has had 3 UTIs in the past 8 months (she is 7 yrs old) and our pediatrician doesn't seem to think there's an issue, but I'm worried.
4 Answers
While it is unlikely that any damage to your child's kidneys has occurred (based upon her age), likely explanations are improper female hygiene when voiding and/or defecating or what we call dysfunctional voiding (infrequent voiding or vaginal voiding). These are things that a general pediatrician should be able to diagnose and treat, and I would strongly urge you to stay in touch with your daughter's pediatrician. Finally, a kidney ultrasound is a simple and relatively inexpensive way to look for any evidence of changes in your daughter's kidneys and I might consider that but before we go into doing imaging, I would first make certain your daughter doesn't have any high blood pressure readings and that she doesn't have abnormal amounts of protein/blood in her urine (indicators that there might be something going on with her kidneys that deserves further investigation.
UTIs are of concern if associated with fever. Children who have had 2 or more febrile UTIs should be worked up with kidney & bladder ultrasound plus bladder x-ray (voiding cystourethrogram) as they may have urinary reflux or some other bladder or urethral abnormality. This confirms guidelines of American Academy of Pediatrics & Society of Pediatric Urology. Non-febrile UTIs are almost invariably benign.
Your pediatrician may be correct because some UTIs, especially in her age group, are caused by either gastrointestinal such as constipation or behavior, such as bladder holding, issues. These issues can be treated conservatively. I would recommend a properly collected urine culture in the future to determine if it is truly an infection before ordering any imaging studies. thank you
Dear troubled mother:
There is something about a 7-year old girl having frequent urinary tract infections. Whereas we see more boys in almost all age groups, girls in that age frequently present with recurrent bladder infections. There are multiple reasons. However, this is the first thing to answer:
1. Were these really urinary tract infections (UTIs). What were the symptoms? Sometimes crystals in the urine can give you the exact same symptoms such as frequency, urgency, accidents, painful urination. Unfortunately, the average child consumes a high salt, high protein and no vegetable diet. This leads to many problems, including calcium wasting due to a high sodium load in the distal tubule, low urine pH because of the acid load from animal protein and sugary food, and a loss of urinary citrate as well as a low potassium intake for which vegetables are the most important source. Also, the children don't drink enough. As a result, you get a concentrated, acidic urine with a high calcium and sodium content and a low urinary citrate: The perfect storm for crystals in the urine or even stones in the urinary tract.
Every 5-10 years, we see a doubling of the incidence of kidney stones in children. The biggest factor is the salt, and it is not from what you add when cooking. Prepared food are full of sodium. The average 7-year old consumes 2,944 mg of sodium per day (National Health and Nutrition Examination Survey, United States, 2007-2008), whereas an adult should take in less than 2,300 mg/day and you have to scale this down to maybe half for a 7-year old. If that is the problem, avoid all processed food, cook yourself from scratch, and add a lot more vegetables to the diet. A simple test checking for urinary sodium, potassium, calcium and creatinine may be very telling.
2. Assuming there were bacteria. The definition of a UTI is not bacteria in the urinary tract, but rather inflammation BECAUSE of bacteria tract. You want to see a significant colony count on the culture together with either white blood cells and/or nitrates on a urinary dipstick. Blood may have different reasons. A vulvitis (Inflammation of the external genital organs of the female (the vulva) can lead to abnormal urine findings. Is she sometimes red in her privates? Then treat that rather than UTIs. Little girls are more prone to external infections in their privates than adults. In an adult woman, the pH in the privates is low, whereas a little girl has the same mild pH barrier in her groin as on her skin: pH 5.85. Bubble bath and alkali can destroy the pH barrier and cause a vulvitis. You may have to switch to showers, unscented pH-balanced body wash agents, and blow dry the inflamed area after a shower with cold air to get rid of the problem. The symptoms can be very similar to a urinary tract infection. Sometimes, there are yeast infections and the antibiotics commonly prescribed for UTIs may make it worse.
3. Let us say, it was a UTI. There were nitrates and leukocytes on dipstick and a significant colony count in the urine culture. There can be two reasons: high pressure or backwash (reflux) from the bladder into the ureters, the tubes that connect the kidneys with the bladder.
Let us start with high pressure. The most common reason is constipation. Owing to low vegetable (and thus soluble fibre) intake, many children are constipated. Sometimes, it may be so bad that you get fecal impaction. A fecal impaction is a solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation. A related term is fecal loading which refers to a large volume of stool in the rectum of any consistency. There can even be fecal incontinence and paradoxical or overflow diarrhea (encopresis) as liquid stool passes around the obstruction (blockage). The distal colon is supposed to be a narrow tube and the bowel movement should be once a day and look like thin snakes (see Bristol Stool chart type IV). Typically a 7-year old passes stool after supper. Think of a large freight train. You push one car in, and then the last car needs to be pushed out. It is supposed to work the same. You have two valves, the inner (I gotta go) valve and the outer (not now) valve. When a child is chronically constipated, the bowel is wide and the inner valve is always open and the normal reflex with a bowel movement 20 minutes after supper does not work. To fix this, you need to give PEG3350 (Restorelax), and enough of it to prevent the stool from being hard, and long enough to make the bowel shrink again. This may take 3 months, and even thereafter you should wean the PEG3350 slowly to get rid of the problem once and for all. Sometimes it is easy to diagnose constipation using the Bristol stool chart. Occasionally, you may need an X-ray to see a large stool mass.
4. It should be noted that holding the pee also can lead to high pressure. Is your daughter a busy bee that is too busy to go to the washroom? She is so involved in playing or whatever she is doing that she is holding her pee? In that case, remind her to go during every recess and every 2 hours at home. She also should be reminded to take her time with peeing, perhaps even count to 20 when she thinks she is done and then pee again to make sure that the bladder is always empty. Sometimes the bladder gets so distended with holding the urine that it is impossible to empty it completely, hence the recommendation to "double void".
The steps to double voiding are as follows:
* sitting comfortably on the toilet and leaning slightly forward
* resting the hands on the knees or thighs, which optimizes the position of the bladder for voiding
* urinating as normal, focusing on emptying the bladder as much as possible
* remaining on the toilet, waiting anywhere from 20 to 30 seconds
* leaning slightly further forward and urinating again
5. Let us say there is no constipation and it were true UTIs. Were they with fever? If they were with fever, you have to assume that the kidneys were involved. We call this a pyelonephritis. This should be worked up and an ultrasound of the kidneys and possibly a test for backwash (reflux) from the bladder (VCUG) into the ureters should be considered. The ultrasound is harmless, and it will be very reassuring if it is normal. The VCUG should be considered if the ultrasound is not normal. It is not the nicest test because it requires a bladder catheter to put the dye into the bladder. Careful, playful explanation is important to reduce the trauma of this test. However, it will be very helpful to assess for reflux and any bladder abnormality. In that case, you may want to ask your doctor for a referral to a specialist (paediatric nephrologists and paediatric urologists). There are not many of them and they are typically only in the large children's hospitals or the university hospitals. If the UTIs were without fever, a little girl is allowed to have three before more tests should be considered.
Hope this is helpful and you can resolve the issue.
Kind regards,
Guido Filler, MD, PhD, FRCPC
There is something about a 7-year old girl having frequent urinary tract infections. Whereas we see more boys in almost all age groups, girls in that age frequently present with recurrent bladder infections. There are multiple reasons. However, this is the first thing to answer:
1. Were these really urinary tract infections (UTIs). What were the symptoms? Sometimes crystals in the urine can give you the exact same symptoms such as frequency, urgency, accidents, painful urination. Unfortunately, the average child consumes a high salt, high protein and no vegetable diet. This leads to many problems, including calcium wasting due to a high sodium load in the distal tubule, low urine pH because of the acid load from animal protein and sugary food, and a loss of urinary citrate as well as a low potassium intake for which vegetables are the most important source. Also, the children don't drink enough. As a result, you get a concentrated, acidic urine with a high calcium and sodium content and a low urinary citrate: The perfect storm for crystals in the urine or even stones in the urinary tract.
Every 5-10 years, we see a doubling of the incidence of kidney stones in children. The biggest factor is the salt, and it is not from what you add when cooking. Prepared food are full of sodium. The average 7-year old consumes 2,944 mg of sodium per day (National Health and Nutrition Examination Survey, United States, 2007-2008), whereas an adult should take in less than 2,300 mg/day and you have to scale this down to maybe half for a 7-year old. If that is the problem, avoid all processed food, cook yourself from scratch, and add a lot more vegetables to the diet. A simple test checking for urinary sodium, potassium, calcium and creatinine may be very telling.
2. Assuming there were bacteria. The definition of a UTI is not bacteria in the urinary tract, but rather inflammation BECAUSE of bacteria tract. You want to see a significant colony count on the culture together with either white blood cells and/or nitrates on a urinary dipstick. Blood may have different reasons. A vulvitis (Inflammation of the external genital organs of the female (the vulva) can lead to abnormal urine findings. Is she sometimes red in her privates? Then treat that rather than UTIs. Little girls are more prone to external infections in their privates than adults. In an adult woman, the pH in the privates is low, whereas a little girl has the same mild pH barrier in her groin as on her skin: pH 5.85. Bubble bath and alkali can destroy the pH barrier and cause a vulvitis. You may have to switch to showers, unscented pH-balanced body wash agents, and blow dry the inflamed area after a shower with cold air to get rid of the problem. The symptoms can be very similar to a urinary tract infection. Sometimes, there are yeast infections and the antibiotics commonly prescribed for UTIs may make it worse.
3. Let us say, it was a UTI. There were nitrates and leukocytes on dipstick and a significant colony count in the urine culture. There can be two reasons: high pressure or backwash (reflux) from the bladder into the ureters, the tubes that connect the kidneys with the bladder.
Let us start with high pressure. The most common reason is constipation. Owing to low vegetable (and thus soluble fibre) intake, many children are constipated. Sometimes, it may be so bad that you get fecal impaction. A fecal impaction is a solid, immobile bulk of human feces that can develop in the rectum as a result of chronic constipation. A related term is fecal loading which refers to a large volume of stool in the rectum of any consistency. There can even be fecal incontinence and paradoxical or overflow diarrhea (encopresis) as liquid stool passes around the obstruction (blockage). The distal colon is supposed to be a narrow tube and the bowel movement should be once a day and look like thin snakes (see Bristol Stool chart type IV). Typically a 7-year old passes stool after supper. Think of a large freight train. You push one car in, and then the last car needs to be pushed out. It is supposed to work the same. You have two valves, the inner (I gotta go) valve and the outer (not now) valve. When a child is chronically constipated, the bowel is wide and the inner valve is always open and the normal reflex with a bowel movement 20 minutes after supper does not work. To fix this, you need to give PEG3350 (Restorelax), and enough of it to prevent the stool from being hard, and long enough to make the bowel shrink again. This may take 3 months, and even thereafter you should wean the PEG3350 slowly to get rid of the problem once and for all. Sometimes it is easy to diagnose constipation using the Bristol stool chart. Occasionally, you may need an X-ray to see a large stool mass.
4. It should be noted that holding the pee also can lead to high pressure. Is your daughter a busy bee that is too busy to go to the washroom? She is so involved in playing or whatever she is doing that she is holding her pee? In that case, remind her to go during every recess and every 2 hours at home. She also should be reminded to take her time with peeing, perhaps even count to 20 when she thinks she is done and then pee again to make sure that the bladder is always empty. Sometimes the bladder gets so distended with holding the urine that it is impossible to empty it completely, hence the recommendation to "double void".
The steps to double voiding are as follows:
* sitting comfortably on the toilet and leaning slightly forward
* resting the hands on the knees or thighs, which optimizes the position of the bladder for voiding
* urinating as normal, focusing on emptying the bladder as much as possible
* remaining on the toilet, waiting anywhere from 20 to 30 seconds
* leaning slightly further forward and urinating again
5. Let us say there is no constipation and it were true UTIs. Were they with fever? If they were with fever, you have to assume that the kidneys were involved. We call this a pyelonephritis. This should be worked up and an ultrasound of the kidneys and possibly a test for backwash (reflux) from the bladder (VCUG) into the ureters should be considered. The ultrasound is harmless, and it will be very reassuring if it is normal. The VCUG should be considered if the ultrasound is not normal. It is not the nicest test because it requires a bladder catheter to put the dye into the bladder. Careful, playful explanation is important to reduce the trauma of this test. However, it will be very helpful to assess for reflux and any bladder abnormality. In that case, you may want to ask your doctor for a referral to a specialist (paediatric nephrologists and paediatric urologists). There are not many of them and they are typically only in the large children's hospitals or the university hospitals. If the UTIs were without fever, a little girl is allowed to have three before more tests should be considered.
Hope this is helpful and you can resolve the issue.
Kind regards,
Guido Filler, MD, PhD, FRCPC
