Pediatric Primary Care (92 page)

b.  Some situations can be managed with outpatient therapy:

•  Parenteral ceftriaxone if child is taking fluids well, parents are reliable enough to contact provider if condition changes.

•  Some older children can be managed as outpatients with cephalosporins, penicillins, sulfonamides. Antibiotic treatment is 7–10 days.

•  Parent involvement is very important when managing patients outside hospital; provider must have confidence in family.

c.  Continue parenteral treatment until culture, sensitivity returns and clinical picture is improving, then place child on appropriate oral antimicrobial.

d.  Quinolones are not yet approved for pediatric UTI management but clinical trials are evaluating the safety and efficacy in children. Some clinical situations may warrant limited off-label use.

e.  Nitrofurantoin is not a good antimicrobial in a systemically ill patient, does not attain high serum concentrations.

3.  Lower tract or bladder infections are referred to as uncomplicated UTI.

a.  Children: 3- to 5-day course of oral antimicrobials.

b.  Nitrofurantoin: good option, provides high urinary concentration (other agents used: sulfonamides, cephalosporins, penicillins).

c.  Antibiotic prophylaxis: maintained after infection is treated to prevent infection from reoccurring before completion of X-ray evaluation. May need to be continued after X-ray evaluation: vesicoureteral reflux, urinary tract obstruction, immunosuppression, recurrent UTIs, or less than 6 monthss of age.

•  Nitrofurantoin: 1.2–2.4 mg/kg or TMP-SMX 2 mg/kg of trimethoprim once a day are common choices.

•  Cephalosporins (such as cephalexin) or ampicillin: 25% treatment dose daily.

•  Nitrofurantoin: Do not use until older than 1 month of age.

•  TMP-SMX: Do not use until older than 2 months of age.

•  Both Keflex and ampicillin can be used in newborn.

d.  Treatment must also include good oral intake of fluids, encouraging toilet-trained patient to void more frequently.

e.  If associated constipation, this must also be addressed.

•  Prevents good urinary evacuation.

•  Provides good medium for microbial growth.

•  Dysfunctional elimination syndrome (poor emptying of bowel and bladder) is hallmark of UTIs in toilet-trained patients.

f.  Educate parent in treatment of problem.

•  Urination on timed schedule usually every 2 hours with techniques for relaxation of external urinary sphincter.

•  Voiding to completion with each attempt is vital to preventing further infections. Have child sit comfortably on the toilet with legs widely separated and feet supported on a footstool if they don't reach the floor. Some children sit backward on the toilet.

•  Stool softeners are often necessary while working on dietary measures to prevent constipation.

g.  Perineal irritation.

•  Scented soaps, bubble baths may irritate urethra, cause burning that results in disrupted urinary stream, poor emptying of bladder; discontinue in patients with recurrent UTIs.

•  Covering perineum with barrier cream helps prevent burning caused from irritation especially with incontinence associated with infection.

•  Vulvovaginitis can be treated with baking soda sitz bath (3 tablespoons) in a shallow tub bath daily for 1 week.

H.  Follow up.

1.  Follow-up culture to prove infection has resolved.

2.  If X-ray evaluation is positive or if infections are recurrent: urology consult preferably with pediatric urology group. Specialist can do postvoid ultrasound/other treatments to help patient learn to empty more effectively, correct any structural abnormalities if necessary.

3.  More thorough education of problems associated with infection will help family and provider.

I.  Complications.

1.  Serious risks, warrants effective management.

a.  Renal scarring, loss of renal function are most serious complications.

b.  Hypertension can result from renal scaring.

c.  Chronic cystitis can result in poor functional use of bladder, sometimes incontinence.

J.  Education.

1.  Understand signs/symptoms of UTIs and need for treatment/evaluation.

2.  Importance of daily antibiotic and/or stool softener (if prescribed); easy to forget to take medication.

3.  Understand dysfunctional elimination and its treatment, primarily need to empty bladder frequently to completion, to avoid constipation.

4.  Follow up critical in management of UTIs due to risk of renal sequelae.

VII. HEMATURIA

A.  Etiology/incidence.

1.  Gross hematuria (blood visible to naked eye) can originate from upper/ lower urinary tract.

2.  Causes: variable; include trauma, UTI, calculi, disorders of renal parenchyma, glomerulonephritis, Alport syndrome, hypercalciuria, benign exercise-induced hematuria, anatomic abnormalities, hemolytic uremic syndrome, sickle cell nephropathy, Henoch-Schönlein purpura, Goodpasture disease, lupus erythematosus, medication toxicity/chemotherapy, urethralgia, viral bladder infections, STDs (in postpubertal child).

B.  Occurrence.

1.  Common in children (unlike adults): rarely associated with neoplasm (1%).

2.  Microscopic hematuria found on routine health exam by dipstick urinalysis in 0.5–2% of school-aged children.

C.  Clinical manifestations.

1.  History important in determining diagnosis.

a.  Urinary frequency, fever, dysuria may indicate infection, most common cause of blood in school-aged child's urine.

b.  May describe recent trauma.

c.  Blood in other sites (i.e., sputum/stools) may indicate blood dyscrasia.

2.  Family history: familial diseases such as hypercalciuria, Alport syndrome, calculi, structural anomalies.

3.  Hemolytic uremic syndrome, one of most common causes of acute renal failure in children: preceded by gastroenteritis, bloody diarrhea.

a.  Question child regarding any joint pain, edema, tenderness.

b.  Any recent cold, upper respiratory symptoms? Sore throat/skin infection present?

4.  Acute nephritic syndrome: associated with gross hematuria, edema, hypertension, renal insufficiency.

a.  Post-streptococcal glomerulonephritis occurs 7–14 days after onset of strep infection.

b.  Winter months: commonly associated with strep pharyngitis.

c.  Summer months: more likely to be skin infections.

5.  When bleeding occurs, urine color is important.

a.  Brown/cola-colored urine: more likely from kidney.

b.  Red/pink urine: more likely from bladder.

c.  Red blood spotting at end of urinary stream/in underwear: most likely from urethra.

D.  Physical findings.

1.  Full-body exam to look for:

a.  Abdominal or renal mass.

b.  Presence of abdominal, CVA tenderness.

2.  Check child's underwear for blood, perineum for signs of trauma.

3.  Assess joints for edema, inflammation, tenderness.

4.  Edema of face, hands, or feet.

5.  Assess for signs of upper respiratory infection, pharyngitis, or other illness.

E.  Diagnostic tests.

1.  Urinalysis may reveal infection or proteinuria.