UTI in a Child

Casebank History
1

You are FY2 in general practice
A mom of 3 years old kid has come to the hospital with some concern.
Talk to mother and do management

Approach:

Greet and confirm identity
Take focused history, since when
Exclude red flags
Ask head to toe questions, bowel bladder, dehydration
BIRDDD, MAF
Do ICE

History information:

  • Her child is peeing a lot these days without drinking much.
  • Passes smelly urine, he was a bit feverish for last 3days.
  • No blood in the urine, bowel fine, feeding well, no rashes, no shy to light.
  • No medical condition or medication history, no allergy, up to date with jabs, development well, no significant birth history.
  • Baby is a bit fussy, irritates and cries while peeing, feels discomfort, he is potty trained.
  • Not playing that much.
  • Mother is worried.

Examination and investigation:

Take observation and head to toe. Routine blood , RBS, urea electrolytes, Urine dipstick, Xray of tummy
Dipstick shows leukocytes an nitrates

Mangement:

  • Explain mom that he is having an infection in the urine , which is very common
  • assure her
  • Tell her to give him plenty of fluid to drink
  • Maintain hygiene
  • Give calpol for fever and tummy pain
  • Offer antibiotic according to the hospital protocol: usually Trimethoprim for 3 days
    – Up to term: Nitrofurantoin
    – Man, Transgender with UTI: Trimethoprim
    – MAP(Morning After Pill): Contraindicated in pregnancy.
  • Follow up
  • Safety netting dehydration , vomiting high fever

Concern:

  1. Will it be as complicated as her last infection (chest)?
    Urine infection is caused by a different bacteria compared to chest infection it is less complicated.
  2. I have a son he doesn’t develop urine infection but me and daughter do, why is that?
    Because in female anatomy the distance between the balder and the outer environment is shorter i.e shorter urethra. The distance between the back passage and front passage is shorter they can get contaminated with feces.
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Patient Information:

Your name is Susan Smith. You are 3 years old. You noticed that your 3-year-old child, Ella Smith has been complaining of pain on passing urine. She passes a little urine each time because she is afraid of the pain. You have also noticed that the urine smell is strong and looks cloudy. She has had fever for the last 2- 3 days. She eats and drinks well. She wet her bed yesterday which is not typical of her. She has been having constipation for the past 3 days. She is up to date with all immunization.

Questions:

  • What is wrong with her?
  • What will you do for her?
  • Will you give her antibiotics?

Examiners Prompt:
Urine dipstick: Nitrites +ve, Leukocytes +ve

GRIPS

How can I help you?

HISTORY TAKING (Focused History)

  • Presenting Complaint
    FODPARA (for pain on passing urine)
    – Has she got a fever?
    – Have you noticed that her urine is smelly?
    – Have you noticed her urine is cloudy?
    – Has she had any vomiting?

  • Systemic review

  • Differential Diagnosis: Common infections

  • PMAFTOSA
    – Risk factors
    Abuse: Who else at home?
    Chemotherapy: Does she have any medical condition?
    DM: Does she have diabetes?
    – Pregnancy and birth history
    – Vaccination and development history

  • ICE
    I – Ideas: Is there anything you feel could be the cause of her symptoms?
    C – Concerns: Is there anything you are worried about?
    E – Expectation: at the end of consultation

  • Effects of Symptoms: Has this affected her in any way?

  • Summarize: Let me go through everything you have told me so far, to make sure I have understood correctly. So, you told me that… Is there anything I missed?

EXAMINATION

  • Observations: As a part of examination, I’d like to check her vitals;
    her BP – Pulse – Oxygen – RR – Temp
  • Specific Examinations
    – Abdominal examination I’d like to examine her tummy.
    – General examination and I’d like to perform a general examination of her body as well.
  • Bed-side tests: Urine dipstick then I’d like to perform a urine dipstick test once she can pass urine.

PROVISIONAL DIAGNOSIS

From what you’ve told me and after examinations and the urine dipstick, it seems that your child has a urinary tract infection.

PAUSE

DEFINE THE DIAGNOSIS

This is an infection of the waterworks, has she ever been diagnosed with UTI before?

MANAGEMENT

  • Routine investigations: We need to run some routine blood tests such as
    FBC - U&E - LFT - Blood sugar - Inflammatory markers
    and we need to perform a Urine culture so we will take a clean catch urine sample and send it to the lab to be tested.
  • Treatment/Decision
    – For now, we will give her some antibiotic for 3 days to clear the infection, which is Trimethoprim 50mg twice a day for 3 days.
    – Paracetamol could be given for the pain and fever as well.
    – You should encourage her to drink plenty of fluids and to eat plenty of fruits and vegetables; this will help with the constipation.
    – I need to take a second opinion from my seniors as well, and if they suggest any different treatment, I’ll let you know.
  • Safety netting
    – Please bring the child back;
    – If symptoms did not improve within 48 hours, as she would need further investigation which is ultrasound.
    – UTI may develop again in the future, and if this happens in the future bring her to the surgery early.
  • Leaflets: Before you go, I’ll bring you a leaflet about urinary tract infection.
  • Summarize: Let us recap what we have discussed…
  • Expectations: What do you think about what we have discussed?
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