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PEDIATRICS IN DAILY PRACTICE: URINARY TRACT INFECTIONS/OBESITY
Audio-Digest Family Practice
Volume 61, Issue 14
April 14, 2013

Febrile UTI in Infants and Young Children – Andrea Marmor, MD
Obesity in Adolescents – Lynette Leighton, MD

  
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Family Practice Program Info  Accreditation InfoCultural & Linguistic Competency Resources

Pediatrics in Daily Practice: Urinary Tract Infections/Obesity

From the University of California, San Francisco, School of Medicine Annual Review in Family Medicine: Controversies and Challenges in Primary Care

Educational Objectives

The goal of this program is to improve management of urinary tract infections (UTIs) in infants, and of obesity in children and adolescents. After hearing and assimilating this program, the clinician will be better able to:

1. Assess likelihood of UTI in infants, based on age and risk factors.

2. Select appropriate screening tests for UTI based on risk.

3. Detect significant urinary tract abnormalities using imaging studies such as ultrasonography and voiding cystourethrography.

4. Discuss predictors of and contributing factors to childhood obesity.

5. Counsel parents and children about changing habits and lifestyle for weight loss.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Febrile UTI in Infants and Young Children

Andrea Marmor, MD, Associate Professor of Pediatrics, University of California, San Francisco, School of Medicine

Introduction: children with fever without source (FWS) may have urinary tract infection (UTI); 75% of young infants with UTI have involvement of upper urinary tract (pyelonephritis); bacteremia common (15%-20%) in infants <30 days of age

American Academy of Pediatrics (AAP) guidelines from 2011: use clinical factors to determine whether risk for UTI >1% to 2%; diagnosis requires positive urinalysis (UA) and culture containing >50,000 colonies/mL; if infant appears sick or toxic and requires antibiotics, collect urine by catheterization and give antibiotics; if antibiotics not immediately required, then assess likelihood of UTI (if likelihood <2%, then testing not needed; if likelihood >2%, collect urine)

Probability of UTI: girls with FWS — risk >2% with presence of 2 additional risk factors (ie, white ethnicity, age <12 mo, body temperature >39°C) or fever lasting >2 days; boys with FWS — all uncircumcised boys have risk >2% and should be tested for UTI; circumcised boys at lower risk for UTI and must have all 3 additional risk factors; infants <3 mo of age with FWS — at high risk for UTI and should be tested; infants >3 mo of age — in girls 3 mo to 2 yr of age with FWS, risk for UTI 5% to 10%; in uncircumcised boys, rate of UTI drops significantly after 3 mo and again after 6 mo of age (UTI rare at 1 yr of age); UTI extremely rare in circumcised boys >3 mo of age; height of fever — higher fever (eg, 39° lasting >2 days) associated with greater likelihood of UTI (especially in children >3 mo of age); ethnicity — in girls, white ethnicity associated with higher risk; in boys, nonblack ethnicities associated with higher risk (even when controlled for circumcision status)

Speaker’s recommendations for testing children with FWS for UTI: 5% probability reasonable threshold, unless infant at high risk (eg, immunosuppressed, premature); infants <3 mo of age with fever >38°C for any period of time should be tested; UTI unlikely in children 3 to 24 mo of age, unless fever >39°; test girls only if fever persists >2 days; test uncircumcised boys <6 mo of age, or <12 mo of age if risk factors present; UTI rare in circumcised boys >3 mo of age (test if child appears sick and has other risk factors); catheter specimen recommended for culture

Bag-collected urine: UA — specificity of leukocyte esterase testing lower (more false positives) compared to catheter-collected urine, but sensitivity similar; negative UA of bag specimen more helpful than positive result (eg, infants at lower end of risk stratification with negative UA can be sent home); culture — gold standard; false positives can occur from contamination from, eg, perineum, diaper, bag removal, technique; false negatives depend on threshold used to determine positivity (speaker usually uses threshold of 100,000 colonies/mL; chance for false positives and negatives equal [15%]); predictive values of culture — with positive culture, probability increases from 5% to 23% in child with low prior probability (eg, older circumcised boy with fever for 1.5 days); negative predictive value <1%; in child with moderate prior probability, higher positive and slightly higher negative predictive values; in child with high prior probability, positive predictive value 60% (negative predictive value 4%); conclusions — in low-probability children, negative culture of bag specimen confidently rules out UTI (positive culture suggests 25% chance of having UTI [treatment with antibiotics for few days reasonable]); in high-probability children, negative bag culture does not rule out UTI with sufficient certainty

Testing: high-risk infantseg, infants <6 mo of age, with systemic illness, or with history of 2 previous UTIs (requiring referral to urologist); obtain catheter specimen; if UA positive, treat for UTI; low- or moderate-risk infants — eg, infants >6 mo of age who appear well, with (perhaps) first UTI; perform bag collection; if UA negative, no further work-up required; if UA positive, options include collecting urine by catheterization for culture or sending bag specimen for culture (perform catheterization if significant downsides of false positives or negatives exist)

Action statement from AAP: positive UA and culture of 50,000 colonies/mL required for UTI; assumptions — 1) chance of negative leukocyte esterase and true UTI very low; false negatives tend to occur in patients who have either false-positive culture or asymptomatic bacteriuria (not true UTI); concluded that true sensitivity of leukocyte esterase higher (negative result confidently rules out UTI); 2) diagnosing asymptomatic bacteriuria (ie, urine culture positive but would clear spontaneously) as UTI does more harm than good; prioritizes benefits of not overtreating over the possible harm of missing UTI; speaker feels assumptions do not hold for very young infants or infants at high risk for complications from UTI

Speaker’s recommendations: high-risk children — collect catheter specimen for UA and obtain culture; >10,000 colonies/mL in clean catheter specimen considered positive; low- or moderate-children — urine collection by bag or catheter acceptable; if UA negative, no further work-up required; if UA positive, choose between sending bag specimen for culture, or collecting catheter specimen for culture; bag specimen should be clean, and high threshold should be used to minimize false positives

Treatment of febrile UTI in children: know local microbiology and sensitivities; Escherichia coli common cause and sensitive to first-generation cephalosporins (eg, cephalexin); evidence suggests oral antibiotics sufficient for most infants; treat infants <2 mo of age and older infants not sufficiently taking oral antibiotics with intravenous (IV) antibiotics; give first dose IV or intramuscularly and let parents pick up oral course (10 days sufficient)

Imaging studies: ultrasonography (US) at earliest convenience recommended for all infants with first-time febrile UTI (more urgently if infant not responding well to treatment); voiding cystourethrography (VCUG) only if US abnormal or if infant presents with second UTI; prophylactic antibiotics not recommended; goals of imaging studies after first UTI — find any significant urinary tract abnormalities (eg, duplicated ureter, urinary tract obstruction); prevent recurrent UTI and damage to kidneys

Posterior urethral valve: most identified on prenatal US; manifestations — grossly enlarged kidneys; distended bladder; failure to thrive and poor growth; systemic illness; may present with urosepsis; presents early with severe complications; 15% to 20% progress to end-stage renal disease

Vesicoureteral reflux (VUR): retrograde flow of urine up to ureters or kidneys during voiding; most common urinary tract abnormality in children; 50% of infants <3 yr of age with first UTI have some degree of reflux; most cases low grade; grade I — reflux into ureter; grade II — reflux into kidney; grade III — some dilation; grade IV — gross dilation, including renal calyces; 95% of VUR (30%-50% in children) grades I, II, or III; grades IV and V rare in children with first-time UTI, but occur in children with end-stage renal disease or complications from UTI

Options for imaging: US — operator dependent; useful for obstruction, growth abnormalities, and high-grade reflux (sensitivity 85%); in relatively low-risk patient, normal US reassuring (no follow-up VCUG required); VCUG — difficult to perform; traumatic for infants and families; high radiation; more sensitive and specific; test of choice for posterior urethral valves

Effects of VUR: no difference in risk for recurrence of UTI between children with or without reflux; renal scarring — more likely in infants with high-grade (grade IV or V) VUR and recurrent UTIs; however, not related to number or severity of UTIs or presence or absence of VUR; tends to be nonprogressive and likely represents damage that occurred prenatally; end-stage renal disease — rare; 5% to 12% of infants and children with end-stage renal disease have history of reflux nephropathy; risk for development after first episode of pyelonephritis extremely low

Prophylactic antibiotics: no effect on scarring, compared to surgical repair of reflux (Cochrane review saw similar rates of recurrent UTI); no significant effect on UTI recurrence or renal scarring in children with first-time UTI (with or without reflux); several studies show trend toward more UTIs and predominance of more resistant organisms with use of antibiotics

Identifying reflux and severe abnormalities: retrospective review found no change in UTI recurrence or detection of high-grade VUR after enactment of more selective imaging policy, but amount of imaging studies and use of prophylactic antibiotics decreased; other study of 400 children with first-time UTI using selective imaging strategy (ie, VCUG after abnormal US) found that only 7% of children had abnormal US, and 13% of those had scarring (concluded that selective imaging strategy does not impair ability to find significant abnormalities); AAP action statement states that VCUG should not be performed routinely, but may be considered after abnormal US or recurrent UTI; US — speaker recommends after first UTI in infants <3 mo of age, and for infants >3 mo of age who have recurrent UTI; US for infants who do not respond well to treatment or remain febrile after 48 hr; VCUG — indicated in infants with evidence of significant obstruction of urinary tract; consider in infants with recurrent UTI and reflux on US only when possible correction of reflux warranted

Summary: consider pyelonephritis or UTI in all infants <2 yr of age with FWS; consider testing for UTI if prior probability >5% or risk for severe infection high (includes infants <3 mo of age regardless of sex or circumcision status); in infants 3 to 24 mo of age, consider circumcision status and clinical factors (eg, height and duration of fever); imaging studies — perform US in cases of complicated or recurrent UTI; consider after first UTI in high-risk infant or infant <3 mo of age; consider VCUG if findings would change management; antibiotics not recommended for prevention of recurrent UTIs or renal scarring even in patients with known or suspected reflux

Obesity in Adolescents

Lynette Leighton, MD, Assistant Professor, Department of Family and Community Medicine, University of California, San Francisco, School of Medicine

Body mass index (BMI) and adolescents: because boys and girls grow at different rates, no specific BMI number used (important to track numbers at every clinical visit); important to watch growth curve; BMI different for every age group; normal weight — BMI in fifth to 85th percentile; lower than fifth percentile concerning; overweight — BMI in 85th to 95th percentile; obesity — BMI above 95th percentile

Socioeconomic aspects: study of 2008 data saw higher prevalence in American Indians, non-Hispanic blacks, and Mexican Americans; 12.4% of preschool-aged children obese (higher in low-income families)

Predictors of obesity in adulthood: age — highest rate of predictability at age 16 and 17 yr; severity — severe obesity during childhood and adolescence predictive of severe obesity (BMI >40) in adulthood; 75% of severely obese teenagers and 8% of moderately obese teenagers become severely obese adults; parental obesity — study found 80% of obese children 10 to 14 yr of age had at least one obese parent; children (even children at healthy weight) who have obese parents 2 times more likely to be obese as adults

Cycle of childhood obesity: increased screen time (eg, watching television, playing video games) and quick, easy foods lead to small weight gains, making exercise more uncomfortable and less attractive; physical activity becomes displaced; physical activity painful for moderate and severely obese children (due to, eg, body changes and alignment issues); depressed children more likely to become obese, and obese children more likely to become depressed

Contributing factors: environmental — German study attributed 78% of all childhood obesity to environmental factors; >3 hr/day of screen time highly correlated with obesity; diet; fewer family meals; decreased physical activity; decreased sleep; neighborhoods with fewer sidewalks and playgrounds; genetic — up to 50% of variation in body types that predisposes some individuals to weight gain; melanocortin-4 receptor mutation found in 4% of severely obese individuals; endocrine — important to check thyrotropin, track growth, and look for signs of Cushing disease; associated with <1% of obese children and adolescents; typically associated with mild obesity; metabolic programming — cells of fetus change to adapt to environment; large for gestational age and small for gestational age infants have increased insulin resistance later in life; mothers with more weight gain or gestational diabetes have higher rates of obesity, as do their children; children born to mothers who had previously lost significant amount of weight after gastric bypass surgery had lower rates of obesity

Complications of childhood obesity: endothelial destruction; hypertension; high cholesterol; endocrine deficiencies; type 2 diabetes; polycystic ovary syndrome; slipped capital femoral epiphysis; Blount disease; fractures; flat feet; gallstones; steatohepatitis; asthma; sleep apnea; low self-esteem; depression; diabetes — positive screening test for diabetes and high cholesterol more likely in adolescents who watch 3 hr of television per day; adolescents develop complications (eg, abnormal cholesterol) rapidly; 13% have microalbuminuria or hypertension; AAP recommends aggressive early treatment to slow complications; also recommends tight glycemic control (hemoglobin [Hb] A1c <7%)

Management: consider medications if no improvement after 3 mo of lifestyle modifications; for symptomatic patients with type 2 diabetes, consider starting medications at time of diagnosis; surgery (discuss with patients)

Screening: diabetes — screen obese patients 2 to 20 yr of age with BMI above 95th percentile; start screening children above 85th percentile at age 10 yr; check Hb A1c or fasting glucose every 2 yr; hypertension — lower threshold for children and adolescents, compared to adults; fasting lipids — screen all adolescents with BMI above 95th percentile; start screening children above 85th percentile at age 10 yr; screen every 3 to 5 yr; liver function testing — screen every 2 yr

Treatment: data limited; focus on behaviors that affect energy intake and expenditure; track BMI to identify weight gain early; assess risk factors; perform clinical interventions routinely; implement staged approach; assess family habits; assess nutrition; screen for food insecurity; understand familial and household culture; assess activity level; assess outdoor safety; interventions — be consistent; talk with family; staged approach — stage 1) prevention; check BMI at every visit; discuss nutrition with family; stage 2) structured weight management; stages 3 and 4) referrals; consider, eg, endocrinologist, social worker, psychiatrist, athletic trainer; tertiary care intervention (eg, bariatric surgery); motivational interviewing — goal to change behaviors; assess patient’s readiness to change; scare tactics ineffective; educate patients about effects of obesity; counseling for behavioral change — food logs helpful; focus on stimulus (eg, chips or sodas) control and on behaviors rather than limiting intake or focusing on weight loss; contracting; positive reinforcement; in mildly obese adolescents, focusing on weight maintenance helpful; for patients with BMI above 95th percentile, setting healthy goals important; losing 1 to 2 lb per month realistic goal for most patients; more aggressive weight loss (eg, 1-2 lb per week) may be more appropriate for obese patients with comorbidities; online goal trackers available; counsel about increasing physical activity and decreasing sedentary activity; to avoid injury, consider supervised or organized physical activity in severely obese patients (may start with nonweight-bearing activities, eg, swimming)

Prevention: high- and low-intensity interventions; change habits and lifestyles; target children at age 6 to 12 yr

Acknowledgments

Drs. Marmor and Leighton spoke in San Francisco, CA, at Annual Review in Family Medicine: Controversies and Challenges in Primary Care, presented December 3-4, 2012, by University of California, San Francisco, School of Medicine. Visit www.cme.ucsf.edu/cme/ for information about upcoming courses from this sponsor. The Audio-Digest Foundation thanks the speakers and the UCSF School of Medicine for their cooperation in the production of this program.

Suggested Reading

No authors listed: Imaging after a first febrile UTI in infants and children: less is more? J Paediatr Child Health. 2012 Oct;48(10):945; Alexander DS et al: The association between recreational parks, facilities and childhood obesity: a cross-sectional study of the 2007 National Survey of Children’s Health. J Epidemiol Community Health. 2013 Jan 30. [Epub ahead of print]; Casazza K et al: Myths, presumptions, and facts about obesity. N Engl J Med. 2013 Jan 31;368(5):446-54; Copeland KC et al: Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics. 2013 Feb;131(2):364-82; Edmonds EW, Templeton KJ: Childhood Obesity and Musculoskeletal Problems: Editorial Comment. Clin Orthop Relat Res. 2013 Jan 26 [Epub ahead of print]; Hunziker M et al: Incidence of febrile urinary tract infections in children after successful endoscopic treatment of vesicoureteral reflux: a long-term follow-up. J Pediatr. 2012 Jun;160(6):1015-20; Katz DL: Childhood obesity trends in 2013: mind, matter, and message. Child Obes. 2013 Feb;9(1):1-2; Lee JH et al: Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection? Acta Paediatr. 2012 Mar;101(3):e105-9; Nemet D et al: Effects of a combined intervention for treating severely obese prepubertal children. J Pediatr Endocrinol Metab. 2013;26(1-2):91-6; Pennesi M et al: Managing children under 36 months of age with febrile urinary tract infection: a new approach. Pediatr Nephrol. 2012 Apr;27(4):611-5; Roberts KB: Revised AAP Guideline on UTI in Febrile Infants and Young Children. Am Fam Physician. 2012 Nov 15;86(10):940-6; Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB: Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep;128(3):595-610; Sharifi M et al: Evaluating the implementation of expert committee recommendations for obesity assessment. Clin Pediatr (Phila). 2013 Feb;52(2):131-8; Tullus K: What do the latest guidelines tell us about UTIs in children under 2 years of age. Pediatr Nephrol. 2012 Apr;27(4):509-11; Young RP, Hopkins RJ: Genetic risk in childhood obesity: implications for clinical practice. JAMA Pediatr. 2013 Feb 1;167(2):196-8.


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