Pediatrics Subject Collection: Genitourinary Tract

Screening for Genitourinary Abnormalities in Adolescent Males [ARTICLES]

Cavanaugh, R. M. — 2009-11-01

Objectives Objectives Introduction Taking the History Performing the Physical... Laboratory Investigation Management Suggested Reading After completing this article, readers should be able to: Describe the importance of screening for genitourinary problems in adolescent boys. Delineate the essential components of screening urology in adolescent boys. Explain when and how to perform sexually transmitted infection testing in adolescent boys. Counsel adolescent boys on sexuality-related issues. Introduction Objectives Introduction Taking the History ...

Increased Prevalence of Renal and Urinary Tract Anomalies in Children With Down Syndrome [ARTICLES]

Kupferman, J. C. — 2009-10-01

OBJECTIVE: The goal was to investigate the prevalence of renal and urinary tract anomalies (RUTAs) in a Down syndrome (DS) population. METHODS: Data were obtained from the New York State Congenital Malformation Registry (NYS-CMR) in this retrospective cohort study. The occurrence of RUTAs was assessed for children with and without DS who were born in NYS between 1992 and 2004. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each malformation. RESULTS: Between 1992 and 2004, 3832 children with DS and 3411833 without DS were born in NYS. The prevalence of RUTAs in the DS population was 3.2%, compared with 0.7% in the NYS population (OR: 4.5 [95% CI: 3.8-5.4]). Children with DS had significantly increased risks of anterior urethral obstruction (OR: 29.7 [95% CI: 4.0-217.7]), cystic dysplastic kidney (OR: 4.5 [95% CI: 1.5-14.1]), hydronephrosis (OR: 8.7 [95% CI: 6.8-11.0]), hydroureter (OR: 8.5 [95% CI: 3.5-20.4]), hypospadias (OR: 2.0 [95% CI: 1.4-2.9]), posterior urethral valves (OR: 7.1 [95% CI: 1.8-28.8]), prune belly syndrome (OR: 11.9 [95% CI: 1.6-85.4]), and renal agenesis (OR: 5.4 [95% CI: 2.8-10.4]). There was no significantly increased risk of ectopic kidney (OR: 1.6 [95% CI: 0.2-11.2]) or ureteropelvic junction obstruction (OR: 1.4 [95% CI: 0.2-9.9]) in the DS population. CONCLUSION: Children with DS have significantly increased risks of RUTAs.

Implications of 99mTc-DMSA Scintigraphy Performed During Urinary Tract Infection in Neonates [ARTICLES]

Siomou, E. — 2009-09-01

OBJECTIVE: To evaluate prospectively whether normal scintigraphic results during urinary tract infections (UTIs) in neonates were predictive of the absence of dilating vesicoureteral reflux (VUR) (grade [≥]III) and permanent renal damage (PRD). METHODS: Term neonates with a first symptomatic, community-acquired UTI participated in the study. Urinary tract ultrasonography and technetium-99m-labeled dimercaptosuccinic acid (99mTc-DMSA) scintigraphy were performed within 72 hours after diagnosis and voiding cystourethrography within 1 to 2 months. DMSA scintigraphy, to determine the development of PRD, was repeated 6 months after UTI. RESULTS: Seventy-two neonates (144 renal units) were enrolled. Acute pyelonephritis was diagnosed through early DMSA scintigraphy in 19% of renal units, VUR in 22%, and grade [≥]III VUR in 13%. The majority (71%) of renal units with grade [≥]III VUR had normal early DMSA scintigraphic results. The sensitivity and specificity of abnormal early DMSA scintigraphic results to predict grade [≥]III VUR were 29% (95% confidence interval: 11%-55%) and 82% (95% confidence interval: 74%-88%), respectively. PRD was found in 7% of renal units, all of which had abnormal early DMSA scintigraphic results. PRD was significantly more frequent among renal units with grade [≥]III VUR than among nonrefluxing renal units (P < .05). CONCLUSIONS: Normal early DMSA scintigraphic results for neonates with symptomatic UTIs were helpful in ruling out later development of PRD but were not predictive of the absence of dilating VUR. To rule out dilating VUR, voiding cystourethrography may be required.

Pediatric Urolithiasis: Clinical Predictors in the Emergency Department [ARTICLES]

Persaud, A. C. — 2009-09-01

OBJECTIVE: The objective of this study was to identify factors that predict the presence of urolithiasis detected with unenhanced computed tomography (UCT) in children. METHODS: A retrospective study of all subjects <21 years of age who presented to the emergency department at Akron Children's Hospital and underwent UCT of the abdomen between January 2002 and December 2005 was performed. Demographic, clinical, diagnostic, treatment, and disposition data were abstracted by using a standardized form. Univariate and logistic regression analyses of factors associated with urolithiasis were performed. RESULTS: A total of 339 eligible patients were identified, with 110 cases of urolithiasis detected with UCT for 95 individual patients. The mean age of the study patients was 14.4 years; 72 patients (66%) were female. In 17 cases (15%) of urolithiasis, initial urinalysis results were negative for blood. Fifty-seven stones (51.8%) were ureteral, 26 (23.6%) were renal, and 4 (3.6%) were in the bladder. Among children who did not have a stone identified through UCT, 23 cases (10%) of potentially significant, alternative diagnoses were identified. A history of urolithiasis, a history of nausea and vomiting, the presence of flank pain on examination, and >2 red blood cells per high-power field in urine microscopy were positively associated with urolithiasis. A history of fever or dysuria and costovertebral angle tenderness on physical examination were inversely associated with urolithiasis on UCT scans. CONCLUSIONS: UCT plays an important role in the diagnostic evaluation of children with flank pain. Approximately 15% of children with urolithiasis do not have hematuria.

Short Stature in a Population-Based Cohort: Social, Emotional, and Behavioral Functioning [ARTICLES]

Lee, J. M. — 2009-09-01

OBJECTIVE: The goal was to determine whether there were significant differences between children of normative versus short stature in behavioral functioning and peer relationships, according to teacher and child reports. METHODS: The study included 712 boys and girls in the sixth grade, from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. Main outcome measures included Achenbach Teacher's Report Form internalizing, externalizing, and total scores; Children's Depression Inventory scores (child report); Life Orientation Test-Revised scores (child report); Child Behavior with Peers questionnaire asocial with peers, excluded by peers, and peer victimization subscale scores (teacher report); peer social support and victimization scores (child report); and relationships with peers score (teacher report). In bivariate comparisons, these outcomes were compared for children of relatively short (height of <10th percentile) versus nonshort (height of [≥]10th percentile) stature, and effect sizes were calculated. Multivariate linear regression models adjusted for maternal education, income/needs ratio, race, and gender. RESULTS: Effect sizes ranged from 0.00 to 0.35. Short children reported marginally higher levels of self-perceived peer victimization, compared with their nonshort peers. There were no significant differences in the rest of the outcomes for children of short versus nonshort stature, in either unadjusted or adjusted models. CONCLUSION: Although short children from a population-based sample reported marginally higher levels of self-perceived peer victimization, they did not differ from their nonshort peers in a range of social, emotional, and behavioral outcomes.

Empiric Use of Potassium Citrate Reduces Kidney-Stone Incidence With the Ketogenic Diet [ARTICLES]

McNally, M. A. — 2009-08-01

OBJECTIVE: Kidney stones are an adverse event with the ketogenic diet (KD), occurring in [~]6% of children who are started on this therapy for intractable epilepsy. Potassium citrate (Polycitra K) is a daily oral supplement that alkalinizes the urine and solubilizes urine calcium, theoretically reducing the risk for kidney stones. METHODS: Children who started the KD from 2000 to 2008 at Johns Hopkins Hospital, with at least 1 month of follow-up, were evaluated (N = 313). From 2000 to 2005, children were treated with daily Polycitra K at 2 mEq/kg per day only in the setting of identified hypercalciuria, whereas, since 2006, it has been started for all children empirically at KD onset. RESULTS: Polycitra K was administered to 198 children preventatively overall, 4 (2.0%) of whom developed kidney stones, compared with 11 (10.5%) of 105 who did not receive Polycitra K (P = .003). Two children since 2006 refused Polycitra K, 1 of whom developed a kidney stone. Successful empiric administration of Polycitra K at KD onset resulted in a kidney-stone incidence of 0.9% (1 of 106) compared with administration only because of hypercalciuria, 6.7% (13 of 195; P = .02). Polycitra K resulted in less acidic urine (mean pH: 6.8 vs 6.2; P = .002) but not reduced serum acidosis. No adverse effects of oral citrates were reported. CONCLUSIONS: Oral potassium citrate is an effective preventive supplement against kidney stones in children who receive the KD, achieving its goal of urine alkalinization. Universal supplementation is warranted.

Management of Childhood Onset Nephrotic Syndrome [SPECIAL ARTICLES]

Gipson, D. S. — 2009-08-01

The therapeutic approach to childhood nephrotic syndrome is based on a series of studies that began with an international collaborative effort sponsored by the International Study of Kidney Disease in Children in 1967. The characteristics of children presenting with nephrotic syndrome have changed over recent decades with greater frequency of the challenging condition focal segmental glomerulosclerosis and a greater prevalence of obesity and diabetes mellitus, which may be resistant to glucocorticoids in the former and exacerbated by long-term glucocorticoid therapy in the latter 2 conditions. The Children's Nephrotic Syndrome Consensus Conference was formed to systematically review the published literature and generate a children's primary nephrotic syndrome guideline for use in educational, therapeutic, and research venues.

Urinary Tract Infections in 1- to 3-Month-Old Infants: Ambulatory Treatment With Intravenous Antibiotics [ARTICLES]

Dore-Bergeron, M.-J. — 2009-07-01

OBJECTIVE: The goal was to examine the feasibility of outpatient management for 1- to 3-month-old infants with febrile urinary tract infections. METHODS: A cohort study was performed with all children 30 to 90 days of age who were evaluated for presumed febrile urinary tract infections in the emergency department of a tertiary-care pediatric hospital between January 1, 2005, and September 30, 2007. Patients were treated with intravenously administered antibiotics as outpatients in a day treatment center unless they met exclusion criteria, in which case they were hospitalized. RESULTS: Of 118 infants included in the study, 67 (56.8%) were admitted to the day treatment center and 51 (43.2%) were hospitalized. The median age of day treatment center patients was 66 days (range: 33-85 days). The diagnosis of urinary tract infection was confirmed for 86.6% of patients treated in the day treatment center. Escherichia coli was identified in 84.5% of urine cultures; 98.3% of isolates were sensitive to gentamicin. Six blood cultures (10.3%) yielded positive results, 5 of them for E coli. Treatment with intravenously administered antibiotics in the day treatment center lasted a mean of 2.7 days. The mean number of visits, including appointments for voiding cystourethrography, was 2.9 visits. The rate of parental compliance with day treatment center visits was 98.3%. Intravenous access problems were seen in 8.6% of cases. Successful treatment in the day treatment center (defined as attendance at all visits, normalization of temperature within 48 hours, negative control urine and blood culture results, if cultures were performed, and absence of hospitalization from the day treatment center) was obtained for 86.2% of patients with confirmed urinary tract infections. CONCLUSIONS: Ambulatory treatment of infants 30 to 90 days of age with febrile urinary tract infections by using short-term, intravenous antibiotic therapy at a day treatment center is feasible.

Age-Related Renal Parenchymal Lesions in Children With First Febrile Urinary Tract Infections [ARTICLES]

Pecile, P. — 2009-07-01

OBJECTIVE: The aim of this study was to define the association between age and the occurrence of acute pyelonephritis and renal scars. METHODS: Between 1999 and 2002, all children 0 to 14 years of age consecutively seen with a first febrile urinary tract infection were enrolled in the study. 99mTc-Dimercaptosuccinic acid renal scintigraphy was performed within 5 days after admission for the detection of renal parenchymal involvement. The presence of vesicoureteral reflux was assessed by using cystography performed 1 month after the infection. If the acute scan results were abnormal, then follow-up 99mTc-dimercaptosuccinic acid scanning was performed after 6 months, to assess the frequency of scars. RESULTS: A total of 316 children were enrolled in the study (190 children <1 year, 99 children 1-4 years, and 27 children 5-14 years of age). 99mTc-Dimercaptosuccinic acid scintigraphy revealed that 59% of the children had renal involvement in the acute phase of infection. The frequency of kidney involvement in infants <1 year of age (49%) was significantly lower than that in children 1 to 4 years of age (73%) and >5 years of age (81%). Of the 187 children with positive acute 99mTc-dimercaptosuccinic acid scan results, 123 underwent repeat scintigraphy after 6 months. Renal scars were found for 28% of children <1 year, 37% of children 1 to 4 years, and 53% of children 5 to 14 years of age. No significant differences in the frequency of scars and the presence or absence of vesicoureteral reflux were noted. CONCLUSIONS: Our findings confirm that acute pyelonephritis and subsequent renal scarring occur only in some children with first febrile urinary tract infections. Children <1 year of age with febrile urinary tract infections have a lower risk of parenchymal localization of infection and renal scarring.

Nocturnal Enuresis and Overweight Are Associated With Obstructive Sleep Apnea [ARTICLES]

Barone, J. G. — 2009-07-01

OBJECTIVE: The objective of this study was to examine the relationship of obstructive sleep apnea (OSA), body weight (BMI percentage [BMI%]), and monosymptomatic nocturnal enuresis (MNE) in children. METHODS: A case-control study design was used. All children were 5 to 15 years of age; case patients were recruited from a comprehensive sleep disorders center (n = 149), and control subjects were recruited from a general pediatric practice in the same catchment area (n = 139). Case patients were subject to overnight polysomnograms and grouped into apnea severity categories (minimal, mild, moderate, or severe) on the basis of respiratory disturbance index and minimum arterial oxygen saturation levels. Data for all children included age; gender; height; weight; and history of MNE, snoring, diabetes, nasal allergies, and/or enlarged tonsils. BMI% was used to group children into weight categories as suggested by the Centers for Disease Control and Prevention (underweight, normal weight, at risk for overweight, and overweight). Two age groupings were created (5-10 years and 11-15 years). Descriptive statistics provided the prevalence of OSA, weight category, and MNE among case patients and control subjects. Cross-tabulations examined the relationship of severity of OSA with weight categories and MNE, stratified by age and gender. A series of logistic regression models explored the interrelationship of the grouping variables. RESULTS: A large majority (79.9%) of control subjects were at risk for overweight, and a large majority (80.0%) of children with MNE also had some degree of OSA. Logistic regression demonstrated that both MNE (odds ratio: 5.29) and overweight (odds ratio 4.16) were significantly associated with OSA but not with each other. CONCLUSIONS: Overweight and MNE are associated with OSA but not with each other. OSA should be considered in overweight children with MNE, especially when they display other symptoms of OSA or fail to respond to standard MNE treatment programs.