This review is consistent with the available evidence that there exists a strong relationship between chronic pyelonephritis and vesicoureteral reflux.17,18 We found no significant differerence in the prevalence of reflux or pyelonephritis, however, between the school-age and the preschool-age children, suggesting that pyelonephritis is not less frequent in the preschool child and that if there is an age when discovery and correction of reflux will prevent chronic pyelonephritis, it is probably before age 5. In looking at Table I, one is tempted to discount the Newcastle Studies since it was in this group that the greatest number of children with pyelonephritis was discovered. With this study deleted, however, the differences are still not statistically significant. There is a suggestion that if we could more closely analyze the preschool group there might be an age at which, if reflux were discovered and treated, pyelonephritis might be prevented.
A careful review of the data of Winberg et al. related to symptomatic urinary tract infection indicates that reflux in infants is closely correlated with pyrexia and acute pyelonephritis, that it occurs with greater frequency in infants than in older children, and that renal scarring (almost always associated with reflux) is progressive in a significant number of patients.19 This study lends substance to the allegation that reflux and bacteriuria may cause progressive renal scarring and that further effort should be encouraged in screening the early preschool-age group. While the methodology and logistics of screening in this group are difficult, home culture programs utilizing parents and low-cost materials may make it feasible.20
The cost-benefit aspects of screening are even harder to assess because data are either lacking or constantly changing. At the present time we do not know the natural history of either reflux or chronic pyelonephritis. It has been implied that chronic pyelonephritis has been overdiagnosed as a cause of end-stage renal failure.21 The greatest cost to the public from chronic urinary tract infection may be related to morbidity and particularly related to lost work days. It is quite apparent that most screening programs grossly underestimate the cost of screening, frequently listing only disposable supplies and technician time and failing to account for the tremendous amount of physician time required in planning and evaluation. Two members of this committee (P.M. and F.B.) have been directly involved in screening programs and can confirm this high cost.
There are several intriguing aspects of screening which may have a high yield but which have not yet been tested. The screening of children with genital defects or of defects in other organ systems may yield a higher prevalence of correctable pathology. Children from lower socioeconomic groups frequently have not had the benefit of routine pediatric care and screening programs may be of some advantage in this group. A recent proposal has been to look at children with high absence rates from school.22 Although there are not sufficient data from this study, the idea is intriguing and this group may provide a higher yield.
Our results indicate that there are no data which clearly show that screening of school children for bacteriuria results in decreased morbidity or mortality. It has been suggested by the National Kidney Foundation Committee that morbidity represents sufficient justification for screening, but they present no objective data to indicate a lessened morbidity in those screened.8
Since morbidity implies awareness of the disease by the patient, the principal method of insuring a decrease in morbidity should be to educate the public in the symptoms of urinary tract infection and the medical profession in the appropriate evaluation and treatment. This would eliminate those major concerns expressed by Dodge and West of a lack of consumer and physician motivation.23 We agree fully with the priorities that are set by the National Kidney Foundation Committee and these are included in our recommendations.
- Copyright © 1977 by the American Academy of Pediatrics