FREQUENCY
OF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSY
Rahida Karim, Jahanzeb Khan Afridi,
Ahmad Saud Dar, Muhammad Batoor Zaman, Afnan Amjad
Best services for writing your paper according to Trustpilot
STRUCTURED
ABSTRACT
Introduction:
Cerebral palsy (CP)
occurs in about 2.0–2.5 per 1000 live births. Rates have remained fairly stable
over the past 40 years. In many children, the cause of CP is unknown. A child
with cerebral palsy is having a difficulty in neuromotor control, a
nonprogressive brain lesion, and an injury to the brain that occurred before it
was fully matured. The morbidity associated with CP comprises of seizure
disorders, mental retardation, abnormalities of vision, problems with
respiratory muscle, and lower urinary tract dysfunctions. Possible reasons for
the propensity to urinary tract infections include vesicoureteral reflux and
incomplete bladder emptying resulting from detrusor hyperreflexia and detrusor
sphincter dyssynergia.
Materials
and Methods: this study was conducted in the department of
pediatrics Hayatabad Medical Complex, Peshawar from 01.01.2016 to 31.12.2016. Through
a descriptive cross-sectional study design, a total of 113 children with cerebral
palsy, selected in a consecutive sampling and med-stream urine specimen was
collected for urine culture to detect UTI.
Results:
The mean age group of
the sample was 7.8 + 3.6 years. 68.1% of the sample was male and 31.9% were female gender. In
our study, UTI was recorded in 32.7% of patients with more propensities towards
age group above 5 years (p < 0.001)
Conclusion: The present study would sum up to
indicate that there is a
high prevalence of UTI among children with CP, which may be due to severe
immobility. Therefore, concerted
efforts should be put in place for effective physiotherapy aimed at attaining the greatest possible
mobility and independence
among children with CP.
Key
Words: Urinary Tract Infection, Urine Culture, Pyrexia, Cerebral Palsy.
INTRODUCTION
Cerebral palsy (CP) occurs in about
2.0–2.5 per 1000 live births1. Rates have remained fairly stable
over the past 40 years. In many children, the cause of CP is unknown. Risk
factors must be distinguished from causes. Known risk factors include low birth
weight and prematurity, for example, infants of very low birth weight are 20–80
times more likely to have CP than infants of a birth weight of more than 2500 g2.
It is likely that in a significant proportion of children, CP results from a
series of events or 'causal pathways' that culminate in motor damage3.
Each year in the United States,
approximately 1 in 278 infants is diagnosed with CP4. A similar
study conducted in Pakistan, regarding incidence of CP showed that out of a
sample of 160 cases with abnormalities of tone, posture and movement, 75%
(n=120) were diagnosed as having CP5. While CP was initially attributed
to injuries resulting from birth asphyxia, recent studies have shown that in
actuality it includes a myriad of factors. Injury to the developing brain may
be prenatal, natal or postnatal. Risk factors now known to play a role in the
development of CP include multiple gestation, gender, infection, prematurity
and low birth weight as well as genetic determinants6.
A child with cerebral palsy is having
a difficulty in neuromotor control, a nonprogressive brain lesion, and an
injury to the brain that occurred before it was fully matured. The morbidity
associated with CP comprises of seizure disorders, mental retardation,
abnormalities of vision, problems with respiratory muscle, and lower urinary
tract dysfunctions7. The lower urinary tract dysfunctions are
manifested symptomatically as urinary incontinence, urgency, frequency,
hesitancy, and urinary tract infection7.
Possible reasons for the propensity to
urinary tract infections include vesicoureteral reflux and incomplete bladder
emptying resulting from detrusor hyperreflexia and detrusor sphincter
dyssynergia. In addition, the impaired cognition and the inability to
communicate bladder fullness and the need to void, together with an impaired
mobility, may also explain the tendency to urinary retention and the attendant
risk of urinary tract infections and is reported in a study in 38.5% of CP
children in a study by Anígilájé EA et al8.
The present study is designed to
determine the frequency of UTI in children presenting cp. As mentioned above,
the CP children are very prone to Urinary tract abnormalities and neurogenic
bladder if leads to reflux can cause UTI among children with CP. This study
will provide us with local magnitude of the problem and the results of this
study will be shared with other local pediatricians and suggestions will be
given regarding future research or screening of children presenting with CP for
UTI.
MATERIALS
AND METHODS
This a descriptive cross-sectional
study, conducted in Department of Pediatrics Hayatabad Medical Complex,
Peshawar. The duration of study was one year, sample size was 113, using proportion
of 38.5% of UTI among children with CP, with 95% confidence interval and 9%
margin of error using WHO sample size calculate sampling technique was non
probability consecutive.
Children of both genders with ages 3
years to 15 years having Cerebral Palsy was included in the study.
Children with history of complicated
UTI, history of antibiotic or steroid use in last one month were not enrolled
in the study.
DATA COLLECTION
PROCEDURE
The
study was conducted after approval from hospitals ethical and research
committee. All children meeting the inclusion criteria and presenting with CP
and having fever was included in the study. The purpose and benefits of the
study was explained to the patient and a written informed consent was obtained.
All patients was subjected to complete
history and clinical examination. From all the children, a two specimen of
clean mid stream urine (02 hours apart) was obtained and sent to hospital laboratory
to detect UTI. All the laboratory investigations was done under supervision of
same consultant microbiologist having minimum of five years of experience.
All
the above mentioned information including name, age, sex was recorded in a pre
designed proforma and strictly exclusion criteria was followed to control
confounders and bias in the study results.
DATA ANALYSIS PROCEDURE
Data was stored and analyzed in SPSS version 20. Mean +
SD was calculated for quantitative variables like age. Frequencies and
percentages were calculated for categorical variables like gender and UTI. UTI
was stratified among age and gender to see the effect modifications. All
results were presented in the form of table and graphs.
RESULTS
The study was conducted on 113 children with cerebral palsy who presented
with fever.
The mean age of the sample was 7.8 + 3.6 years. The range
of age in our study was 10.00 years with minimum age of 3.5 years and maximum
age of 13.5 years. On grouping the sample in different age groups, we observed
that 33.6% of patients were in the age group up to 5 years, 36.3% were in the
age group > 5 to 10 years and 30.1% of patients were in the age group >
10 to 15 years. (Table 1)
While distributing the patients with regards to gender, we observed
that in our study 68.1% of the sample was male and 31.9% were female gender.
(Table 2)
Form all the patients, a mid stream
specimen of urine was collected in sterile container and was sent to hospital
laboratory for detection of UTI which is defined where Urine analysis showed
greater than or equal to 2-5 WBCs or 15 bacteria per high power field (HPF) in
centrifuged urine sediment and the urine culture showing growth of more than 105
organisms per ml of urine. In our study, UTI was recorded in 32.7% of patients.
(Table 3)
While we stratified UTI with regards to age groups, we observed
that the difference was statistically significant after applying chi square
test with a p value of < 0.001 (Table 4)
While we stratified UTI with regards to gender, we observed that
difference was statistically insignificant after applying chi square test with
a p value of 0.34 (Table 5)
Table 1
AGE-WISE
DISTRIBUTION OF SAMPLE (n=113)
n
Range
Minimum
Maximum
Mean
Std. Deviation
Age of the patient
113
10.00
3.50
13.50
7.8496
3.61167
Age Groups
Frequency
Percent
Up to 5 years
38
33.6
> 5 to 10 years
41
36.3
>10 to 15 years
34
30.1
Total
113
100.0
TABLE 2
GENDER-WISE
DISTRIBUTION OF SAMPLE (n=113)
Gender
Frequency
Percent
Male
77
68.1
Female
36
31.9
Total
113
100.0
Table 3
FREQUENCY OF
URINARY TRACT INFECTION (n=113)
UTI
Frequency
Percent
Yes
37
32.7
No
76
67.3
Total
113
100.0
Table 4
AGE GROUP WISE STRATIFICATION OF UTI
(n=113)
Urinary Tract Infection
P Value
Yes
No
Age Groups
Up to 5 years
0
38
< 0.001 0.0% 100.0% > 5 to 10 years
29
12
70.7%
29.3%
>10 to 15 years
8
26
23.5%
76.5%
Total
37
76
32.7%
67.3%
Table 5
GENDER GROUP WISE STRATIFICATION OF
UTI (n=113)
Urinary Tract Infection
P Value
Yes
No
Gender of the patient
Male
23
54
0.34
29.9%
70.1%
Female
14
22
38.9%
61.1%
Total
37
76
32.7%
67.3%
DISCUSSION
Acute
urinary tract infection (UTI) is common in children. By the age of seven years,
8.4%of girls and 1.7% of boys will have suffered at least one episode9.
Death is now a rare complication but hospitalization is frequently required
(40%), particularly in infancy. Transient damage to the kidneys occurs in about
40% of children affected and permanent damage occurs in about 5%10
sometimes even following a single infection. Symptoms are systemic rather than
localized in early childhood and consist of fever, lethargy, anorexia, and
vomiting. UTI is caused by Escherichia coli in over 80% of cases11
and treatment consists of a course of antibiotics.
Children
who have had one infection are at risk of further infections. Recurrent UTI
occurs in up to 30%12. The risk factors for recurrent infection are
vesicoureteric reflux (VUR), bladder instability and previous infections11,
13. Recurrence of UTI occursmore commonly in girls than boys12.
Febrile urinary tract infections have
the highest incidence
during the first year of life in both sexes, whereas nonfebrile urinary tract infections occur predominantly in girls
older than 3 years14. After infancy, urinary tract infections confined to the
bladder are generally accompanied by localized symptoms and are easily treated. In contrast,
the presence of fever increases the probability of kidney involvement (sensitivity, 53
to 84%; specificity, 44 to 92%)15 and is associated with an increased likelihood
of underlying nephrourologic abnormalities
and a greater risk of consequent renal scarring. Kidney scarring related to urinary
tract infection has been considered a cause of substantial long-term morbidity16.
Thus, children with proven infections have been intensively evaluated and treated, and
they have often undergone surgery or have received long-term antibiotic prophylaxis.15
Such approaches have been questioned17.18. A number of trials have been conducted
or are under way to determine optimal approaches to the assessment and management of
initial febrile urinary tract infections
and subsequent interventions for them.
In our
study, we studied the frequency of UTI in children presenting with cerebral palsy
and fever. We observed it to be 32.7% with equal propensity of either gender
towards UTI. Studies reporting the incidence and prevalence of UTI in children
have varied by population, sampling method, and diagnostic criteria. Rates
therefore vary widely, from 0.25% in a small UK GP study19 to 13.5%
in a hospital-based study of febrile infants20.
The frequency of UTI of 32.7% found
in the present
study is comparable to the 32.5% reported by Ozturk et al. in Turkey21, but
is much higher than the respective
7.4% and 2.2% reported by Reid and Borzyskowski in London22
and Hellquist et al. in North Carolina23. Although not reported in
our study, antibiotics had been used prior to presentation of the CP patients in the latter two
studies22, 23 and may possibly
explain the discrepancies in the frequency of the UTI. Furthermore, the symptoms and signs
of UTI, a history of
constipation, enuresis, a prior history of UTI, urinalyses findings, and culture proven UTI
were significantly more frequent
in subjects with cerebral palsy than their age- and sex-matched comparators without
cerebral palsy. Similar findings
have also been reported by Ozturk et al. in Turkey21.
Children with cerebral palsy who
often have to be carried from one place to the other by their siblings or their
parents because of difficulty in mobility and both manually propelled or
electrically powered wheelchairs are often beyond the reach of these families.
Often, these children are neglected and, stationed supine in one place for a
long time, with the majority developing pressure sores on the occiputs and the
buttocks and the poor personal hygiene resulting from prolonged smearing by
their faeces may increase the risk of UTI. Also, because of poor mobility, UTI
may develop easily following urinary retention resulting from the difficulty in
getting to the toilets to micturate in a few that may be urinary continent.
Closely linked to the poor mobility are the poor water intake and the resultant
risk of kidney stones whichmay predisposing these children to UTI24.
In addition, a high burden of pinworms seen in some of these children25
may be linked to a higher risk of UTI. Furthermore, the propensity to
developing constipation in poorly mobile CP children may also have contributed
to the higher risk of UTI in this group of children.
In our study, we found that all the
C Psubjects with UTI are over-five children. These findings may probably result
from recruitment bias as more CP patients that are over five (65%) were
recruited in our study. Furthermore, UTI presents more symptomatically, and
therefore all efforts should be put in place to review symptoms of UTI among
the CP patients when they come for follow-up in our clinics in order to confirm
and treat a UTI and thus prevent its potential complications.
CONCLUSION
The
present study would sum up to indicate that there is a high prevalence of UTI among our
children with CP, which
may be due to severe immobility. Therefore, concerted efforts should be put in
place for effective physiotherapy
aimed at attaining the greatest possible mobility and
independence among
our children with CP.
REFERENCES
Delgado
MR Hirtz D. Practice parameter: pharmacologic treatment of spasticity in
children and adolescents with cerebral palsy (an evidence-based review):
report of the Quality Standards Subcommittee of the American Academy of
Neurology and the Practice Committee of the Child Neurology Society.
Neurology 2010;74:336–43.van
Haastert IC, Groenendaal F, Uiterwaal CS, Termote JU, van der
Heide-Jalving M, Eijsermans MJ. Decreasing incidence and severity of
cerebral palsy in prematurely born children. J Peds 2011;159(1):86-91.Kesar
TM, Sawaki L, Burdette JH, Cabrera MN, Kolaski K, Smith BP et al. Motor
cortical functional geometry in cerebral palsy and its relationship to
disability. Clinical Neurophysiology 2012;123(7):1383-1390.Hurley
DS, Moulton TS, Msall ME, Spira DG, Krosschell KJ, Dewald JP. The Cerebral
Palsy Research Registry: Development and Progress Toward National
Collaboration in the United States; J Child Neurol 2011;26:1534-41.Bangash
AS, Hanafi MZ, Idrees R, Zehra N. Risk factors and types of cerebral
palsy. J Pak Med Assoc 2014;64(1):103-7.Gladstone
M. A review of the incidence and prevalence, types and aetiology of
childhood cerebral palsy in resource-poor settings. Ann Tro Paediatr
2010;30:181-96.Sibel
ÜD, Canan C, Hakan T, Murat K, Sumru Ö, Ali A. Evaluation of lower urinary
system symptoms and neurogenic bladder in children with cerebral palsy: relationships
with the severity of cerebral palsy and mental status. Turk J Med Sci
2009;39:571–8. Anígilájé
EA, Bitto TT. Prevalence and predictors of urinary tract infections among
children with cerebral palsy in Makurdi, Nigeria. Int J Nephrol, 2013. Available
at; http://www.hindawi.com/journals/ijn/2013/937268/abs/
Accessed November 19. 2015
9.
Hellstrom A, Hanson E, Hansson S, Hjalmas K, Jodal U.
Association between urinary symptoms at 7 years old and previous urinary tract
infection. Archives of Disease in Childhood 1991;66(2):232–4.
10.
Coulthard MG, Lambert HJ, Keir MJ. Occurrence of renal
scars in children after their first referral for urinary tract infection. BMJ
1997;315(7113):918–9.
11.
Rushton HG. Urinary tract infections in children.
Epidemiology, evaluation and management. Pediatric Clinics ofNorth America
1997;44(5):1133–69.
12.
Winberg J, Bergstrom T, Jacobsson B. Morbidity, age and
sex distribution, recurrences and renal scarring in symptomatic urinary tract
infection in childhood. Kidney International – Supplement 1975;4:S101–6.
13.
Hellerstein S. Recurrent urinary tract infections in
children. Pediatric Infectious Disease 1982;1(4):271–81.
14.
Marild S, Jodal U.
Incidence rate of first-time symptomatic urinary tract infection in children
under 6 years of age. Acta Paediatr 1998;87:549-52.
15.
American Academy
of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract
Infection. The diagnosis, treatment, and evaluation of the initial urinary
tract infection in febrile infants and young children. Pediatrics
1999;103:843-52.
16.
Pistor K, Sch.rer
K, Olbing H, Tamminen- M.bius T. Children with chronic renal failure in the
Federal Republic of Germany. II. Primary renal diseases, age and intervals from
early renal failure to renal death: Arbeitsgemeinschaft fur Padiatrische
Nephrologie. Clin
Nephrol 1985;23:278-84.
17.
National Institute
for Health and Clinical Excellence. Urinary tract infection in children:
diagnosis, treatment and longterm management. 2007. (http://www.nice
.org.uk/nicemedia/pdf/CG54fullguideline.pdf.)
18.
Royal Children’s
Hospital Melbourne. Clinical practice guidelines. (http://www .rch.org.au/clinicalguide/cpg.cfm?doc_id=5241.)
19.
Dickinson J. Incidence and outcome of symptomatic UTI in
children. BMJ 1975;1(6174):1330–1332.
20. Carpenter MA,
Hoberman A, Mattoo TK, Mathews R, Keren R, Chesney RW, et al. The RIVUR Trial:
Profile and Baseline Clinical Associations of Children With Vesicoureteral
Reflux. Pediatrics. Jul 2013;132(1):e34-45.
Ozturk M, Oktem F,
Kisioglu M. Bladder and bowel control in
children with cerebral palsy: case-control study. Croatian Medical
Journal, 2006;47(2):264–270..Reid CD, Borzyskowski M. Lower
urinary tract dysfunction
in cerebral palsy. Archives of Disease in Childhood 1993;6:739–742.Hellquist JM, McKinneyJr RE,
Worley G. Urinarytract
infections in cerebral patients. Pediatric Research,
1985;5:295, 1985.Alamdaran A, Naseri M. Urinary
tract infection and predisposing
factors in children. Iran Journal of Paediatrics, 2007;17:263–270. Nwaneri
DU, Sadoh AE, Ofovwe GE, Ibadin MO. Prevalence of intestinal
helminthiasis in children with chronic neurological disorders in Benin
city, Nigeria. Nigerian Journal
of Paediatrics, 2012;39:7–12.