OF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSY
Rahida Karim, Jahanzeb Khan Afridi,
Ahmad Saud Dar, Muhammad Batoor Zaman, Afnan Amjad
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
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.
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.
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.
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
>10 to 15 years
DISTRIBUTION OF SAMPLE (n=113)
URINARY TRACT INFECTION (n=113)
AGE GROUP WISE STRATIFICATION OF UTI
Urinary Tract Infection
Up to 5 years
< 0.001 0.0% 100.0% > 5 to 10 years
>10 to 15 years
GENDER GROUP WISE STRATIFICATION OF
Urinary Tract Infection
Gender of the patient
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.
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.
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.
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
our children with CP.
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