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Emergency Medicine Australasia (2015) 27, 348–350
doi: 10.1111/1742-6723.12442
CLINICAL PROCEDURES
Urine collection in young children John A CHEEK,1,2,3,4 Simon S CRAIG,1,2,3 Robert W SEITH1,2 and Adam WEST1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, 2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia, 3Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, and 4 Emergency Department, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
Urine collection in young children Collecting urine in babies, infants and young children who are not toilet trained can be a frustrating, timeconsuming and traumatic experience for patients, parents and clinicians. This article aims to provide an overview of the techniques available for these children.
When should I collect a urine sample? Although the diagnosis of a UTI in non-verbal children can be difficult, not all children with a fever need a urine test. Like all tests, an understanding of pre- and post-test probability is required. A full discussion is beyond the scope of this article; however, the probability of the well-appearing child having his/her first UTI when no other source of fever is evident drops dramatically with increasing age, particularly in boys1,2 (Table 1). A pragmatic suggested approach is that ‘when children appear well or have alternative potential sources . . . early pursuit of urinary tract infection seems likely to subject children to invasive testing and treatment without detectable benefits’.2 In children who are at low risk for a UTI there is no need to delay dis-
charge waiting for the ‘just in case’ urine test. One option is to discharge them home with early clinical review with their general practitioner (GP) – if they have a UTI, delaying diagnosis by a day in this group will not result in harm.2 In summary, urine should be collected in all ‘unwell’ or septic children, febrile children aged 3 cm,15 depth of >3 cm16 or an anterior-posterior diameter of >2 cm17 with a point of care US has been reported to increase success rates to above 97%. Automated bladder scanners are not very useful in babies as they are poor at identifying volumes under 20 mL.
Anything to worry about afterward? Invasive collection techniques can sometimes result in some microscopic haematuria, which will self-resolve with time. 18 Although there is a theoretical chance of perforating a bowel loop with a SPA, we are not aware of any reports of complications resulting from this in the literature.
Competing interests None declared.
References
Figure 1.
6F feeding tube.
1. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a metaanalysis. Pediatr. Infect. Dis. J. 2008; 27: 302–8.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
350
JA CHEEK ET AL.
2. Newman DH, Shreves AE, Runde DP. Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis? Ann. Emerg. Med. 2013; 61: 559– 65. 3. National Institute for Health and Care Excellence. Urinary tract infection in children. Diagnosis, treatment and long-term management, 2007. 4. 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; 128: 595–610. 5. Tosif S, Baker A, Oakley E, Donath S, Babl FE. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J. Paediatr. Child Health 2012; 48: 659–64. 6. Kassab M, Foster JP, Foureur M, Fowler C. Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Cochrane Database Syst. Rev. 2012; CD008411. 7. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and
8.
9.
10.
11.
12.
13.
nonpharmacological management. Int. J. Pediatr. 2010; 2010: 474838. Shavit I, Feraru L, Miron D, Weiser G. Midazolam for urethral catheterisation in female infants with suspected urinary tract infection: a casecontrol study. Emerg. Med. J. 2014; 31: 278–80. Weiser G, Cohen D, Krauss B, Galbraith R, Shavit I. Premedication with midazolam for urethral catheterization of febrile infants. Eur. J. Emerg. Med. 2014; 21: 314–18. Vaughan M, Paton EA, Bush A, Pershad J. Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial. Pediatrics 2005; 116: 917–20. Mularoni PP, Cohen LL, DeGuzman M, Mennuti-Washburn J, Greenwald M, Simon HK. A randomized clinical trial of lidocaine gel for reducing infant distress during urethral catheterization. Pediatr. Emerg. Care 2009; 25: 439–43. Herreros Fernández ML, González Merino N, Tagarro García A et al. A new technique for fast and safe collection of urine in newborns. Arch. Dis. Child. 2013; 98: 27– 9. Altuntas N, Celebi Tayfur A, Kocak M, Razi HC, Akkurt S. Midstream clean-catch urine collection in new-
14.
15.
16.
17.
18.
borns: a randomized controlled study. Eur. J. Pediatr. 2015; 174: 577–82. Bevan C, Buntsma D, Stock A, Griffiths T, Donath S, Babl FE. Assessing bladder volumes in young children prior to instrumentation: accuracy of an automated ultrasound device compared to real-time ultrasound. Acad. Emerg. Med. 2011; 18: 816–21. García-Nieto V, Navarro JF, Sánchez-Almeida E, García-García M. Standards for ultrasound guidance of suprapubic bladder aspiration. Pediatr. Nephrol. 1997; 11: 607–9. Chu RWP, Wong YC, Luk SH, Wong SN. Comparing suprapubic urine aspiration under real-time ultrasound guidance with conventional blind aspiration. Acta Paediatr. 2002; 91: 512–16. Božicˇ nik S, Díez Recinos A, Moreno Cantó MC, Pavlovicˇ S, García-Muñoz Rodrigo F. Ultrasound-guided suprapubic bladder aspiration increases the success of the technique in infants less than 4 months-old. An. Pediatr. (Barc.) 2013; 78: 321–5. Pollack CV, Pollack ES, Andrew ME. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Ann. Emerg. Med. 1994; 23: 225–30.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2015) 27, 348–350
doi: 10.1111/1742-6723.12442
CLINICAL PROCEDURES
Urine collection in young children John A CHEEK,1,2,3,4 Simon S CRAIG,1,2,3 Robert W SEITH1,2 and Adam WEST1,2 1 Emergency Department, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia, 2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia, 3Murdoch Children’s Research Institute, Melbourne, Victoria, Australia, and 4 Emergency Department, Royal Children’s Hospital Melbourne, Melbourne, Victoria, Australia
Urine collection in young children Collecting urine in babies, infants and young children who are not toilet trained can be a frustrating, timeconsuming and traumatic experience for patients, parents and clinicians. This article aims to provide an overview of the techniques available for these children.
When should I collect a urine sample? Although the diagnosis of a UTI in non-verbal children can be difficult, not all children with a fever need a urine test. Like all tests, an understanding of pre- and post-test probability is required. A full discussion is beyond the scope of this article; however, the probability of the well-appearing child having his/her first UTI when no other source of fever is evident drops dramatically with increasing age, particularly in boys1,2 (Table 1). A pragmatic suggested approach is that ‘when children appear well or have alternative potential sources . . . early pursuit of urinary tract infection seems likely to subject children to invasive testing and treatment without detectable benefits’.2 In children who are at low risk for a UTI there is no need to delay dis-
charge waiting for the ‘just in case’ urine test. One option is to discharge them home with early clinical review with their general practitioner (GP) – if they have a UTI, delaying diagnosis by a day in this group will not result in harm.2 In summary, urine should be collected in all ‘unwell’ or septic children, febrile children aged 3 cm,15 depth of >3 cm16 or an anterior-posterior diameter of >2 cm17 with a point of care US has been reported to increase success rates to above 97%. Automated bladder scanners are not very useful in babies as they are poor at identifying volumes under 20 mL.
Anything to worry about afterward? Invasive collection techniques can sometimes result in some microscopic haematuria, which will self-resolve with time. 18 Although there is a theoretical chance of perforating a bowel loop with a SPA, we are not aware of any reports of complications resulting from this in the literature.
Competing interests None declared.
References
Figure 1.
6F feeding tube.
1. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a metaanalysis. Pediatr. Infect. Dis. J. 2008; 27: 302–8.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
350
JA CHEEK ET AL.
2. Newman DH, Shreves AE, Runde DP. Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis? Ann. Emerg. Med. 2013; 61: 559– 65. 3. National Institute for Health and Care Excellence. Urinary tract infection in children. Diagnosis, treatment and long-term management, 2007. 4. 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; 128: 595–610. 5. Tosif S, Baker A, Oakley E, Donath S, Babl FE. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J. Paediatr. Child Health 2012; 48: 659–64. 6. Kassab M, Foster JP, Foureur M, Fowler C. Sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age. Cochrane Database Syst. Rev. 2012; CD008411. 7. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and
8.
9.
10.
11.
12.
13.
nonpharmacological management. Int. J. Pediatr. 2010; 2010: 474838. Shavit I, Feraru L, Miron D, Weiser G. Midazolam for urethral catheterisation in female infants with suspected urinary tract infection: a casecontrol study. Emerg. Med. J. 2014; 31: 278–80. Weiser G, Cohen D, Krauss B, Galbraith R, Shavit I. Premedication with midazolam for urethral catheterization of febrile infants. Eur. J. Emerg. Med. 2014; 21: 314–18. Vaughan M, Paton EA, Bush A, Pershad J. Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial. Pediatrics 2005; 116: 917–20. Mularoni PP, Cohen LL, DeGuzman M, Mennuti-Washburn J, Greenwald M, Simon HK. A randomized clinical trial of lidocaine gel for reducing infant distress during urethral catheterization. Pediatr. Emerg. Care 2009; 25: 439–43. Herreros Fernández ML, González Merino N, Tagarro García A et al. A new technique for fast and safe collection of urine in newborns. Arch. Dis. Child. 2013; 98: 27– 9. Altuntas N, Celebi Tayfur A, Kocak M, Razi HC, Akkurt S. Midstream clean-catch urine collection in new-
14.
15.
16.
17.
18.
borns: a randomized controlled study. Eur. J. Pediatr. 2015; 174: 577–82. Bevan C, Buntsma D, Stock A, Griffiths T, Donath S, Babl FE. Assessing bladder volumes in young children prior to instrumentation: accuracy of an automated ultrasound device compared to real-time ultrasound. Acad. Emerg. Med. 2011; 18: 816–21. García-Nieto V, Navarro JF, Sánchez-Almeida E, García-García M. Standards for ultrasound guidance of suprapubic bladder aspiration. Pediatr. Nephrol. 1997; 11: 607–9. Chu RWP, Wong YC, Luk SH, Wong SN. Comparing suprapubic urine aspiration under real-time ultrasound guidance with conventional blind aspiration. Acta Paediatr. 2002; 91: 512–16. Božicˇ nik S, Díez Recinos A, Moreno Cantó MC, Pavlovicˇ S, García-Muñoz Rodrigo F. Ultrasound-guided suprapubic bladder aspiration increases the success of the technique in infants less than 4 months-old. An. Pediatr. (Barc.) 2013; 78: 321–5. Pollack CV, Pollack ES, Andrew ME. Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Ann. Emerg. Med. 1994; 23: 225–30.
© 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
