Krystal Richardson, ND
Most family doctors who see kids in their practice have run across a case of vesicoureteral reflux (VUR), which is characterized as the retrograde passage of urine from the bladder into the upper urinary tract. VUR is the most common urologic finding in children and occurs in about 1% of newborns.1 However, in young children presenting with a urinary tract infection, VUR is present in 30 to 40% of kids.1 For this reason, VUR should be included in the differential diagnosis anytime a child under the age of 2 comes into your office presenting with a febrile or afebrile urinary tract infection (UTI). In a child with VUR, it is much more likely that a UTI will progress to pyelonephritis (due to the reflux of urine from the bladder into the upper urinary tract, as well as the urinary stasis that tends to occur with VUR). Treatment of VUR is based on severity. In the past, all kids with VUR, no matter the severity, were prescribed prophylactic antibiotics. This is no longer the case. Doctors are now rethinking this practice, based on the latest research showing that the benefits of prophylactic antibiotics in kids with VUR may not always outweigh the potential risks.2
Diagnosis of VUR in Children
The American Academy of Pediatrics (AAP) has published treatment guidelines for the diagnosis and management of the initial UTI in febrile infants and children aged 2 to 24 months.3 Once a UTI has been confirmed via urine culture (it is important to note that this needs to be done via catheterization of an infant to minimize contamination), the next step is not a voiding cystourethrogram (VCUG), which was once the common practice. Rather, the next step is to get a renal and bladder ultrasound (RBUS). An RBUS confirming abnormalities should then be followed up with a VCUG. Standards of care have moved away from a VCUG as the first step because it is not only uncomfortable and costly, but also requires the use of some radiation.3 It is always important to weigh the risks against the benefits.
Treatment of VUR – Conflicting Guidelines
Once a diagnosis of VUR is made and the grade (1-4) has been determined, treatment options can be weighed. In June 2014, the New England Journal of Medicine published an article discussing antibiotic prophylaxis in kids with VUR.2 This article highlighted a 2-year, multi-site, randomized, placebo-controlled trial that included 607 children with VUR diagnosed after the first or second febrile (or symptomatic) UTI and which examined the use of trimethoprim-sulfamethoxazole prophylaxis in preventing UTI recurrences as a primary outcome. Renal scarring, treatment failure, and antimicrobial resistance were investigated as secondary outcomes. The results of the study showed that antibiotic prophylaxis reduced the recurrence of UTIs by about 50% but did not significantly change the incidence of renal scarring.2 This was very interesting because the goal of prophylactic antibiotics is to prevent a UTI from becoming pyelonephritis (which, if bad enough, can cause renal scarring). This research is in stark contrast to the AAP guidelines and the research they used that showed a direct correlation between the number of recurrent UTIs and the risk of scarring.3
Is Antibiotic Prophylaxis Necessary?
So, what guidelines should doctors follow? Well, it depends on who you talk to. Some urologists are not treating children with low-grade VUR with antibiotic prophylaxis unless they have had 2 or 3 recurrent febrile or symptomatic UTIs. Instead, some medical doctors and specialists are using measures that naturopathic doctors are very familiar with for helping to prevent the occurrence of UTIs. For example, they are using supplements like cranberry or blueberry capsules (or juice) and D-mannose powder, as well as educating about and emphasizing proper hygiene. In addition, specialists are recommending circumcision among male children with VUR, to decrease the risk of a UTI.
Another key reason not to automatically treat with prophylactic antibiotics in children with low-grade VUR is the dramatic increase in antibiotic resistance. The NEJM article highlighted that 63% of the patient group taking prophylactic antibiotics had resistance to trimethoprim-sulfamethoxazole (vs only 19% in the placebo control group). It is important to note that children taking prophylactic antibiotics not only had a much higher risk for resistance to trimethoprim-sulfamethoxazole, but also to other antibiotics.1 These numbers are very concerning in light of the increasing risk of antibiotic resistance worldwide.
Grade I/II VUR will spontaneously resolve in 80% of kids by 5 years old.1 This is great news and shifts the conversation to how doctors can prevent damage while allowing the VUR to resolve on its own. The relative risk (RR) of renal scarring versus grade of VUR is 1.2 (95% CI 0.43-3.35) in grade I; RR is 2.17 (95% CI 1.33-3.56) in grade II; RR is 2.5 (95% CI 1.55-4.01) in grade III; and the RR is 4.61 (95% CI 3.23-6.57) in grade IV.1 The amount of scarring that occurs congenitally is unknown.1 We do know that if a UTI is able to progress into pyelonephritis (which in a child with VUR is more likely to happen) then the risk of renal scarring increases. This is the reason for prompt and swift treatment of any UTI in a child, but especially in a child with VUR. Another potential complicating factor is bowel bladder dysfunction (BBD). If you suspect BBD, it is important to work with a specialist, as this can make treating VUR much more complicated.
Summary
In conclusion, management goals in a child with VUR should be to prevent recurring UTIs, prevent renal scarring, and minimize the risks associated with treatment. It is no longer straightforward whether prophylactic antibiotics should be given to every child diagnosed with VUR. Those kids that have higher-grade VUR need to be managed by a specialist, and it is highly likely they will require antibiotic prophylaxis. However, in those children with low-grade VUR, that have not had recurrent UTIs, it may be reasonable to consider other preventative options first. Lastly, if ever there is question on the appropriate course of action, never hesitate to consult with or refer to a specialist.
Krystal Richardson, ND, is a naturopathic doctor who graduated from Bastyr University in 2014. She is currently a 1st-year resident at Naturopathic Family Medicine in Seattle, WA. Dr Richardson is passionate about family medicine and enjoys working with all ages. She believes in creating a relationship with her patients that focuses on a partnership where patient and doctor can work together towards achievable goals. Dr Richardson’s greatest joy comes from working with the pediatric population and encouraging healthy habits early, but she also believes that achieving a better level of health is possible at any age.
References:
- Mattoo TK, MD, Greenfield SP. Clinical presentation, diagnosis, and course of primary vesicoureteral reflux. Updated October 27, 2014. UpToDate Web site. http://www.uptodate.com/contents/clinical-presentation-diagnosis-and-course-of-primary-vesicoureteral-reflux. Accessed April 1, 2015.
- RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. New Engl J Med. 2014;370(25):2367-2376.
- 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(3):595-610.
