Urinary tract infection in babies and children

A urinary tract infection (UTI) is an infection of the bladder or kidneys, usually caused by bacteria from the bowel. In babies it often shows up only as fever and fussiness, so a urine test is important when no other cause is found. Prompt treatment with the right antibiotic clears it well and protects the kidneys.

What are the symptoms of UTI in a baby?

In babies and toddlers, fever is often the only sign of a UTI. There may be no obvious problem with passing urine.

Other signs in babies include:

• Irritability, poor feeding or vomiting.
• Poor weight gain, or a baby who just seems unwell.
• Smelly or cloudy urine, or crying when passing urine.
• In newborns, jaundice that appears late or low temperature.

Because the signs are so vague, doctors test the urine of a baby with fever when no clear cause such as a cold or ear infection is found.¹

What are UTI symptoms in older children?

Older children usually complain of burning or pain when passing urine, needing to go often or urgently, and tummy pain.

New daytime wetting in a child who was dry, smelly urine, and blood in the urine are other clues. Fever, pain in the back or side, vomiting and feeling very unwell suggest the infection has reached the kidney (pyelonephritis). That needs prompt medical care.

How common are UTIs in babies?

UTIs are one of the most common serious bacterial infections in babies with fever. A review found a UTI in about 7 percent of babies who had fever.²

Risk is highest in girls under 12 months and in uncircumcised boys under 3 months. In febrile boys under 3 months, about 20 percent of uncircumcised boys had a UTI, compared with about 2 percent of circumcised boys.² This does not mean circumcision is needed; it simply explains why doctors test young boys with fever.

How is urine collected from a baby?

The preferred method is a "clean catch": you wait with an open, sterile container and catch the urine as your baby passes it.¹

Clean the genital area with water first. If a clean catch is not possible, special urine collection pads can be used. Do not use cotton wool, gauze or sanitary pads to collect urine.¹ When a quick, clean sample is needed in a very sick or young baby, a doctor may use a thin tube (catheter) or a fine needle into the bladder guided by ultrasound.¹ These are quick and safe in trained hands.

Is there a trick to make a baby pass urine faster?

Yes. Gently rubbing the lower tummy above the pubic bone with cold, wet gauze can trigger a baby to pass urine within minutes.

In a trial of babies aged 1 to 12 months, this "Quick-Wee" method made a clean catch within 5 minutes about three times more likely (30 percent compared with 9 percent).³ Offering a feed a little beforehand can also help.

Why are urine bags not ideal?

Sticky urine bags are easy, but they often pick up germs from the skin and give false positive results.

A bag sample that shows nothing is reassuring. A bag sample that shows infection often needs to be repeated with a cleaner method before a diagnosis is made. The diagnosis of UTI needs both signs of inflammation in the urine and a significant growth of one type of bacteria in a properly collected sample.⁴

Why does a UTI in a baby need prompt treatment?

Prompt treatment shortens the illness and helps limit damage to the kidneys. A kidney infection in a baby can leave a scar.

A review of studies found that after a first UTI, about 15 percent of children had some kidney scarring on a later scan.⁵ Scarring was more likely in children with vesicoureteric reflux, where urine flows backwards from the bladder towards the kidneys.⁵ Large scars can, over many years, lead to high blood pressure or kidney problems, so children with scars need regular follow-up.⁶

Does my baby need to be admitted for a UTI?

A baby younger than 3 months who may have a UTI needs to be seen by a children's specialist, and usually needs antibiotics by injection or drip.¹

Older babies and children who are drinking well and not very unwell can often be treated with antibiotics by mouth. A trial in children aged 1 to 24 months with fever and UTI found that oral antibiotics worked as well as starting with antibiotics through a drip, with similar rates of later kidney scarring.⁷ Children who are vomiting, dehydrated or look very sick need hospital care. A treatment course usually lasts 7 to 14 days for a febrile UTI.⁴

Does every child need a kidney ultrasound after a UTI?

Not every child. Guidelines differ, but most advise an ultrasound for babies and young children after a first UTI with fever, and for any child with an unusual or repeat infection.

The American Academy of Pediatrics advises a kidney and bladder ultrasound for children aged 2 to 24 months after a first febrile UTI.⁴ NICE in the UK advises it for babies under 6 months, and for children with atypical or recurrent UTIs, such as those who are very ill, do not improve within 48 hours, or have poor urine flow.¹ The ultrasound is painless and needs no injection.

What is vesicoureteric reflux?

Vesicoureteric reflux (VUR) means urine flows backwards from the bladder up the tubes towards the kidneys. It makes kidney infections more likely.

It is graded from mild to severe, and mild reflux often improves as the child grows. It is diagnosed with a special X-ray test called a micturating cystourethrogram (MCU), in which dye is put into the bladder through a thin tube. The AAP does not advise this test routinely after a first UTI, but suggests it if the ultrasound is abnormal or the child has a second febrile UTI.⁴ The Indian Society of Pediatric Nephrology statement from 2011 advised it after a first UTI in infants.⁶ Your paediatrician will decide based on your child's case.

Does my child need daily antibiotics to prevent UTIs?

Some children with reflux benefit from a small daily antibiotic dose, but it is not needed for every child.

In the RIVUR trial of 607 children with reflux, daily antibiotics halved the chance of another UTI. They did not reduce kidney scarring, and germs became more resistant to the antibiotic.⁸ So the decision is made case by case, weighing the grade of reflux, how many infections the child has had, and bladder and bowel habits.

What causes repeat UTIs in children?

Constipation and poor bladder habits are among the most common causes of repeat UTIs in toilet-trained children.

In a study of children under 6 years after a UTI, more than half of those who were toilet trained had bladder and bowel problems, such as holding urine, daytime wetting or constipation. Children with both these problems and reflux had the highest rate of repeat UTIs, about 51 percent.⁹ A full bowel presses on the bladder and stops it emptying well.

How can I prevent UTIs in my child?

Treat constipation, encourage regular toilet trips, and keep the area clean. These simple steps prevent many repeat infections.

• Give enough water, especially in Kolkata's heat.
• Prevent constipation with fruit, vegetables, dal and whole grains.
• Remind school-age children to pass urine regularly through the day and not to hold on.
• Teach girls to wipe from front to back.
• Change nappies promptly, and avoid harsh soaps and bubble baths.
• Do not forcibly pull back the foreskin in baby boys.
• Finish every antibiotic course as prescribed.

Do cranberry juice or home remedies help?

Dr Dutta does not rely on cranberry products or home remedies for UTIs in children. They do not treat an active infection.

Barley water, coconut water and plenty of fluids are fine for hydration, but a child with fever and a suspected UTI needs a urine test and antibiotics. Delays can allow the infection to reach the kidneys.

When should I take my child to a doctor or hospital?

See a doctor the same day, or go to hospital urgently, if your child has:

• Any fever (38 degrees C or more) in a baby under 3 months. This one is always urgent: go to hospital now, day or night.
• Fever with no clear cause lasting more than 24 to 48 hours in a baby or toddler.
• Vomiting, refusing feeds or drinks, or signs of dehydration.
• Pain in the back or side with fever.
• Unusual sleepiness, floppiness or a very unwell look.
• No improvement 48 hours after starting antibiotics.
• Poor urine stream, or a swelling in the tummy.
• Blood in the urine.
• A second UTI, so the cause can be looked for.