OF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSY
Rahida Karim, Jahanzeb Khan Afridi, Ahmad Saud Dar, Muhammad Batoor Zaman,
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.
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.
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: Cerebral Palsy, Pyrexia, Urinary Tract Infection, Urine Culture. 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 cerebral palsy child had injury to brain before it was fully matured. It is a non-progressive injury and they have difficulty in neuromuscular control. Mental retardation mental retardation, seizure disorders, abnormalities of vision, respiratory problems and lower urinary tract dysfunctions or associate morbidities with cerebral palsy7 urgency frequency hesitancy, urinary incontinence and urinary tract infection or manifestation or lower urinary tract dysfunctions7. Vesicoureteral reflux and incomplete bladder emptying resulting from detrusor hyperreflexia and detrusor sphincter dyssynergia are possible reasons for propensity to urinary tract infections. In addition, impaired mobility and inability to communicate bladder fullness and the need to void, because of impaired cognition may also explain the tendency to urinary retention and 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 were 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 were 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)
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 TABLE 2 GENDER-WISE DISTRIBUTION OF SAMPLE (n=113) Age Groups Frequency Percent Up to 5 years 38 33.6 > 5 to 10 years
>10 to 15 years
3; FREQUENCY OF URINARY TRACT INFECTION (n=113)
4; AGE GROUP WISE STRATIFICATION OF UTI (n=113)
Urinary Tract Infection
Up to 5 years
< 0.001 0.0% 100.0% > 5 to 10 years
>10 to 15 years
5; GENDER GROUP WISE STRATIFICATION OF UTI (n=113)
Urinary Tract Infection
Gender of the patient
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
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.
al. in Turkey has reported 32.5% frequency of UTI21 which
is comparable to present study 32.7%, 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. The discrepancies in frequency of UTI in latter two
studies22 ,23 may be due to the prior use of antibiotics, although
not reported in our study. CP subjects more frequently had symptoms and signs
of UTI, history of constipation and enuresis, prior history of UTI, urinalyses
findings and culture proven UTI than their age and sex matched comparators
without CP. Similar findings have also been reported by Ozturk et al. in Turkey21.
Parents and siblings have to carry Cerebral palsy from one
place to other, because of difficulty in mobility and both manually propelled
or electrically powered wheelchairs are often beyond the reach of these
families. The are neglected children who stay supine for prolonged period of
time, with the majority developing pressure source on occiputs and buttocks and
prolonged smearing by their faeces due to poor personal hygiene may increase
risk of UTI. Few of them may be urinary continent but due to poor mobility, UTI
may develop easily following urinary retention resulting from difficulty in
getting to the toilets to micturate. Poor
water intake due to immobility results in kidney stones which may predispose to
UTI24. In addition some of these children have high burden of
pinworms25 which may be linked to higher risk of UTI. Poorly mobile
CP children had propensity to develop constipation which also contributes to
higher risk of UTI in this group of children. 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.
found that all the CP children with UTI are over-five in our study. Majority of
the CP patients are over five (65%) were recruited in our study. So these
findings may probably result from recruitment bias. When CP patients come for
follow up in our clinics we should review symptoms of UTI as it presents
symptomatically, it should be confirmed and treated in order to prevent its
We concluded from this study
that severe immobility in CP children is responsible for high prevalence of
UTI, therefore efforts should be made for effective physiotherapy, so that CP
children can attain maximum mobility and independence.
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
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
10. Coulthard MG, Lambert HJ, Keir MJ. Occurrence of renal scars in
children after their first referral for urinary tract infection. BMJ
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.
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.
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
Institute for Health and Clinical Excellence. Urinary tract infection in
children: diagnosis, treatment and longterm management. 2007. (http://www.nice
Children’s Hospital Melbourne. Clinical practice guidelines. (http://www
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.
M, Oktem F, Kisioglu M. Bladder and
in children with cerebral palsy: case-control study. Croatian Medical
CD, Borzyskowski M. Lower urinary tract dysfunction in cerebral palsy. Archives of Disease in
JM, McKinneyJr RE, Worley G. Urinarytract infections in cerebral patients. Pediatric Research,
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