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What not to do – paediatrics



Investigation

Do not use a bag collection route to obtain a urine specimen when investigating UTI in an infant.

These increase the risk of contamination and evidence shows that bags may sterilise truly infected urine samples.1 Clean-catch specimens are recommended in the community.

A diagnosis of a UTI should not be made following a positive dipstick test for leucocyte esterase alone.2

Leucocytes are frequently found in urine when a child has infection elsewhere. The finding of nitrites (with or without leucocyte esterase) on an appropriately collected, fresh specimen in children is suggestive of a UTI. Care must be taken in reaching a diagnosis, especially in infants, as false diagnosis leads to inappropriate antibiotics which may partially mask another focus, such as meningitis. Ideally, UTIs should be diagnosed by confirmed microbiological evidence, particularly in children under three, to guide treatment and any further investigations (for unusual organisms).  Following clinically successful treatment of a UTI in a child – defined as adherence to treatment and resolution of symptoms – a repeat specimen is not indicated.2

Treatment

Do not use antipyretic agents with the sole aim of reducing body temperature in children with fever.3

Despite widespread use, there is surprisingly little evidence for the efficacy of antipyretics in the treatment of fever in children. Giving medications to children can be challenging and potentially more distressing than the fever itself, especially when oral intake is reduced. Most parents and health professionals feel comforted by the child’s improved appearance and function when fevers subside, yet this will frequently occur without administration of antipyretics. Reassurance and assessment for red flags (such as rashes or irritability, especially in young infants and unvaccinated children), with appropriate safety netting, should be the first-line approach.

Avoid combining antipyretics simultaneously in children with fever.

If medications are to be given, there is insufficient evidence suggesting that simultaneous ibuprofen and paracetamol is better than individual therapy, in particular in improving discomfort.4

There is no evidence that antipyretics prevent febrile seizures.

Although many parents may find the use of antipyretics reassuring, a number of studies have failed to demonstrate a role for them in the prevention of febrile convulsions for either primary or recurrent seizures.5

Do not perform tepid sponging to reduce fever.

Care must be taken with physical methods to reduce fever. Tepid sponging should not be performed as it tends to reduce peripheral temperature, leads to a rise in core temperature and increases discomfort.3 Over-exposure by under-dressing children can lead to similar problems. The best advice is to not under-dress or over-wrap children with fevers.

Do not automatically empirically treat a UTI with trimethoprim.

The most common pathogenic organism in UTI in children is Escherichia coli. Increasing levels of resistance of E.coli to trimethoprim across the UK6 means that GPs should seek local microbiological guidance for empirical therapy. A single, simple UTI is relatively common in childhood, and prophylactic antibiotics are not indicated as risk of recurrence is low and treatment contributes to bacterial resistance.2 Children who have recurrent UTIs (more than three simple UTIs) should be considered for prophylaxis, and generally referred to a paediatrician for consideration of imaging.2

Local or systemic decongestants and antihistamines should not be prescribed or advised for otitis media with effusion.

A Cochrane review showed these medications caused significant side-effects and do not alter disease outcome.7 Where families have used over-the-counter remedies by the time of consultation, the advice should be to stop them unless there is significant benefit.

Antibiotics should not be routinely prescribed for otitis media with effusion.

Another Cochrane review showed that long-term courses were needed to see benefits from antibiotics, which were offset by side-effects and potential antibiotic resistance.8

Tricyclic medication (such as imipramine) should not be used as a first-line treatment for bed-wetting.

Side-effects, although rare, can be significant (mostly relating to the cardiovascular system) and a physician with expertise in enuresis should supervise their use. Initial management should begin with advice on toileting and fluid intake.9 Second-line treatment depends on whether a family and child’s goals are short-term (drug therapy) or longer-term (where alarms will be more effective). Goals frequently correspond with a child’s age and the impact of bed wetting on function (such as sleepovers). Strategies using the interruption of urinary stream, or encouraging infrequent passing of urine during the day to increase bladder capacity, should not be recommended as the value is unproven compared with the treatments mentioned above.9

Dr Lee Hudson is a consultant general paediatrician at Great Ormond Street Hospital

References

  1. Etoubleau C, Reveret M, Brouet D et al. Moving from bag to catheter for urine collection in non-toilet-trained children suspected of having urinary tract infection: a paired comparison of urine cultures. J Paediatr 2009;154:803-6
  2. NICE. CG54: UTI in children. London: NICE; 2007
  3. NICE. CG160: Feverish illness in children. London: NICE; 2013
  4. Wong T, Stang AS, Ganshorn H et al. Combined and alternating paracetamol and ibuprofen therapy for febrile children. Cochrane Database Syst Rev, 2013; CD009572
  5. Strengell T, Uhari M, Tarkka R et al. Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Arch Paediatr Adolesc Med 2009;163:799.
  6. Chakupurakal R, Ahmed M, Sobithadevi DN et al. Urinary tract pathogens and resistance pattern. J Clin Pathol 2010;63:652-4
  7. Griffin G, Flynn CA. Antihistamines and/or decongestants for otitis media with effusion (OME) in children. Cochrane Database Syst Rev, 2011; 7:CD003423
  8. Van Zon A, van der Heijden GJ, van Dongen TM et al. Antibiotics for otitis media with effusion in children. Cochrane Database Syst Rev, 2012; 9:CD009163
  9. NICE. CG111: Nocturnal enuresis – the management of bed wetting in children. London: NICE; 2010