FREQUENCYOF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSYAuthors:Rahida Karim, Jahanzeb Khan Afridi, Ahmad Saud Dar, Muhammad Batoor Zaman,Afnan Amjad, ABSTRACTBackground: Cerebralpalsy (CP) occurs in about 2.0–2.

5 per 1000 live births. Rates have remainedfairly stable over the past 40 years. In many children, the cause of CP isunknown. A child with cerebral palsy is having a difficulty in neuromotorcontrol, a nonprogressive brain lesion, and an injury to the brain thatoccurred before it was fully matured. The morbidity associated with CPcomprises 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 includevesicoureteral reflux and incomplete bladder emptying resulting from detrusorhyperreflexia and detrusor sphincter dyssynergia.  Materials andMethods: this study was conductedin the department of pediatrics Hayatabad Medical Complex, Peshawar from01.01.

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2016 to 31.12.2016. Through a descriptive cross-sectional study design, atotal of 113 children with cerebral palsy, selected in a consecutive samplingand med-stream urine specimen was collected for urine culture to detect UTI.  Results: Themean age group of the sample was 7.8 + 3.6years. 68.

1% of the sample was male and 31.9%were female gender. In our study, UTI was recorded in 32.

7% of patientswith more propensities towards age group above 5 years (p < 0.001) Conclusion:The present study wouldsum up to indicate that there is a high prevalence of UTI among children with CP, which may be due to severeimmobility. Therefore, concertedefforts should be put in place for effective physiotherapy aimed at attaining thegreatest possible mobility and independence among children with CP. Key Words: Cerebral Palsy, Pyrexia, Urinary TractInfection, Urine Culture. INTRODUCTIONCerebralpalsy (CP) occurs in about 2.

0–2.5 per 1000 live births1. Rates haveremained fairly stable over the past 40 years. In many children, the cause ofCP is unknown.

Risk factors must be distinguished from causes. Known riskfactors include low birth weight and prematurity, for example, infants of verylow birth weight are 20–80 times more likely to have CP than infants of a birthweight of more than 2500 g2. It is likely that in a significantproportion of children, CP results from a series of events or ‘causal pathways’that culminate in motor damage3.Eachyear in the United States, approximately 1 in 278 infants is diagnosed with CP4.A similar study conducted in Pakistan, regarding incidence of CP showed thatout of a sample of 160 cases with abnormalities of tone, posture and movement,75% (n=120) were diagnosed as having CP5.

While CP was initiallyattributed to injuries resulting from birth asphyxia, recent studies have shownthat in actuality it includes a myriad of factors. Injury to the developingbrain may be prenatal, natal or postnatal. Risk factors now known to play arole in the development of CP include multiple gestation, gender, infection,prematurity and low birth weight as well as genetic determinants6.Acerebral palsy child had injury to brain before it was fully matured. It is anon-progressive injury and they have difficulty in neuromuscular control.

Mental retardation mental retardation, seizure disorders, abnormalities ofvision, respiratory problems and lower urinary tract dysfunctions or associatemorbidities with cerebral palsy7 urgency frequency hesitancy,urinary incontinence and urinary tract infection or manifestation or lowerurinary tract dysfunctions7. Vesicoureteralreflux and incomplete bladder emptying resulting from detrusor hyperreflexia anddetrusor sphincter dyssynergia are possible reasons for propensity to urinarytract infections. In addition, impaired mobility and inability to communicatebladder fullness and the need to void, because of impaired cognition may alsoexplain the tendency to urinary retention and attendant risk of urinary tractinfections and is reported in a study in 38.5% of CP children in a study byAnígilájé EA et al8.Thepresent study is designed to determine the frequency of UTI in childrenpresenting cp.

As mentioned above, the CP children are very prone to Urinarytract abnormalities and neurogenic bladder if leads to reflux can cause UTIamong children with CP. This study will provide us with local magnitude of theproblem and the results of this study will be shared with other localpediatricians and suggestions will be given regarding future research orscreening of children presenting with CP for UTI.  MATERIALS ANDMETHODS            This a descriptive cross-sectionalstudy, conducted in Department of Pediatrics Hayatabad Medical Complex,Peshawar. The duration of study was one year, sample size was 113, using proportionof 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 nonprobability consecutive.

 Childrenof both genders with ages 3 years to 15 years having Cerebral Palsy wereincluded in the study.Childrenwith history of complicated UTI, history of antibiotic or steroid use in lastone month were not enrolled in the study.  DATA COLLECTION PROCEDURE            Thestudy was conducted after approval from hospitals ethical and researchcommittee. All children meeting the inclusion criteria and presenting with CPand having fever was included in the study. The purpose and benefits of thestudy was explained to the patient and a written informed consent was obtained.Allpatients were subjected to complete history and clinical examination. From allthe children, a two specimen of clean mid stream urine (02 hours apart) wasobtained and sent to hospital laboratory to detect UTI.

All the laboratoryinvestigations was done under supervision of same consultant microbiologisthaving minimum of five years of experience.             Allthe above mentioned information including name, age, sex was recorded in a predesigned proforma and strictly exclusion criteria was followed to controlconfounders and bias in the study results.  DATA ANALYSIS PROCEDURE            Datawas stored and analyzed in SPSS version 20. Mean + SD was calculated forquantitative variables like age. Frequencies and percentages were calculatedfor categorical variables like gender and UTI. UTI was stratified among age andgender to see the effect modifications.

All results were presented in the formof table and graphs.  RESULTSThe study was conducted on 113 children with cerebral palsy who presentedwith fever. The mean age of the sample was 7.8 + 3.6 years. The rangeof age in our study was 10.00 years with minimum age of 3.5 years and maximumage of 13.

5 years. On grouping the sample in different age groups, we observedthat 33.6% of patients were in the age group up to 5 years, 36.3% were in theage 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, weobserved that in our study 68.1% of the sample was male and 31.9% were femalegender.

(Table 2)Formall the patients, a mid stream specimen of urine was collected in sterilecontainer and was sent to hospital laboratory for detection of UTI which isdefined where Urine analysis showed greater than or equal to 2-5 WBCs or 15bacteria per high power field (HPF) in centrifuged urine sediment and the urineculture 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 observedthat the difference was statistically significant after applying chi squaretest with a p value of < 0.001 (Table 4)While we stratified UTI with regards to gender, we observed thatdifference was statistically insignificant after applying chi square test witha p value of 0.34 (Table 5) Table 1 AGE-WISEDISTRIBUTION 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 41 36.3 >10 to 15 years 34 30.1 Total 113 100.

0   Gender Frequency Percent   Male 77 68.1 Female 36 31.9 Total 113 100.0  Table3; FREQUENCY OF URINARY TRACT INFECTION (n=113) UTI Frequency Percent   Yes 37 32.

7 No 76 67.3 Total 113 100.0  Table4; AGE GROUP WISE STRATIFICATION OF UTI (n=113)   Urinary Tract Infection P Value Yes No Age Groups Up to 5 years 0 38 < 0.001 0.0% 100.0% > 5 to 10 years 29 12 70.7% 29.

3% >10 to 15 years 8 26 23.5% 76.5% Total 37 76 32.7% 67.3%  Table5; GENDER GROUP WISE STRATIFICATION OF UTI (n=113)   Urinary Tract Infection P Value Yes No Gender of the patient Male 23 54 0.34 29.

9% 70.1% Female 14 22 38.9% 61.1% Total 37 76 32.7% 67.

3%  DISCUSSIONAcute 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 arare complication but hospitalization is frequently required (40%),particularly in infancy. Transient damage to the kidneys occurs in about 40% ofchildren affected and permanent damage occurs in about 5%10sometimes even following a single infection.

Symptoms are systemic rather thanlocalized in early childhood and consist of fever, lethargy, anorexia, andvomiting. UTI is caused by Escherichia coli in over 80% of cases11and treatment consists of a course of antibiotics.Children who have had oneinfection 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 UTIoccursmore commonly in girls than boys12.Febrile urinary tract infections have the highest incidence during the first yearof life in both sexes, whereas nonfebrile urinary tract infections occur predominantlyin girls older than 3 years14. After infancy, urinary tract infections confined to thebladder are generally accompanied by localized symptoms and are easily treated. Incontrast, the presence of fever increases the probability of kidney involvement(sensitivity, 53 to 84%; specificity, 44 to 92%)15 and is associated with an increasedlikelihood of underlying nephrourologic abnormalities and a greater risk of consequentrenal scarring. Kidneyscarring related to urinary tract infection has been considered a cause ofsubstantial long-termmorbidity16.

Thus, children with proven infections have been intensively evaluated andtreated, and they have often undergone surgery or have received long-term antibioticprophylaxis.15 Such approaches have been questioned17.18.A number of trials havebeen conducted or are under way to determine optimal approaches to the assessment and managementof initial febrile urinary tract infections and subsequent interventions for them.In our study, we studied thefrequency of UTI in children presenting with cerebral palsy and fever. Weobserved it to be 32.

7% with equal propensity of either gender towards UTI.Studies reporting the incidence and prevalence of UTI in children have variedby population, sampling method, and diagnostic criteria. Rates therefore varywidely, from 0.

25% in a small UK GP study19 to 13.5% in ahospital-based study of febrile infants20. Ozturk etal.

in Turkey has reported 32.5% frequency of UTI21 whichis comparable to present study 32.7%, but is much higher than the respective7.4% and 2.2% reportedby Reid and Borzyskowski in London22 and Hellquist et al.

in NorthCarolina23. The discrepancies in frequency of UTI in latter twostudies22 ,23 may be due to the prior use of antibiotics, althoughnot reported in our study. CP subjects more frequently had symptoms and signsof UTI, history of constipation and enuresis, prior history of UTI, urinalysesfindings and culture proven UTI than their age and sex matched comparatorswithout CP. Similar findings have also been reported by Ozturk et al. in Turkey21.

Parents and siblings have to carry Cerebral palsy from oneplace to other, because of difficulty in mobility and both manually propelledor electrically powered wheelchairs are often beyond the reach of thesefamilies. The are neglected children who stay supine for prolonged period oftime, with the majority developing pressure source on occiputs and buttocks andprolonged smearing by their faeces due to poor personal hygiene may increaserisk of UTI. Few of them may be urinary continent but due to poor mobility, UTImay develop easily following urinary retention resulting from difficulty ingetting to the toilets to micturate.

  Poorwater intake due to immobility results in kidney stones which may predispose toUTI24. In addition some of these children have high burden ofpinworms25 which may be linked to higher risk of UTI. Poorly mobileCP children had propensity to develop constipation which also contributes tohigher risk of UTI in this group of children. Furthermore, the propensity todeveloping constipation in poorly mobile CP children may also have contributed tothe higher risk of UTI in this group of children. Wefound that all the CP children with UTI are over-five in our study. Majority ofthe CP patients are over five (65%) were recruited in our study.

So thesefindings may probably result from recruitment bias. When CP patients come forfollow up in our clinics we should review symptoms of UTI as it presentssymptomatically, it should be confirmed and treated in order to prevent itspotential complications.  CONCLUSIONWe concluded from this studythat severe immobility in CP children is responsible for high prevalence ofUTI, therefore efforts should be made for effective physiotherapy, so that CPchildren can attain maximum mobility and independence. REFERENCESDelgado 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.

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