Pediatric Primary Care Case Studies (109 page)

   Discuss the use of oral antibiotics, the importance of giving them on a routine basis, and completing any treatment antibiotics that are prescribed.

   Discuss potential side effects of antibiotics and any evaluation that is necessary.

   Reassure the family that with urinary tract infection prevention, the child will likely do well. It does require patience, however, to work with children this young to modify behavior.

   Provide positive reinforcement to the child for practicing the toileting habits that improve bladder and bowel emptying.

   Instruct parents to bring the child to the clinic for prompt evaluation of urine if there are any signs or symptoms of urinary tract infection.

   Discuss the importance of dysfunctional elimination management to prevent infection and promote VUR resolution.

Ashley is only 4 years old, but you tell her in simple terms about:

   the specific toilet posture to facilitate emptying (have the child demonstrate in the office)

   the importance of not delaying urination or stooling

   the use of a chart and stickers to reward her efforts

   the importance of an appropriate diet and fluid intake to decrease symptoms of constipation

When do you want to see this patient back again?

Renal ultrasound and voiding cystourethrogram should be obtained about 10 days after beginning treatment of a UTI. A time should be scheduled to review results with family, recheck the urine, and determine compliance with dysfunctional elimination management and antibiotic prophylaxis. An abdominal examination should be performed to assess for constipation. The bladder should not be percussible after voiding if the child is emptying well.

At the next visit 2 weeks later, Ashley is taking her antibiotics on a daily basis. She has been working hard on voiding every 2 hours and has been practicing the voiding techniques to help empty her bladder. Her abdomen is soft and nontender, and there is no evidence of a mass indicating constipation. The parents report that she is having a daily bowel movement that is soft and not painful. Her bladder is not percussible, and her urinalysis today is negative. Renal ultrasound and VCUG results are normal.

The plan will be to see her back in 6 to 8 weeks. If she continues to do well, then surveillance could be spread out to 6 months and then a year. At that point, her ultrasound and VCUG should be repeated.

Complications

There are rare cases in which children with dysfunctional elimination, UTI, and reflux have symptoms that persist or worsen, even with appropriate management. This outcome could indicate a neurologic abnormality, so evaluation of the lower spine by MRI may need to be done. Other symptoms that can be associated with neurologic issues are chronic back and lower extremity pain, gait abnormalities, and stool incontinence. Physical evidence of bony abnormalities can sometimes be seen on plain radiographs, or as sacral dimples, gluteal asymmetry, lower spine discolorations, or a sacral hair patch.