WASHINGTON, DC USA (UroToday.com) - The pediatric VUR guidelines have been recently revised but are currently not available.
The pediatric VUR guidelines have been recently revised but are currently not available. It is anticipated that the guidelines will be available online first on the AAP website, perhaps the end of May early June of 2011.
The 1999 guidelines focused primarily on the initial diagnosis and screening of VUR; the 2010 guidelines focused on the management of those children with known VUR. The 2010 guidelines addressed management of the child with VUR over one year of age, management of the infant with VUR, and management of VUR in children with bowel and bladder dysfunction. Screening was addressed as it pertained to the screening of siblings and offspring of patients with reflux and the infant with prenatal hydronephrosis. The initial evaluation of the child with reflux should include height, weight and urinalysis to rule out proteinuria and infection. Serum creatinine is an option but checking it is recommended in the child with bilateral anomalies. Renal US is recommended to assess for renal damage. A DMSA is considered in children with higher grades of VUR, an abnormal ultrasound and/or recurrent UTIs. Prophylaxis is recommended in all children < 1 year of age with a history of febrile UTI. In the absence of a history of febrile UTI, continuous prophylaxis is recommended in the infant with grades 3 to 5 VUR. With respect to bowel/bladder dysfunction, symptoms of underlying bowel/bladder dysfunction should be sought and if present should be treated prior to considering any surgical intervention for VUR. Lastly, in infants with reflux diagnosed as part of a screening evaluation, prophylaxis is an option for low grade VUR.
Dr. Greenfield discussed the NICE recommendations regarding VUR. The recommendations categorized UTIs as typical (responding to antibiotics within 48 hrs), atypical (including abnormal ultrasound, HTN, voiding dysfunction, spinal anomaly, family hx VUR) and recurrent.
In the infant < 6 months of age with typical UTI, an ultrasound only is recommended. VCUG is indicated if the US is abnormal. If there is a history of an atypical UTI then an US, DMSA and VCUG are warranted. For the child 6 months to 3 years of age, no evaluation is indicated for the typical UTI, whereas for the atypical/recurrent an US is recommended at the time of infection and a VCUG warranted if the infection is with an organism that is not e. coli. Over 3 years of age, no VCUG is recommended as initial evaluation with any of the types UTIs. The NICE guidelines have been criticized as potentially missing significant VUR and scarring.
Moderator was Dr. Saul Greenfield and panelists were Dr. Steven Skoog and Dr. Julian Wan at the American Urological Association (AUA) Annual Meeting - May 14 - 19, 2011 - Walter E. Washington Convention Center, Washington, DC USA
Reported for UroToday by Pamela I. Ellsworth, MD, Associate Professor Surgery (Urology), Alpert Medical School of Brown University.
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