Is screening urinalysis in children worthwhile?

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Is screening urinalysis in children worthwhile?
EVIDENCE-BASED ANSWER

Screening urinalysis in asymptomatic children has not been shown to be beneficial (strength of recommendation: B; based on extrapolation from 1 meta-analysis). It is unlikely to be cost-effective and should be discontinued. While random urinalyses can be used for case finding of glucosuria, hematuria, pyuria, bacteriuria, and proteinuria, the routine use of screening urinalysis in asymptomatic patients is not likely to be an effective strategy.

 

Evidence summary

The prevalence of urinary tract infection in childhood has been estimated to be roughly 1%.1 For those children with asymptomatic bacteriuria, fewer than 10% progress to symptomatic urinary tract infections.2 The prevalence of other glomelonephropathies is <0.05%.3,4 Currently vailable screening urinalyses using chemical dipstick testing have reported sensitivities ranging from 53% to 93% and specificities of 72% to 98% for detecting significant bacteriuria.5 All positive screening tests for acteriuria require confirmation by standard urine culture.

No prospective randomized trials of screening urinalysis in childhood have been published to date. Expert opinion varies as to the necessity of screening urinalysis. No prospective randomized trials demonstrate improved outcomes, and limited evidence suggests that detection and treatment of asymptomatic bacteriuria improves long-term outcomes such as renal scarring, hypertension, or pyelone phritis.6

Recommendations from others

The American Academy of Pediatrics recommends 1 screening dipstick urinalysis at age 5.7 The American Academy of Family Physicians,8 Bright Futures,9 Canadian Task Force on the Periodic Health xamination,10 and the United States Preventive Services Task Force11 do not recommend screening for asymptomatic bacteriuria in children. The Institute for Clinical Systems Improvement recommends that consideration be given to eliminating routine urinalyses in asymptomatic children.12

CLINICAL COMMENTARY

Numerous false-positives may lead to harmful interventions
Julian T. Hsu, MD
A. F. Williams Family Medicine Center, University of Colorado Health Sciences Center, Denver

In my practice, I have rarely found screening urinalysis to be useful. As mentioned above, it is not cost-effective and currently no available data demonstrate that outcomes are improved. What is not mentioned is the likely high rate of false-positive findings that would need further investigation—eg, hematuria and proteinuria. These investigations could be invasive and potentially harmful and would increase costs further, not to mention add unnecessary worry to concerned parents. Some parents still request a urinalysis, largely due to habits from a previous physician. I have found that a brief discussion of the risks and benefits of a screening urinalysis is enough to reassure parents.

References

1. Jakobsson B, Esbjorner E, Hansson S, et al. Minimum incidence and diagnostic rate of first urinary infection. Pediatrics 1999;104:222-226.

2. US Public Health Service. Screening urinalysis in children and adolescents. Ch. 10 in: The Clinician’s Handbook of Preventive Services: Put Prevention into Practice. 2nd ed. Washington, DC: US Dept of Health and Human Services, Public Health Service, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1998.

3. Cho BS, Kim SD, Choi YM, Kang HH. School urinalysis screening in Korea: prevalence of chronic renal disease. Pediatr Nephrol 2001;16:1126-1128.

4. Lin CY, Hsieh CC, Chen WP, Yang LY, Wang HH. The underlying diseases and follow-up in Taiwanese children screened by urinalysis. Pediatr Nephrol 2001;16:232-237.

5. Liao JC, Churchill BM. Pediatric urine testing. Pediatr Clin North Am 2001;48:1425-1440.

6. Kemper KJ, Avner ED. The case against screening urinalyses for asymptomatic bacteriuria in children. Am J Dis Child 1992;146:343-346.

7. American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine. Recommendations for Preventive Pediatric Health Care. Document RE9939. March 2002.

8. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. Kansas City, Mo: American Academy of Family Physicians. August, 2002.

9. Bright Futures: Guidelines for Health Supervision of Infants Children and adolescents. Washington, DC: Bright Futures at Georgetown University; 2002. Available at: www.brightfutures.org/bf2/about.html. Accessed on September 22, 2003.

10. Canadian Task Force on the Periodic Health Examination. Screening for urinary infection in asymptomatic infants and children. Ch. 21 in: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Canada Communication Group; 1994.

11. US Preventive Services Task Force. Screening for asymptomatic bacteriuria. Ch. 31 in: Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams & Wilkins; 1996.

12. Institute for Clinical Systems Improvement. Health Care Guideline: Preventive Services for Children and Adolescents. September, 2002. Available at: www.icsi.org. Accessed on September 22, 2003.

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Mark B. , MD, MS
Uniformed Services University of the Health Sciences, Bethesda, MD;

Laura Wilder, MLS
University of Texas Southwestern Medical Center Library, Dallas

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Uniformed Services University of the Health Sciences, Bethesda, MD;

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University of Texas Southwestern Medical Center Library, Dallas

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Uniformed Services University of the Health Sciences, Bethesda, MD;

Laura Wilder, MLS
University of Texas Southwestern Medical Center Library, Dallas

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EVIDENCE-BASED ANSWER

Screening urinalysis in asymptomatic children has not been shown to be beneficial (strength of recommendation: B; based on extrapolation from 1 meta-analysis). It is unlikely to be cost-effective and should be discontinued. While random urinalyses can be used for case finding of glucosuria, hematuria, pyuria, bacteriuria, and proteinuria, the routine use of screening urinalysis in asymptomatic patients is not likely to be an effective strategy.

 

Evidence summary

The prevalence of urinary tract infection in childhood has been estimated to be roughly 1%.1 For those children with asymptomatic bacteriuria, fewer than 10% progress to symptomatic urinary tract infections.2 The prevalence of other glomelonephropathies is <0.05%.3,4 Currently vailable screening urinalyses using chemical dipstick testing have reported sensitivities ranging from 53% to 93% and specificities of 72% to 98% for detecting significant bacteriuria.5 All positive screening tests for acteriuria require confirmation by standard urine culture.

No prospective randomized trials of screening urinalysis in childhood have been published to date. Expert opinion varies as to the necessity of screening urinalysis. No prospective randomized trials demonstrate improved outcomes, and limited evidence suggests that detection and treatment of asymptomatic bacteriuria improves long-term outcomes such as renal scarring, hypertension, or pyelone phritis.6

Recommendations from others

The American Academy of Pediatrics recommends 1 screening dipstick urinalysis at age 5.7 The American Academy of Family Physicians,8 Bright Futures,9 Canadian Task Force on the Periodic Health xamination,10 and the United States Preventive Services Task Force11 do not recommend screening for asymptomatic bacteriuria in children. The Institute for Clinical Systems Improvement recommends that consideration be given to eliminating routine urinalyses in asymptomatic children.12

CLINICAL COMMENTARY

Numerous false-positives may lead to harmful interventions
Julian T. Hsu, MD
A. F. Williams Family Medicine Center, University of Colorado Health Sciences Center, Denver

In my practice, I have rarely found screening urinalysis to be useful. As mentioned above, it is not cost-effective and currently no available data demonstrate that outcomes are improved. What is not mentioned is the likely high rate of false-positive findings that would need further investigation—eg, hematuria and proteinuria. These investigations could be invasive and potentially harmful and would increase costs further, not to mention add unnecessary worry to concerned parents. Some parents still request a urinalysis, largely due to habits from a previous physician. I have found that a brief discussion of the risks and benefits of a screening urinalysis is enough to reassure parents.

EVIDENCE-BASED ANSWER

Screening urinalysis in asymptomatic children has not been shown to be beneficial (strength of recommendation: B; based on extrapolation from 1 meta-analysis). It is unlikely to be cost-effective and should be discontinued. While random urinalyses can be used for case finding of glucosuria, hematuria, pyuria, bacteriuria, and proteinuria, the routine use of screening urinalysis in asymptomatic patients is not likely to be an effective strategy.

 

Evidence summary

The prevalence of urinary tract infection in childhood has been estimated to be roughly 1%.1 For those children with asymptomatic bacteriuria, fewer than 10% progress to symptomatic urinary tract infections.2 The prevalence of other glomelonephropathies is <0.05%.3,4 Currently vailable screening urinalyses using chemical dipstick testing have reported sensitivities ranging from 53% to 93% and specificities of 72% to 98% for detecting significant bacteriuria.5 All positive screening tests for acteriuria require confirmation by standard urine culture.

No prospective randomized trials of screening urinalysis in childhood have been published to date. Expert opinion varies as to the necessity of screening urinalysis. No prospective randomized trials demonstrate improved outcomes, and limited evidence suggests that detection and treatment of asymptomatic bacteriuria improves long-term outcomes such as renal scarring, hypertension, or pyelone phritis.6

Recommendations from others

The American Academy of Pediatrics recommends 1 screening dipstick urinalysis at age 5.7 The American Academy of Family Physicians,8 Bright Futures,9 Canadian Task Force on the Periodic Health xamination,10 and the United States Preventive Services Task Force11 do not recommend screening for asymptomatic bacteriuria in children. The Institute for Clinical Systems Improvement recommends that consideration be given to eliminating routine urinalyses in asymptomatic children.12

CLINICAL COMMENTARY

Numerous false-positives may lead to harmful interventions
Julian T. Hsu, MD
A. F. Williams Family Medicine Center, University of Colorado Health Sciences Center, Denver

In my practice, I have rarely found screening urinalysis to be useful. As mentioned above, it is not cost-effective and currently no available data demonstrate that outcomes are improved. What is not mentioned is the likely high rate of false-positive findings that would need further investigation—eg, hematuria and proteinuria. These investigations could be invasive and potentially harmful and would increase costs further, not to mention add unnecessary worry to concerned parents. Some parents still request a urinalysis, largely due to habits from a previous physician. I have found that a brief discussion of the risks and benefits of a screening urinalysis is enough to reassure parents.

References

1. Jakobsson B, Esbjorner E, Hansson S, et al. Minimum incidence and diagnostic rate of first urinary infection. Pediatrics 1999;104:222-226.

2. US Public Health Service. Screening urinalysis in children and adolescents. Ch. 10 in: The Clinician’s Handbook of Preventive Services: Put Prevention into Practice. 2nd ed. Washington, DC: US Dept of Health and Human Services, Public Health Service, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1998.

3. Cho BS, Kim SD, Choi YM, Kang HH. School urinalysis screening in Korea: prevalence of chronic renal disease. Pediatr Nephrol 2001;16:1126-1128.

4. Lin CY, Hsieh CC, Chen WP, Yang LY, Wang HH. The underlying diseases and follow-up in Taiwanese children screened by urinalysis. Pediatr Nephrol 2001;16:232-237.

5. Liao JC, Churchill BM. Pediatric urine testing. Pediatr Clin North Am 2001;48:1425-1440.

6. Kemper KJ, Avner ED. The case against screening urinalyses for asymptomatic bacteriuria in children. Am J Dis Child 1992;146:343-346.

7. American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine. Recommendations for Preventive Pediatric Health Care. Document RE9939. March 2002.

8. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. Kansas City, Mo: American Academy of Family Physicians. August, 2002.

9. Bright Futures: Guidelines for Health Supervision of Infants Children and adolescents. Washington, DC: Bright Futures at Georgetown University; 2002. Available at: www.brightfutures.org/bf2/about.html. Accessed on September 22, 2003.

10. Canadian Task Force on the Periodic Health Examination. Screening for urinary infection in asymptomatic infants and children. Ch. 21 in: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Canada Communication Group; 1994.

11. US Preventive Services Task Force. Screening for asymptomatic bacteriuria. Ch. 31 in: Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams & Wilkins; 1996.

12. Institute for Clinical Systems Improvement. Health Care Guideline: Preventive Services for Children and Adolescents. September, 2002. Available at: www.icsi.org. Accessed on September 22, 2003.

References

1. Jakobsson B, Esbjorner E, Hansson S, et al. Minimum incidence and diagnostic rate of first urinary infection. Pediatrics 1999;104:222-226.

2. US Public Health Service. Screening urinalysis in children and adolescents. Ch. 10 in: The Clinician’s Handbook of Preventive Services: Put Prevention into Practice. 2nd ed. Washington, DC: US Dept of Health and Human Services, Public Health Service, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1998.

3. Cho BS, Kim SD, Choi YM, Kang HH. School urinalysis screening in Korea: prevalence of chronic renal disease. Pediatr Nephrol 2001;16:1126-1128.

4. Lin CY, Hsieh CC, Chen WP, Yang LY, Wang HH. The underlying diseases and follow-up in Taiwanese children screened by urinalysis. Pediatr Nephrol 2001;16:232-237.

5. Liao JC, Churchill BM. Pediatric urine testing. Pediatr Clin North Am 2001;48:1425-1440.

6. Kemper KJ, Avner ED. The case against screening urinalyses for asymptomatic bacteriuria in children. Am J Dis Child 1992;146:343-346.

7. American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine. Recommendations for Preventive Pediatric Health Care. Document RE9939. March 2002.

8. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examinations. Kansas City, Mo: American Academy of Family Physicians. August, 2002.

9. Bright Futures: Guidelines for Health Supervision of Infants Children and adolescents. Washington, DC: Bright Futures at Georgetown University; 2002. Available at: www.brightfutures.org/bf2/about.html. Accessed on September 22, 2003.

10. Canadian Task Force on the Periodic Health Examination. Screening for urinary infection in asymptomatic infants and children. Ch. 21 in: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Canada Communication Group; 1994.

11. US Preventive Services Task Force. Screening for asymptomatic bacteriuria. Ch. 31 in: Guide to Clinical Preventive Services. 2nd ed. Baltimore: Williams & Wilkins; 1996.

12. Institute for Clinical Systems Improvement. Health Care Guideline: Preventive Services for Children and Adolescents. September, 2002. Available at: www.icsi.org. Accessed on September 22, 2003.

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