Editor—Jadresic is concerned that our nurse led study of general practice management of children with urine infection resulted in many children undergoing imaging but few kidney scars being found. Sandell also advocates investigating fewer children, as he believes serious disease is rare.
Their conclusions are misleading, however, because they ignore the many children whose scarring related hypertension or renal failure does not present until adult life. Some 20 adults receive transplants annually in England's north east, and many more develop hypertension resulting from scarring that started in infancy.1 The question remains, can scarring be prevented, rather than just imaged once it has happened?
We agree with Jadresic that the priority in managing children with urinary tract infections is for prompt recognition and treatment which may allow prevention of scarring. We have shown that in about three quarters of infants (who are at greatest risk of scarring) urinary tract infection is not normally diagnosed but that our study intervention improved this. Our study practices also identified 12 infants with vesicoureteric reflux and infection before they developed scarring.
Sandell argues for basing all practice on evidence, but often no ideal data exist, so clinical plans need to be formulated from the best available evidence plus theoretical speculation. Until early diagnosis is consistently achieved there is no point in constructing randomised controlled intervention trials. Our model can produce a reliable diagnosis rate that will allow questions to be addressed, such as the value of particular imaging strategies and antibiotic prophylaxis. That is the next stage.
Competing interests: None declared.
References
- 1.Vernon SJ, Coulthard MG, Lambert HJ, Keir MJ, Matthews JNS. New renal scarring in children who at age 3 and 4 years had had normal scans with dimercaptosuccinic acid: follow up study. BMJ 1997;315: 905-908. [DOI] [PMC free article] [PubMed] [Google Scholar]