A new technique for fast and safe collection of urine in newborns Herreros Fernández ML, González Merino N, Tagarro García A, Pérez Seoane B, de la Serna Martínez M, Contreras Abad MT, García-Pose A. Arch Dis Child. 2013 Jan;98(1):27-9 Clinical question • 7 day old infant presents with temperature > 38. • Off feeds but otherwise appears well • Mildly coryzal but no other clear focus • Full septic screen – Blood cultures – Lumbar puncture – Urine – how would you obtain? Before or after antibiotics? Background to the study • Urine samples from infants and children are frequently requested: – Septic screen – Other clinical reasons eg. TORCH/metabolic screen • Collection in neonates and infants is challenging • Several methods have been trialled – – – – SPA (invasive, uncommonly performed) Catheterisation (invasive) Bag/pad urine (difficult to interpret the results if positive) Mid stream/ clean catch (patience required!) Local guidelines • SCH advise that a “midstream urine” or “cleancatch” is the preferred option • Recognise may be difficult and pad urines etc are acceptable • If “not possible” or “practical” catheter samples or SPA should be performed • Should not delay treatment when waiting for a urine if child appears unwell • Obtain x 2 urines if possible Collection of clean catch urine samples – local guidelines • Perineum cleaned with water • Small cardboard urine collecting pot held near the urethral opening until child passes urine • No indication as to how long to wait (!) Image removed for copyright reasons Need for a new method… Image removed for copyright reasons The solution… • Utilise “stimulation techniques” that facilitate emptying of bladder in cases of bladder dysfunction • Purpose of this study is to assess if can be used in neonates to encourage micturition and obtain a clean catch urine Picture removed for copyright purposes Methods • Prospective “feasibility and safety study” • Assessed 90 infants who needed urine collecting for a variety of clinical reasons – all less than 30 days • Primary end point was the success rate in obtaining an MSU within 5 minutes • Secondary variables were time to obtain the sample and any complications • No comparison group Procedure • Feed the baby – Breastfeed or bottle feed • 25 minutes after feeding clean the genitals • Administered sucrose to “lessen crying” • Hold the baby under the arms with legs dangling • Gently tap on bladder for 30 seconds • Massage sacrum for 30 seconds • Catch the urine Video demonstration • http://adc.bmj.com/content/98/1/27/suppl/DC1 Video removed for copyright purposes Results • 90 children included in study – 10 excluded due to “poor oral intake” • • • • • • Mean age approximately 6 days 86% succcess rate (passing urine within 5 minutes) Mean time for collection was 57 seconds No complications “Controlled crying” in all infants Now adopted as preferred method of urine collection in authors’ centre Critical appraisal • Difficult to appraise using CASP criteria or GATE as no direct comparison group • One previous study used a “vibration device” – times typically took one hour for infants to pass urine (Davies et al., 2008) • There is some previous evidence for technique – Abdominal vibration (similar to percussion) effective in patients with MS (Prasad et al., 2003) – Massage of lumbar region can cause detrusor contraction • No evidence of its use in neonates or infants prior to this study Limitations • Lack of control group – Eg. Would neonates fed 30 minutes before pass urine anyway when nappy removed? • No indication of parental preference – Is it more acceptable than eg catheterisation? • Do not comment on contamination rate/false positives for MSU from this technique • What is success rate if child not been fed recently (could it be used in our clinical scenario)? • Is it effective in older children? Conclusion • Undoubtedly a clinical problem • Is it an effective solution? • Results need replicating in different centre with control group • Wider range of ages should be included (? less than one year) • Would be useful to know parental opinions about technique and whether acceptable Will you be trying it? References Davies P, Creenwood R, Benger J. Randomised trial of a vibrating bladder stimulator—the time to pee study. Arch Dis Child 2008;93:423–4. Prasad RS, Smith SJ, Wright H. Lower abdominal pressure versus external bladder stimulation to aid bladder emptying in multiple sclerosis: a randomized controlled study. Clin Rehabil 2003;17:42–7.