Browse the corpus

Urinary tract infection (UTI) is one of the most common infectious diseases in children, characterized by a high incidence and a propensity for recurrence (). Clinical manifestations vary by age, with symptoms often atypical in young infants and toddlers, leading to frequent missed or incorrect diagnoses (). Although modern diagnostic and therapeutic approaches have reduced mortality rates to nearly zero, UTIs remain a significant cause of renal scarring, urinary stones, hypertension, progressive renal damage, and renal failure in children (). Since daily care for affected children is primarily provided by non-professional caregivers such as parents, UTI prevention depends heavily on sustained home management. Timely identification of risk factors and implementation of preventive measures are crucial to avoiding disease onset and recurrence. Health education plays a pivotal role in disease prevention and health promotion; however, current educational content for pediatric UTIs is limited and lacks systematic, comprehensive, evidence-based guidance. Additionally, parents demonstrate a significant demand for information regarding the prevention, diagnosis, treatment, and prognosis of pediatric UTIs ().

Therefore, this study adopts a disease lifecycle management perspective, integrating the background, needs, and preferences of affected children. Using evidence-based methods, it synthesizes the best available evidence to provide comprehensive health education throughout the pediatric UTI cycle. To our knowledge, no prior evidence summary has systematically collected and graded pediatric UTI health education evidence across the full disease continuum from 14 top-tier sources. This study offers a caregiver-oriented, actionable framework that translates clinical guidelines into practical health education messages. It provides healthcare professionals with a reference for developing holistic health education strategies.

According to the ‘6S’ evidence resource model, evidence retrieval is searched from the top-down. The databases searched included: BMJ Best Practice, Up To Date, National Institute for Health and Care Excellence (NICE), Guidelines International Network (GIN), National Guideline Clearinghouse (NGC), Registered Nurses’Association of Ontario (RNAO), Canadian Medical Association (CMA), New Zealand Ministry of Health Guidance Library (NZ MOH Guidance Library), MedLive, American Academy of Pediatrics (AAP), European Association of Urology (EAU), Cochrane Library, EMbase, Ovid MEDLINE, PubMed, Web of Science, CINAHL, China Knowledge Resource Integrated Database (CNKI), Wanfang, VIP, and SinoMed.

The search terms were created based on the combination of Medical Subject Headings andfree terms, and search encompassed clinical decisions, guidelines, evidence summaries, expertconsensus statements, and systematic reviews. The search terms are “Child/children/childhood/pediatric/toddlers/infants/pediatric patients/young children”; “urinary system infection/urinary infection*/urinary tract infection/urine tract infection/genitourinary tract infection/UTI”; “health education/healthy education/education/health care education/Community Health Education/management/nursing”; “guideline/clinical practice guideline*/Best practice/Meta-Analysis/Systematic Review/consensus.”The search strategy for PubMed is presented as follows:((((“Urinary Tract Infections”[Mesh]) OR (“urinary system infection”[Title/Abstract] OR “urinary infection*”[Title/Abstract] OR “urine tract infection”[Title/Abstract] OR “genitourinary tract infection”[Title/Abstract] OR “UTI”[Title/Abstract])) AND ((“Health Education”[Mesh]) OR (“healthy education”[Title/Abstract] OR “education”[Title/Abstract] OR “health care education”[Title/Abstract] OR “Community Health Education”[Title/Abstract] OR “management”[Title/Abstract] OR “nursing”[Title/Abstract]))) AND ((“Child”[Mesh]) OR (“children”[Title/Abstract] OR “childhood”[Title/Abstract] OR “pediatric”[Title/Abstract] OR “toddlers”[Title/Abstract] OR “infants”[Title/Abstract] OR “pediatric patients”[Title/Abstract] OR “young children”[Title/Abstract]))) AND ((“Guidelines as Topic”[Mesh]) OR (“guideline”[Title/Abstract] OR “clinical practice guideline*”[Title/Abstract] OR “Best practice”[Title/Abstract] OR “Systematic Review”[Title/Abstract] OR “consensus”[Title/Abstract])). The search spanned from database inception to October 31, 2025.

Inclusion criteria : (1) Clinical decision, guidelines, evidence summaries, systematic reviews, meta-analyses, or expert consensus on health education content for pediatric UTIs; (2) the latest version of guidelines; (3) draft or trial versions when formal guidelines are unavailable; (4) published in Chinese or English. Exclusion criteria : (1) full text unavailable; (2) Guideline interpretations, direct translations, or duplicate publications.

The guidelines were appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework (), which includes 23 items across six domains, each scored 1–7. Recommendation grades (A, B, C) were determined based on domain-specific standardized percentages (calculated as: (obtained score − minimum)/(maximum − minimum) × 100%). Evidence summaries were evaluated using the CASE tool (). Expert consensus and systematic reviews were assessed using JBI critical appraisal checklists (). High-grade Clinical decision-making were directly referenced (). Three researchers independently appraised guidelines; two researchers appraised other document types. Disagreements were resolved through discussion or consultation with evidence-based nursing specialists.

Two reviewers independently screened the retrieved literature against predefined inclusion and exclusion criteria. Disagreements were resolved through discussion until consensus was reached or by consulting a third reviewer. Evidence synthesis followed three principles: (1) when content was consistent, selecting concise, clear, and professionally appropriate evidence; (2) when content was complementary, merging evidence logically; and (3) when content conflicted, prioritizing evidence-based studies, high-quality evidence, and the most recent authoritative sources. Evidence was graded according to the 2014 JBI Evidence Grading System (Levels 1–5) (). The strength of recommendations (A: strong, B: weak) was determined based on the JBI FAME structure (Feasibility, Appropriateness, Meaningfulness, Effectiveness).

A total of 1,285 publications were retrieved, of which 14 met the inclusion criteria after screening (, ). The study selection process is presented in , and the general information of the included literature is shown in .

This study included five guidelines (), Quality assessment results are shown in . Three expert consensuses (, , ) met all six criteria and were included. One systematic review () met all 11 criteria and was included. One evidence summary () met all 10 criteria and was included. Additionally, four Clinical Decision-Making () were directly cited as high-level evidence.

The evidence was extracted from the final literature, and the evidence was evaluated by JBI grading of evidence and recommendation system. Through the induction and integration of the evidence, the evidence was finally summarized from eight aspects: Disease awareness, Symptom recognition, Diagnosis and evaluation, Urine Specimen Collection, imaging examinations, therapeutic medication, recurrence prevention and Follow-up Instructions, and 42 best evidences were formed, as shown in .

Pediatric UTI is a common condition with a high recurrence rate. Effective health education is therefore essential for prevention and home-based management. Accurate disease awareness, early symptom recognition, and proactive preventive measures are critical to reducing recurrence, improving patient outcomes, and enhancing family quality of life. Following a systematic search, 14 relevant articles were included. Through quality appraisal and evidence grading, 42 best-evidence statements across eight domains were synthesized. The overall quality of the evidence is high, indicating strong scientific rigor and considerable clinical utility.

Evidence statements 1–9 in this study focus on disease awareness and symptom recognition in pediatric urinary tract infection (UTI). The clinical manifestations of UTI in children are diverse. They range from asymptomatic bacteriuria and urinary irritative symptoms—with or without fever and gastrointestinal disturbances such as abdominal pain and vomiting—to potentially life-threatening sepsis. In infants and young children, symptoms are particularly nonspecific, complicating diagnosis relative to adults and often leading to delayed treatment. This delay increases the risk of serious complications, including renal scarring and end-stage renal disease. Almatrafi et al. () reported that most parents cannot recognize UTI symptoms in their children and lack knowledge of associated risks and treatment, contributing to misdiagnosis or poor treatment adherence. Similarly, Gates et al. () observed that parents frequently experience fear and anxiety regarding their child’s UTI, an emotional response rooted in insufficient understanding of the disease’s presentation. When children exhibit nonspecific symptoms, parents struggle to identify the underlying problem. Consequently, lower parental knowledge of UTIs is associated with greater disease uncertainty. Thus, identifying gaps in parental knowledge regarding pediatric UTIs and their prevention is critically important.

The occurrence of pediatric UTI is closely associated with multiple factors, including age, vesicoureteral reflux, phimosis, bladder and bowel dysfunction (BBD), inadequate fluid intake, habitual urine retention, allergic predisposition, reduced immunoglobulin levels, anemia, and malnutrition (). Identifying these predisposing factors enables adherence to standardized hygiene practices and targeted behavioral interventions, which significantly reduce and help prevent UTIs (). Caregivers require not only knowledge of the disease, its risk factors, and complications but also essential practical skills. These include identifying and eliminating UTI risk factors; reducing the risk of urethral contamination (e.g., preventing vulvar and preputial inflammation, promoting good hygiene practices, and changing underwear daily); clearing pathogens from the bladder (e.g., ensuring complete bladder emptying, maintaining adequate fluid intake, voiding regularly, and avoiding urine retention); and recognizing early symptoms to enable prompt response ().

Diagnosing UTI in infants and young children remains challenging. Current evidence suggests that UTI should be considered in any child with fever of unknown origin without an identifiable cause (, ). Urine culture is the “gold standard” for UTI diagnosis (), but it is accurate only when specimen collection is performed properly. The collection technique directly influences both the timeliness and accuracy of diagnosis (). Prompt assessment and diagnosis are essential to prevent short-term complications (e.g., sepsis) as well as long-term sequelae, including renal scarring, chronic kidney disease, and hypertension (). However, due to difficulties in collecting urine specimens from infants and young children—coupled with their atypical clinical presentations—delayed or missed diagnoses are common. Ensuring correct and timely urine specimen collection is therefore clinically important. Research indicates that insufficient feeding prior to collection reduces the success rate of urine collection; thus, adequate feeding should be provided beforehand (). It is recommended that infants be breastfed or bottle-fed for no more than 20 min, with collection initiated 20–25 min after feeding (), as infants typically empty their bladders 20–30 min post-feeding.

Nevertheless, in clinical practice, healthcare providers often lack awareness of assessing the infant’s feeding status, resulting in missed optimal collection windows. Consequently, before collecting urine specimens from infants and young children, providers should strengthen feeding-related education and administer appropriate feeding based on the child’s age and body weight (allowing extended feeding time for those who have difficulty feeding). During the urine sample collection and testing process, aseptic technique must be strictly adhered to, and unnecessary delays avoided. If non-invasive methods fail to yield a clean urine sample, an invasive collection method should be employed to ensure sample accuracy, thereby enabling timely and precise diagnosis.

The primary role of imaging is to identify congenital anomalies of the kidney and urinary tract (CAKUT) affecting long-term renal outcomes. Renal and bladder ultrasound (RBUS), a non-invasive, radiation-free screening tool, can assess structural abnormalities such as hydronephrosis and renal dysplasia. According to NICE guidelines, RBUS should be performed in all UTI patients aged <6 months, whereas it may not be routinely required in older children who respond well to treatment (). Although this restrictive strategy is cost-effective, it may miss a considerable proportion of urinary tract abnormalities (). As a first-line screening tool, guidelines generally recommend performing RBUS 2–4 weeks after the first febrile UTI. This timing avoids false-positive findings during the acute phase and enables better detection of renal and urinary tract abnormalities. For complicated or atypical UTIs—such as those presenting with sepsis, fever lasting >72 h, or non- Escherichia coli infection—RBUS should be performed during the acute phase ().

Voiding cystourethrography (VCUG) is the gold standard for diagnosing and grading vesicoureteral reflux (VUR) () and can clearly delineate urethral and bladder anatomy, making it essential prior to planning surgical intervention for VUR (). However, this technique has disadvantages, including radiation exposure and patient discomfort from catheterization. Most guidelines consider VCUG not a routine indication but rather reserved for cases where RBUS suggests urinary tract malformations or other specific clinical circumstances ().

In contrast, the 2021 EAU/ESPU update suggests that relying solely on RBUS may miss up to 33% of children with structural abnormalities. Accordingly, it recommends that all children <1 year of age with febrile UTI undergo imaging to rule out VUR. The guidelines propose two strategies: the “bottom-up” approach (VCUG first, followed by DMSA scan if positive) and the “top-down” approach (DMSA scan first, followed by VCUG if positive) (). Each method has its advantages. Comparative effectiveness analyses based on the RIVUR/CUTIE database indicate that although the top-down approach is associated with a higher risk of UTI recurrence, it reduces the need for VCUG and RBUS (). Synthesizing the available evidence, VCUG is recommended in the following situations: after the first febrile UTI when the pathogen is non- E. coli , or when RBUS reveals renal dysplasia, high-grade hydronephrosis, ureteral dilatation, urothelial thickening, or bladder abnormalities. VCUG is also indicated after every second febrile UTI episode. Furthermore, VCUG is always required prior to planning surgical intervention for VUR ().

Antibiotic treatment decisions for pediatric UTI require a delicate balance between acute infection control and long-term renal outcomes. Empirical antibiotic therapy should be initiated immediately after obtaining a urine culture specimen (, ). Its core value extends beyond eradicating infection and improving clinical symptoms to include preventing bacteremia and renal parenchymal damage, particularly in neonates during the first few months of life when the immune system is immature (). Regarding treatment duration, guidelines provide stratified recommendations based on infection site and age. Febrile uncomplicated UTI warrants 7–10 days of treatment, whereas complicated UTI requires 10–14 days. For children >3 months of age with lower urinary tract infection confined to the lower tract, the duration may be shortened to 5 days. For infants <3 months of age—owing to their immature immune system, incomplete blood–brain barrier, and high risk of complications—intravenous administration for 10–14 days is recommended to ensure adequate renal tissue penetration and complete eradication of infection (, , , ). However, the long-term benefits of prophylactic antibiotics remain controversial. Although they reduce UTI recurrence rates, their efficacy in preventing renal scarring is limited (). Studies have shown no significant difference in the incidence of renal scarring between prophylaxis and control groups. Moreover, long-term use may increase the risk of recurrence by 2.4-fold (). Consequently, guidelines have shifted away from routine prophylactic antibiotic use in children with normal urinary tract anatomy and no bladder and bowel dysfunction. Instead, prophylaxis should be considered on an individualized basis only for those with moderate to severe (grade III–V) vesicoureteral reflux or recurrent febrile infections with risk of renal injury ().

Adherence is a critical yet often overlooked determinant of treatment success. Studies indicate that among children with recurrent UTI, only 32.2% adhere to long-term antimicrobial regimens, and 19% completely fail to use the prescribed medication (). This gap stems from several factors: parental misconceptions that treatment can be discontinued once symptoms improve, difficulties in administering medication to children, fatigue with long-term therapy, and excessive concerns about antibiotic safety. In summary, current evidence does not support routine prophylactic antibiotic use in children with recurrent UTI following their first infection. Treatment success depends not only on the prescription itself but also on improving adherence through parental education—covering disease risk factors, the importance of completing full treatment courses, and the benefits and barriers of preventive behaviors—alongside systematic strategies such as simplified dosing regimens and digital reminder tools. Only by achieving a delicate balance among efficacy, safety, cost-effectiveness, and antimicrobial resistance control can long-term renal outcomes in children be maximally protected.

Children, as a special population with limited self-protection capabilities, remain susceptible to various adverse factors that may lead to infection. The prevention of pediatric urinary tract infections (UTIs) largely depends on home-based management. Therefore, addressing modifiable risk factors is essential to prevent recurrent infections.

Studies have identified BBD as a significant risk factor for both the occurrence and recurrence of pediatric UTIs, as well as a key contributor to the progression of renal scarring (, ). BBD refers to lower urinary tract dysfunction, clinically characterized by a range of lower urinary tract and bowel symptoms, including urgency, urinary withholding, daytime urinary incontinence, constipation, and painful defecation (). A major concern for the long-term prognosis of patients with BBD is incomplete bladder emptying, elevated intravesical pressure, and invasion of the urothelium by enteric pathogens—all of which contribute to UTI recurrence (). Furthermore, fecal retention due to constipation can lead to urinary stasis by compressing the bladder and elongating the urethra, thereby promoting pathogen adhesion and increasing UTI risk ().

Conservative treatment for BBD includes timed voiding, pelvic floor awareness training, fluid management, and treatment or prevention of constipation. Approximately half of patients experience improvement with conservative measures alone (). Urotherapy, constipation management, and other conservative strategies are central to BBD treatment. Studies indicate that adding secondary non-pharmacological interventions to urotherapy and constipation management can improve lower urinary tract symptoms and reduce the risk of UTI recurrence, with far fewer side effects than pharmacological or surgical treatments ().

For children with UTI and inadequate fluid intake, increased fluid consumption is encouraged. Adequate hydration reduces bladder retention time and promotes bacterial clearance. However, fluid overload may lead to bladder overdistension, which can induce voiding dysfunction and increase post-void residual (PVR) volume. A voiding frequency/fluid intake chart can assist parents in monitoring their child’s voiding frequency and fluid intake (). Timed voiding is recommended, typically every 2–3 h during the day. Older children may use watch alarms or timers as reminders to reduce urine retention time and avoid bladder overdistension (). Additionally, some children habitually delay voiding due to concerns about insufficient privacy or poor hygiene in school bathrooms. Behavioral issues arising during toilet training—such as habitual resistance, fear or anxiety, and power struggles with parents or caregivers—may also contribute to voiding delay. The goal of corrective voiding interventions is to restore normal bladder and sphincter function and reestablish healthy voiding habits. A daily record should be maintained after initiating such interventions. A voiding diary should include the time and volume of each void, timing of incontinence episodes, fluid intake, bowel movement times, and episodes of fecal incontinence. Parents and age-appropriate children should be educated on normal voiding habits. Key recommendations include monitoring proper voiding posture (avoiding positions that hinder voiding, such as forcefully crossing the legs, squatting, or applying perineal pressure with hands or heels), encouraging voiding proactively before the urge is felt, emptying the bladder completely, and avoiding abdominal straining. A reward system is also recommended to enhance children’s adherence and self-confidence ().

Regarding dietary nutrition, Uwaezuoke et al. identified malnutrition as a predisposing factor for pediatric UTI (). Secretory immunoglobulin A (sIgA) in urine represents a defense mechanism against UTIs, and its role in the pathogenesis of UTI episodes has been reported. Low urinary sIgA may be an important predisposing factor for recurrent UTIs. One of the impacts of malnutrition on the immune system is a diminished IgA response (). Therefore, children require adequate nutrition to enhance immunity and resist bacterial invasion. Caregivers should consistently monitor the child’s nutritional status to prevent malnutrition. Additionally, reducing intake of foods that may provoke bladder overactivity—such as caffeine, orange juice, tomato products, and spicy foods—is recommended ().