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Paediatrica Indonesiana VOLUME 48

May ‡

NUMBER 3

Original Article

Relationship between protein energy malnutrition and urinary tract infection in children Arief Wijaya Rosli, Syarifuddin Rauf, J. S. Lisal, Husein Albar, Dasril Daud

Abstract

Background8ULQDU\WUDFWLQIHFWLRQV 87, LVDFRPPRQKHDOWK problem in children. Its occurrence depends on several predis posing factors and individual immunocompetence. Children ZLWKSURWHLQHQHUJ\PDOQXWULWLRQ 3(0 KDYHLPSDLUHGLPPXQH function. Thus early detection and prompt treatment of associated infections in children with PEM are very important. Objective To determine the relationship between PEM and the occurrence of UTI in children. Methods 7KLVFURVVVHFWLRQDOVWXG\FRQGXFWHGLQ'U:DKLGLQ6XG LURKXVRGR+RVSLWDODQG/DEXDQJ%DML*HQHUDO+RVSLWDO0DNDVVDU EHWZHHQ0DUFKDQG-XQH7KHWDUJHWSRSXODWLRQ LQFOXGHG3(0SDWLHQWVDJHGWR\HDUV:HOOQRXULVKHGSDWLHQWV PDWFKHGIRUDJHDQGVH[ZHUHVHOHFWHGIRUFRQWUROJURXS Results2XWRISDWLHQWVKDG87,FRQVLVWHGRIPDOHV DQG  IHPDOHV (LJKWHHQ RI WKHP KDG 3(0 DQG  ZHUH ZHOO nourished subjects. There was a statistical significant difference 3  LQWKHRFFXUUHQFHRI87,EHWZHHQFKLOGUHQZLWK3(0 DQGLQZHOOQRXULVKHGFKLOGUHQ7KHUHODWLRQVKLSEHWZHHQ3(0 DQG87,DVGHWHUPLQHGE\SUHYDOHQFHUDWLRYDOXH 35 ZDV ZLWKFRQILGHQFHLQWHUYDO &, RIWRVXJJHVWHGWKH ULVNRIJHWWLQJ87,ZDVWLPHVKLJKHULQFKLOGUHQZLWK3(0DV compared to normal controls. Conclusions 7KH IUHTXHQF\ RI 87, LQ 3(0 ZDV  &KLO GUHQ ZLWK 3(0 KDYH WKH ULVN RI JHWWLQJ 87,  WLPHV KLJKHU DV FRPSDUHG WR ZHOOQRXULVKHG FKLOGUHQ [Paediatr Indones 2008;48:166-9].

Keywords: protein energy malnutrition, urinary tract infection, children

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TI is common in children and it is the second highest cause of morbidity in children after respiratory tract infections. There are two types of UTI, i. e., symptomatic UTI and asymptomatic UTI. In general, asymptomatic UTI is more common than symptomatic one. In preschool children, the incidence of UTI among male and IHPDOHSDWLHQWVDUHDQGUHVSHFWLYHO\ZKLOH LQVFKRRODJHDERXWRI87,FDVHVZHUHPDOH DQGZHUHIHPDOH1$FFRUGLQJWR6DOHNHGH the LQFLGHQFHRI87,FDVHVLQ'U:DKLGLQ6XGLURKRVXGR *HQHUDO +RVSLWDO ZDV  7KH RFFXUUHQFH RI infections depends on two factors: predisposing factors and host immunity factors. Predisposing factors of UTI in children include an obstructive defect of urinary tract, chronic constipation, and vesicoureteral UHIOX[3,4 In normal children, proliferation of bacteria in mucosal bladder can be prevented by a strong flow of XULQHDQGH[LVWHQFHRIORFDOPXFRVDOEODGGHUDQWLERG\ system.4 Children with PEM have impaired immune function including depressed hypersensitivity response,

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166‡Paediatr Indones, Vol. 48, No. 3, May 2008

Arief Wijaya Rosli et al: Relationship between protein energy malnutrition and urinary tract infection

low T lymphocytes, disturbance of lymphocyte UHVSRQVH GHFUHDVHG SKDJRF\WRVLV VHFRQGDU\ WR ODFN of complements and low secretion of immunoglobulin $ ,J$  In this country, the prevalence of PEM is high in children below five years of age. Based on WKH6RFLDO(FRQRP\6XUYH\LQRIFKLOGUHQ XQGHU ILYH \HDUV ROG ZHUH XQGHUQRXULVKHG DQG  malnourished. ,W LV ZHOO NQRZQ WKDW WKHUH LV D V\QHUJLVWLF LQWHUDFWLRQ EHWZHHQ 3(0 DQG LQIHFWLRQ DQ\ NLQG of infection can worsen the nutritional status. On the other hand, PEM, even mild, may affect the immune system and compromise body defense against infections. Therefore, early detection and prompt treatment of infection in children with PEM is very important. Ibrahim8 found that the prevalence of 87,LQFKLOGUHQZLWK3(0ZDVDERXWDQGWKDW VH[DQGW\SHRIPDOQXWULWLRQZHUHQRWFRQWULEXWLQJ factors. While in India, Arvind Bagga et al found that the prevalence of bacteriuria in malnourished FKLOGUHQZDVDQGWKHULVNRIEDFWHULXULDLQFUHDVHG significantly with the severity of malnutrition. This study aimed to determine the relationship between protein energy malnutrition and urinary tract infection in children.

Methods This was a cross sectional design to compare the occurrence of UTI in children with PEM and in ZHOOQRXULVKHG FKLOGUHQ 7KH VWXG\ ZDV FRQGXFWHG LQ:DKLGLQ6XGLURKXVRGRDQG/DEXDQJ%DML*HQHUDO +RVSLWDOV0DNDVVDUIURP0DUFKXQWLO-XQH   7KH WDUJHW SRSXODWLRQV ZHUH KRVSLWDOL]HG SDWLHQWVZLWK3(0DJHG\HDUV Children with PEM (undernourished and PDOQRXULVKHG DJHG\HDUVZHUHLQFOXGHGPDWFKHG FRQWUROV IRU DJH DQG VH[ ZHUH DOVR UHFUXLWHG :H

H[FOXGHGSDWLHQWVZLWKFRQVWLSDWLRQWKRVHUHFHLYLQJ DQWLELRWLFV LQ WKH SUHYLRXV WZR ZHHNV RU KDG FRQJHQLWDODQRPDO\RIWKHH[WHUQDOJHQLWDOVDQGVSLQH or those with immunocompromized diseases such as +,9OHXNHPLDRUQHSKURWLFV\QGURPH A child was considered undernourished if body ZHLJKWIRUKHLJKW6'WR6' 1&+6UHIHUHQFH VWDQGDUG ZKLOHPDOQRXULVKHGZDVGHILQHGLIWKHERG\ ZHLJKW IRU KHLJKW  6' :HLJKW ZDV PHDVXUHG with standard mechanical personal scale and height ZDVPHDVXUHGLQWZRZD\VVWDQGLQJKHLJKWZDVXVHG LQFKLOGUHQWDOOHUWKDQFPDQGVXSLQHOHQJWKZDV XVHGLQWKRVHVKRUWHUWKDQFPRUWKRVHZKRZHUH unable to stand. Urine specimens were collected with midstream urine collection and cultured. The standard set up for XULQHFXOWXUHZDVWKHXVHRIWZRSODWHVVKHHSEORRG DJDU %$3 DQG0DF&RQNH\RU(0% HRVLQPHWK\OHQH EOXH SODWH$FFRUGLQJWR.DVVVLJQLILFDQWEDFWHULD ZDV GHILQHG DV  RU JUHDWHU &)8PO LQ D PLG stream urine specimens.

Results 7ZRKXQGUHGDQGWZHQW\FKLOGUHQDJHGWR\HDUV ZHUHHQUROOHGFRQVLVWLQJRIFKLOGUHQZLWK3(0  ZHUHXQGHUQRXULVKHGDQGPDOQRXULVKHG DQG ZHOOQRXULVKHGFKLOGUHQDVFRQWUROV2XWRIWKHWRWDO VDPSOH  FKLOGUHQ KDG 87,  FKLOGUHQ EHORQJHG to undernourished and malnourished children and EHORQJHGWRZHOOQRXULVKHGFKLOGUHQ  Table 1 ,W VKRZV WKDW 87, RFFXUUHG LQ  RI FKLOGUHQ ZLWK 3(0EXWRQO\LQZHOOQRXULVKHGFKLOGUHQ7KH difference was statistically sighnificant. The relationship between PEM and UTI can also EHDVVHVVHGEDVHGRQSUHYDOHQFHUDWLRYDOXH 35 7KH 35ZDVZLWKFRQILGHQWLQWHUYDO &, RI WRUHYHDOLQJWKDWFKLOGUHQZLWK3(0KDGDULVNRI

Table 1. Results of urine culture among PEM and well-nourished children Urine Culture

Nutritional Status

Total

UTI (+)

UTI (-)

PEM

18 (16.4%)

92 (83.6%)

110 (100%)

Well-nourished

7 (6.4%)

103 (93.6%)

110 (100%)

25

195

220

Total X = 5.461 df = 1

P=0.019

Paediatr Indones, Vol. 48, No. 3, May 2008‡167

Arief Wijaya Rosli et al: Relationship between protein energy malnutrition and urinary tract infection

87,RFFXUUHQFHRIWLPHVKLJKHUFRPSDUHGWRWKDW RIZHOOQRXULVKHGFKLOGUHQ 2XWRIWKHFKLOGUHQZLWK3(0KDG87, consisted of four undernourished and 14 malnourished FKLOGUHQ 7KH UHPDLQLQJ  FKLOGUHQ ZKR GLG QRW KDYH 87,  ZHUH XQGHUQRXULVKHG DQG  ZHUH malnourished children (Table 2  7KH 35 YDOXH ZDV  ZLWK &, RI   LQGLFDWLQJ WKDW PDOQRXULVKHG FKLOGUHQ KDG D FKDQFHRIJHWWLQJ87,WLPHVKLJKHUFRPSDUHGWR undernourished children. )URP WKH  VSHFLPHQV FROOHFWHG  KDG 87, FRQVLVWHG RI  PDOQRXULVKHG DQG  ZHOOQRXULVKHG children. The other 144 did not have UTI of which 41 ZHUHPDOQRXULVKHGDQGZHOOQRXULVKHG Table 3  $ VLJQLILFDQW GLIIHUHQFH 3   RI 87, RFFXUUHQFHZDVIRXQGEHWZHHQPDOQRXULVKHG   DQG ZHOOQRXULVKHG FKLOGUHQ   7KH 35 YDOXH ZDVZLWK&,WRGHQRWLQJWKDW87, occurred 4 times higher in malnourished as compared WRZHOOQRXULVKHGFKLOGUHQ 2XWRIWKHVSHFLPHQVKDG87,RIZKLFK ZHUHLQWKHXQGHUQRXULVKHGJURXSDQGLQZHOO nourished group (Table 4  6WDWLVWLFDO DQDO\VLV VKRZHG D VLJQLILFDQW GLIIHUHQFH 3   RI 87, RFFXUUHQFH EHWZHHQ

XQGHUQRXULVKHG FKLOGUHQ DQG ZHOOQRXULVKHG FKLOGUHQ7KH35YDOXHZDVZLWK&,WR  FRQFOXGLQJ WKDW XQGHUQRXULVKHG FKLOGUHQ ZDV QRW DW D KLJKHU ULVN RI FRQWUDFWLQJ 87, FRPSDUHG WRZHOOQRXULVKHGFKLOGUHQ6HYHUDORUJDQLVPZHUH LVRODWHGIURPXULQHFXOWXUHRIFDVHVDVVKRZQLQ Table 5. The most common organisms causing UTI in the PEM group were E. coli and Acinetobacter sp, ZKHUHDVLQWKHZHOOQRXULVKHGJURXSZHUH.OHEVLHOOD VSDQG$ONDOLJHQHVVS

Discussion 7KHSUHYDOHQFHRI87,LQWKLVVWXG\ZDV  RXWRIVXEMHFWV RIZKLFKZDVLQWKH3(0 group. Previous study by Bagga et al showed the SUHYDOHQFHRI87,LQPDOQRXULVKHGFKLOGUHQZDV while the study by Ibrahim8 found a prevalence of UTI LQFKLOGUHQZLWKVHYHUH3(0 6WDWLVWLFDO DQDO\VLV VKRZHG QR VLJQLILFDQW GLIIHUHQFH 3   EHWZHHQ PDOH DQG IHPDOH distribution on the occurrence of UTI. In another study on preschool children, the incidence of UTI in PDOHZDVZKHUHDVLQIHPDOH16WXGLHVLQ 6ZHGHQVKRZHGWKHRFFXUUHQFHRI87,LQPDOHDQG

Table 2. Frequency of UTI among undernourished and malnourished subjects Nutritional Status Undernourished Malnourished Total X2 = 6.64

df = 1

Urine Culture UTI (+) 4 (7.3%) 14 (25.5%) 18

UTI (-) 51 (92.7%) 41 (74.5%) 92

Total 55 (100%) 55 (100%) 110

P=0.010

Table 3. Frequency of UTI among malnourished and well-nourished children Nutritional Status Malnourished Well-nourished Total X = 12.03

df = 1

Urine Culture UTI (+) 14 (25.5%) 7 (6.4%) 21

UTI (-) 41 (74.5%) 103 (93.6%) 144

Total 55 (100%) 110 (100%) 165

P=0.001

Table 4. Frequency of UTI among undernourished and well-nourished subjects Nutritional Status Undernourished Well-nourished Total X = 0.05 df = 1

Urine Culture UTI (+) 4 (7.3%) 7 (6.4%) 11 P=0.825

168‡Paediatr Indones, Vol. 48, No. 3, May 2008

UTI (-) 51 (92.7%) 103 (93.6%) 154

Total 55 (100%) 110 (100%) 165

Arief Wijaya Rosli et al: Relationship between protein energy malnutrition and urinary tract infection

IHPDOHVXEMHFWVZHUHVLPLODULHPDOHDQGIHPDOH DWWKHDJHRI\HDUV11 These differences may be due to our small number of samples. In our study we found UTI in PEM group was VLJQLILFDQWO\ KLJKHU WKDQ WKDW LQ ZHOOQRXULVKHG FKLOGUHQ 3  WKHUHODWLRQVKLSEHWZHHQ3(0 DQG87,DVPHDVXUHGE\SUHYDOHQFHUDWLR 35 YDOXH ZDVZLWK&,GHQRWLQJWKDWFKLOGUHQ ZLWK3(0KDGWLPHVKLJKHUULVNRIKDYLQJ87, FRPSDUHGWRZHOOQRXULVKHGFKLOGUHQ7KHIUHTXHQF\ of UTI in malnourished and undernourished children ZDV VLJQLILFDQWO\ GLIIHUHQW ZLWK 35 RI  &,    +RZHYHU WKH IUHTXHQF\ RI 87, EHWZHHQ XQGHUQRXULVKHG DQG ZHOOQRXULVKHG FKLOGUHQ ZDV QRW VLJQLILFDQWO\ GLIIHUHQW ZLWK 35 RI  &,  :HOOQRXULVKHGFRQGLWLRQVHHPHGWRKDYH more significant influence as protecting factor than undernourished status. $QDO\VLV EHWZHHQ PDOQRXULVKHG DQG ZHOO nourished children showed a high significant GLIIHUHQFH 3   LQ WKH 87, IUHTXHQF\ ZLWK D 35RI &, 7KHRFFXUUHQFHRI87, in malnourished children was four times higher than WKDWLQZHOOQRXULVKHGFKLOGUHQ%DJJDet al detected WKDWWKHULVNRIEDFWHULXULDLQFUHDVHGVLJQLILFDQWO\ZLWK the degree of malnutrition. The results of urine culture showed that the major contributing organisms causing UTI in PEM were E. coli and Acinetobacter, each accounted for ILYHFDVHV  ,QZHOOQRXULVKHGFKLOGUHQWKHPDMRU FRQWULEXWRUV ZHUH .OHEVLHOOD DQG $ONDOLJHQHV HDFK DFFRXQWHGIRUWZRFDVHV  3UHYLRXVVWXG\VKRZHG that the highest contributing organisms in UTI was ( FROL   IROORZHG E\ .OHEVLHOOD   3URWHXV  (QWHURFRFFXV  6WDSK\ORFRFFXV  DQG3VHXGRPRQDV  3 The author realized that this study had some limitations including small number of subjects which might not show significant difference of incidence of UTI according to gender and ignored other diseases which can influence the occurrence of UTI such as diarrhea and fever. We conclude that the frequency of UTI in 3(0 LV PXFK KLJKHU WKDQ WKDW LQ ZHOOQRXULVKHG children. There is no difference of UTI occurrence between male and female subjects.

References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eusch TG. The history of nutrition, infection, and LPPXQLW\-1XWU6  6XGDU\DWL 6 6MDULI 5' 0DOQXWULVL HQHUJL SURWHLQ ,Q 3XVSRQHJRUR'+5H]HNL6HGLWRUV6WDQGDUSHOD\DQDQPHGLV NHVHKDWDQDQDNVWHG-DNDUWD%DGDQ3HQHUELW,'$, S 8. Ibrahim RA. Urinary tract infection in severely malnourished FKLOGUHQDWWKHXQLYHUVLW\RI0DLGXJXULWHDFKLQJKRVSLWDO- 7URS3HGLDWU  :DWHUORZ &- 3URWHLQHQHUJ\ PDOQXWULWLRQ JHQHUDO LQWURGXFWLRQ ,Q :DWHUORZ &- HGLWRUV 3URWHLQ HQHUJ\ PDOQXWULWLRQ/RQGRQ*UHDW%ULWDLQS  .DVV (+ 6DYDJH : 6DQWDPDULQD %$* 7KH VLJQLILFDQFH of bacteriuria in preventive medicine. In: Kass EH, editor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