Siblings of a child with a form of urinary reflux may see little benefit from being screened for the disease themselves, despite being at higher risk, a new analysis suggests.
The disease in question is vesicoureteral reflux, or VUR, in which the urine travels backwards from the bladder, causing infections. Approximately 1% of children have VUR, and their siblings are at higher risk – more than one-quarter of children whose sibling has VUR also have the disease.
Consequently, many doctors suggest screening all siblings of VUR patients, regardless of whether or not they have symptoms.
But in a study in Pediatrics, researchers found that screening siblings of VUR patients before they developed symptoms would prevent only a small number of urinary tract infections (UTI), while costing a significant amount and needlessly exposing many children to radiation and an unpleasant procedure.
“You really have to screen a large number of asymptomatic siblings in order to prevent one infection,” study author Dr. Jonathan Routh of Children’s Hospital Boston told Reuters Health.
Specifically, Routh and his colleagues estimated that universal screening of all children with a sibling who has VUR may require screening hundreds of children to prevent only one UTI, at a potential cost of hundreds of thousands of dollars.
To complicate things further, it’s not clear how effective antibiotics are in preventing UTIs in children with VUR.
Assuming that prophylactic antibiotics worked, only 30 one-year-old siblings would need to be screened in order to prevent one febrile UTI (meaning an infection accompanied by fever, a sign the infection may involve the kidneys), at a cost of $56,000 per averted infection, the investigators say.
But assuming more conservative estimates of the effectiveness of prophylaxis, they calculate that 430 siblings would have to be screened to prevent one UTI, costing $820,000 per infection.
“Best case scenario: You’d still have to screen 30 perfectly normal children in order to prevent one febrile urinary tract infection,” Routh noted.
To estimate the benefits of screening, Routh and his team built a mathematical model that included variables such as the prognosis for siblings of a VUR patient based on the latest research, the radiation and cost associated with the screening procedure (cystography), and the costs of treating the complications of VURs. They then applied that model to 100,000 imaginary children whose siblings had VUR.
The American Urological Association has not recommended universal screening, and in July issued updated guidelines for when screening makes sense in siblings of children with VUR.
Of course, parents are more concerned about the benefits of screening in their child, not in a large group of children, Routh acknowledged. But these results apply to individual children as well, he noted. “It is unlikely that any one child is going to have a direct benefit from that screening.”
The findings confirm what many practicing urologists believe, but couldn’t prove, Dr. Kourosh Afshar, who has studied VUR at the University of British Columbia, told Reuters Health. Testing the benefits of screening in real children would require following many children over many years, at an exorbitant cost, he explained.
The chance that universal screening will prevent an infection is “so little,” the researcher said, “that I don’t recommend it as a doctor.”
SOURCE: Pediatrics online October 18, 2010.
