Polyuria and ‘watery wee’ in a toddler
- 1Department of Paediatrics, Royal Alexandra Children’s Hospital, Brighton, UK
- 2Department of Paediatrics, Brighton and Sussex University NHS Trust, Brighton, UK
- Correspondence to Dr Leonie Perera,
A 2-year-old girl presented with intermittent dysuria. Following triage in paediatric A+E, the nursing staff became concerned with the large sample of colourless urine she produced, which tested positive for leucocytes. She was described as a ‘big drinker’ to the SHO, raising concerns about diabetes insipidus. On detailed questioning it emerged that she had recently drunk a herbal tea preparation (buchu, couchgrass, marshmallow and plantain) to help ‘flush out’ her urinary system. She was advised to stop the tea. She had localised genital irritation and was discharged home with hygiene/barrier advice, pending urine culture results. She represented 2 days later with worsening dysuria and fever. Her urine was of normal colour and tested positive for leucocytes, nitrites and blood, hence she started antibiotics (urine cultures subsequently grew coliforms). Herbal use in children is not uncommon and should be considered as a cause of polyuria.
Herbal medicine is not commonly used to treat acute urinary tract infection (UTI) in this country. This case highlights the importance of detailed history-taking and that herbal remedies are pharmacologically active. The preparation of dried herbs was bought from a well-known health shop, in the full knowledge that it was to be given to a young child. No precautions were provided verbally or in written format regarding the use in children or duration of usage.
A 2-year-old girl on holiday from Germany presented with a 2-day history of pain on micturition and attempting to avoid urination. She was playful in the department with an unremarkable examination. She was noted to have erythematous, dry skin around her vulva. She produced a colourless urine sample of approximately 400 ml volume with the appearance of water. A targeted history was taken with regard to her fluid intake. After a further (third) history was taken, it emerged that the previous day the parents had bought a herbal tea preparation from a London health shop for treatment of her suspectedUTI, which included buchu, couchgrass, marshmallow, plantain and corn syrup. Urinalysis showed large leucocytes, moderate blood but no nitrites, with specific gravity of 1.000. The urine sample was sent for microscopy, culture and sensitivity. Paired serum and urine samples were also sent for electrolyte and osmolality. In the absence of fever and presence of localised redness, the leucocytes were thought to be due to vulvovaginitis. Topical application of barrier emollients to the vulval area were suggested with avoidance of bath additives and to wear loose, cotton underwear and avoid tight trousers. The parents were advised to stop the herbal remedy, as this appeared to have acted as a strong diuretic. Telephone follow-up was arranged for urine culture results.
Serum sodium 139 mmol/l (136–145)
Serum osmolality 283 mOsm/kg (275–295)
Urinary sodium <20 mmol/l
Urinary osmolality 53 mosm/kg (400–1400)
Urine mc+s: white blood cells 97×106/l, with pure growth of coliforms.
Dysuria in children is associated with (1) local irritation or excoriation (balanitis/vulvovaginitis, thread worm) (2)UTI or (3) urethritis, for example, sexually transmitted infections.
Polyuria in children is caused by (1) diabetes mellitus, (2) diabetes insipidus, (3) chronic renal failure, (4) primary polydipsia and (5) hypokalaemia/hypercalcaemia.
Outcome and follow-up
Two days later she re-presented, having now developed fever and worsening dysuria (vulval irritation had resolved). A repeat urine sample was obtained which had a normal yellow appearance. Urine dipstick was strongly positive for leucocytes, nitrites and blood and she was started on trimethoprim. Urine osmolality had risen to 333 mOsm/kg. Microscopy found white blood cells of 100×106/l, with pure growth of coliforms.
The use of complimentary and alternative medicine in Western Culture is growing. The UK figures⇓ show a prevalence of approximately 17–37% of children using complimentary medicine.1 ,2 It is also reported that two-thirds of Welsh and Australian parents do not reveal to their childrens’ doctors their administration of herbal products;3 it was only through rigorous questioning that the herbal intake in this case came to light. Many parents are under the impression that complimentary medicine is less likely to cause harm than allopathic medicine; however, herbal remedies are known to have pharmacological actions, interact with conventional medications and have the potential to cause adverse effects.4 This case illustrates the diuretic action of a seemingly innocuous herbal preparation.
Herbal medicine is widely available and commonly used in Germany.5 It is not unusual for German parents with well children and minor ailments to try alternative therapy first before seeing a medical practitioner; these parents report a similar practice among themselves and their peers. Many German paediatricians have complimentary medicine qualifications.6
UTIs and their amelioration with herbs have been described since ancient Egypt.7 The herbal tea preparation in this case contained several herbs:
‘Buchu’ (species Agathosma), a shrub originating in Southern Africa, is commonly found as an ingredient in ‘water retention’ tablets. It is proposed to have diuretic and antiseptic properties due to phenolic compounds8 ,9 and anti-inflammatory activity via the 5-lipooxygenase pathway.10 Despite buchu's rich history as a diuretic, few studies quantify its actual strength of diuresis.
Couchgrass (species Agropyron) is reported to, ‘overcome difficulties with urination and aid the kidneys in their work’.
Marshmallow root (species Althaea) is thought to possess expectorant and diuretic properties. It is also thought to ease the discomfort of passing urine,11 via the thick, gluey consistency of the root.
Plantain (species Plantago) is proposed to have anti-inflammatory, analgesic, weak antibiotic and diuretic actions8 ,12 although a randomised, placebo cross-over trial in healthy volunteers found no effect on urinary volume or sodium.13
It is well recognised that the sensitivity for urinary nitrites/leucocytes on dipstick is lower in children under 3 years of age.14 Children with UTIs void frequently, exacerbated in this case by the diuretic effect of the herbs. Urine needs to remain in the bladder long enough (at least 4 h) for bacteria to metabolise nitrate to nitrite.15 Urinalysis of the second sample was positive for nitrites, possibly due to her voiding less frequently after stopping the herbal tea. Urinalysis was positive for leucocytes at the outset. Pyuria is known to occur in febrile children16 (presumably due to increased urinary white cell excretion), tuberculosis, appendicitis and vulvovaginitis (contamination from vaginal leucocytes); the latter can also cause dysuria from local irritation/excoriation, hence the initial diagnosis of vulvovaginitis.
Herbal remedies are widely available in the UK. Their use in children is at the discretion of herbal practitioners and parents. New legislation introduced in April 2011 aims to regulate over the counter sale such that herbal products used for simple, self-limiting conditions with a history of use for 30 years (of which 15 years must be in the EU) receive a license.17 The government have also called for the UK Herbalists to undergo statutory regulation by the Health Professions Council.18 This case highlights the risks of herbal product usage in children, particularly where warnings or caveats have not been provided by the retailer. This child developed a very low-urine osmolality and may well have developed serum electrolyte disturbance if the herbal tea usage continued.
Herbal remedy use among paediatric patients is not uncommon.
Parents may not be forthcoming regarding alternative therapies.
Drug history should include both conventional and alternative treatments.
Over the counter herbal remedies can have pharmacological effects and interactions.
Urine dipstick testing is less sensitive in children under 3 years of age, therefore samples should be sent for microscopy and culture where there is clinical suspicion of a urinary tract infection.