1. 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 Jan;98(1):27-9

2. 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?

3. 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!)

4. Local guidelines
SCH advise that a “mid-stream urine” or “clean-catch” 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

5. 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 (!)
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6. Need for a new method…
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7. 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
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8. 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

9. Procedure Feed the baby 25 minutes after feeding clean the genitals
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

10. Video demonstration http://adc.bmj.com/content/98/1/27/suppl/DC1
Video removed for copyright purposes

11. Results 90 children included in study Mean age approximately 6 days
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

12. 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

13. Limitations Lack of control group No indication of parental preference
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?

14. 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

15. Will you be trying it?

16. 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.