Use of clean intermittent catheterization in children aged two years and under with myelomeningocele: findings from the UMPIRE protocol
Jennifer Ahn, MD, MS1, Jacqueline Mix, PhD2, Earl Cheng, MD3, David Joseph, MD4, Evalynn Vasquez, MD, MBA5, M. Chad Wallis, MD6, Douglass Clayton, MD7, Susan Jarosz, DO8, Elizabeth Roth, MD9, Tonya Williams, PhD2, Jonathan Routh, MD, MPH10, John Wiener, MD10.
1Seattle Children's Hospital, Seattle, WA, USA, 2Centers for Disease Control and Prevention, Atlanta, GA, USA, 3Lurie Children's Hospital, Chicago, IL, USA, 4Children's of Alabama, Birmingham, AL, USA, 5Children's Hospital Los Angeles, Los Angeles, CA, USA, 6University of Utah, Salt Lake City, UT, USA, 7Vanderbilt Children's Hospital, Nashville, TN, USA, 8Texas Children's Hospital, Houston, TX, USA, 9Children's Wisconsin, Milwaukee, WI, USA, 10Duke Children's Hospital, Durham, NC, USA.
BACKGROUND: Clean intermittent catheterization (CIC) is commonly used in bladder management for individuals with myelomeningocele (MMC). Optimal use of CIC in infants and young children has not been established. We examined CIC use in children aged 2 years and under enrolled in the Urologic Management to Preserve Initial Renal Function Protocol for Young Children with Spina Bifida (UMPIRE) protocol.
Methods: The UMPIRE protocol requires initiation of CIC among all newborns with MMC soon after birth and weaning if volumes remain low. Clinical indicators for resuming CIC in the protocol are: hydronephrosis, high-risk bladder, grade 5 vesicoureteral reflux, or clinical discretion. We evaluated hydronephrosis, urodynamics, and vesicoureteral reflux, and anticholinergic use at routine time points until 2 years of age (0, 6, 12, 18 and 24 months). We compared clinical and sociodemographic characteristics between the baseline and 2-year visit using Chi-square tests of independence.
Results: 232 participants were included and 17% required CIC at 3 months of age. The proportion requiring CIC increased to 26% at 12-15 months and 35% at 2 years of age. CIC use at 2 years was not associated with sex, race/ethnicity, insurance, prenatal closure, level of lesion, shunt, or hydronephrosis, but was associated with presence of vesicoureteral reflux (p=0.02) and anticholinergic use (p<0.001). Reasons for CIC re-initiation were per protocol in 82% of cases, and per clinician discretion for the remaining 18%, with recurrent urinary tract infections and urinary retention among the common reasons.
Conclusions: Following our strict protocol, less than one-fifth of newborns with MMC required CIC, but that proportion doubled within the first two years of life. Because bladder characteristics can change over time, findings indicate that routine surveillance to monitor clinical changes may help inform re-initiation of CIC.
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