Race Should Not Limit Urinary Tract Infection Workup in Young Febrile Children

By Will Boggs MD

January 14, 2020

NEW YORK (Reuters Health) - Race should be eliminated from the American Academy of Pediatrics (AAP) Clinical Practice Guideline (CPG) for urinary tract infection (UTI) in infants and young children with fever, according to an opinion paper.

"When the CPG came out, in 2011, it was less controversial than it is now, because there wasn't the same understanding that race is a social construct rather than a biologic category," Dr. Rachel H. Kowalsky from New York Presbyterian Hospital-Weill Cornell Medicine and Cornell Center for Health Equity, New York, told Reuters Health by email. "Removing race from the guidelines may remove a significant source of structural racism from pediatric practice."

Dr. Kowalsky and colleagues make a case for doing this in their online viewpoint article in JAMA Pediatrics.

They contend that racial categories used in the seminal studies on UTI prevalence have unacceptably low validity and, in fact, that race cannot be dichotomized because the categories of black and white are neither comprehensive nor mutually exclusive.

Moreover, there is no evidence to support race, however defined, as having the same importance as fever when calculating the probability of a UTI.

Finally, it requires a cognitive leap to believe that blackness somehow confers protection against UTI. They contend that the premise that black children are less vulnerable than white children to UTI intersects "in a disturbing way" with historic stereotypes about higher-pain thresholds, superior physical strength, and invulnerability to certain diseases that have been used to justify slavery and other brutalities.

"The downstream effect of the guideline in its current form is that black children with fever are tested for urinary tract infection less often than other children, and they are required to present with more risk factors to meet the testing threshold," Dr. Kowalsky said. "Considering the many febrile infants and toddlers that present to doctors' offices and emergency rooms each day, the CPG may perpetuate structural racism at an enormous rate, without this ever being the intent of a single person who uses it."

"Structural racism can inflect our literature and our work, without this ever being the intent," she said. "Historic narratives have been articulated, and integrated into the psyche, over decades and centuries. They are inherently bigger than individuals, but it is individuals who must question and disassemble them. Where history is concerned, there is no return path. The only way to mitigate past mistakes and misassumptions is to journey forward in a prudent, responsible, and thoughtful way."

Dr. Nader Shaikh from University of Pittsburgh and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, who has researched various aspects of pediatric UTI, told Reuters Health by email, "The attached article raises some valid concerns about misuse of race, but I feel they picked the wrong 'straw man' for their cause."

"The fact is that UTI is one of the few diseases that occur less frequently in black children," he said. "Sure, it is not the race per se that determines risk, but our understanding is so limited that we do not know the exact mechanism by which this occurs, and thus have no way of testing for this. So if we were to ignore race, we would unnecessarily test a lot of black children who have a low risk of UTI, which would be ethically questionable."

"I understand the general concerns about inappropriate use of race in medical practice," he said, "but to not use it at all may also cause its own issues."

SOURCE: http://bit.ly/30es0oq JAMA Pediatrics, online January 13, 2020.