Is There a Role for D-Mannose, Cranberry or Probiotics in Preventing Pediatric UTIs?Is There a Role for D-Mannose, Cranberry or Probiotics in Preventing Pediatric UTIs? https://pediatricsnationwide.org/wp-content/uploads/2020/01/AdobeStock_72248222-1024x683.jpg 1024 683 Deborah L. Ungerleider, MD, FAAP Deborah L. Ungerleider, MD, FAAP https://pediatricsnationwide.org/wp-content/uploads/2021/10/Deborah-Ungerleider-MD-photo.jpg
- August 31, 2022
- Deborah L. Ungerleider, MD, FAAP
Alternatives for prophylaxis of UTIs in children may help reduce antibiotic overuse.
Preventing urinary tract infections (UTIs) in children is important, as multiple UTIs can lead to scarring of the kidneys, which can then lead to hypertension or end-stage renal disease.1 UTIs in children are generally treated with antibiotics, which are sometimes also used for prophylaxis. However, as Christina Ching, MD, urologist and principal investigator in The Kidney and Urinary Tract Center at Nationwide Children’s Hospital emphasizes, “Antibiotic use can come at a cost. There are certainly concerns regarding antibiotic overuse and the potential for increased bacterial resistance, side effects and intolerances.”
Antibiotic-independent methods are attractive and being sought more than ever.
“Antibiotics are used with more hesitancy,” Dr. Ching adds. “Families are questioning antibiotic prophylaxis, but families are also concerned with repeated infections being disruptive, uncomfortable for the patient and concerning from a health standpoint. Parents want something done. ‘What alternatives do we have?’”
If structural problems, such as vesicoureteral reflux or an obstruction, are leading to recurrent UTIs, surgical intervention may be needed and antibiotic prophylaxis still might be recommended, as it is in the American Urological Association’s guidelines, says Dr. Ching. However, the use of low-dose antibiotic prophylaxis is controversial with conflicting results.1,2
Based on the concern with antibiotic overuse, research has been ongoing to try to find other methods for prevention. Commonly studied non-antibiotic prophylactics include D-mannose, cranberry and probiotics.1 Dr. Ching recently reviewed the literature on this topic in Current Urology Reports. The methods studied work in different ways; probiotics competitively inhibit the survival of bacteria in the urinary tract, whereas D-mannose and cranberry prevent bacterial attachment.1
Studies on D-mannose, which is a powder from a simple sugar found in fruit 3 that is quickly absorbed in the gastrointestinal (GI) tract and excreted in the urine, have been done in adult women; those data have been extrapolated to children. A study done on women comparing 6 months of D-mannose to nitrofurantoin and no intervention demonstrated that the D-mannose was just as effective as the antibiotic, with fewer side effects, and was more effective than no intervention.1 Other studies in adults have found success with D-mannose added to dietary supplements compared to no treatment.1 One of the concerns with D-mannose is the poor bioavailability.1 More recently, a small study was done in the pediatric population, which found that D-mannose was as effective as prophylaxis. In a population of pediatric patients with complex urological issues who had previously been on prophylactic antibiotics, it reduced the risk of UTIs by 53% (P = .0029), with very few adverse effects.3
Cranberry impedes bacterial attachment to the urinary tract through one of several mechanisms. However, studies in both adults and children have not provided strong evidence of its efficacy. One randomized study in the pediatric population of cranberry juice versus placebo did not find a difference in the number of children with UTIs (P = .21); however, the density of UTIs in the cranberry juice group was significantly lower than that in the placebo group (P = .035), leading to less antibiotic use.1 Other studies have also been inconclusive. Dosing, safety and tolerability have all been potential issues with cranberry juice.1
By changing a patient’s GI and perineal bacterial flora, probiotics, such as lactobacillus, may prevent bacterial adhesion and, in combination with that, protect the urinary tract with other factors they produce. Clinical trials looking at the efficacy of probiotics in children, compared to antibiotics, placebo and cranberry, have been largely positive in outcomes; however, the studies are small, making the role of probiotics in preventing UTIs in children unclear. Future studies may give more conclusive data.1
So What Should We Tell Families?
Dr. Ching tells patients and parents that probiotics probably will not hurt and may help. Unfortunately there is not guidance on specific dosages as probiotics are not FDA-approved, but certain types of bacteria may be more helpful and are supported in studies, such as lactobacillus and bifidobacteria.
Dr. Ching says she is starting to consider suggesting D-mannose to families and integrating it more into her practice. She references Brownlee’s study, mentioned above, which looks at formulations and dosage, although it still only had a small number of patients.
Regarding other advice for patients, Dr. Ching says the following are also important for UTI prophylaxis and bladder health:
- Proper bladder and bowel habits
- Regular emptying of one’s bladder through timed voiding
- Good hydration
- Addressing any constipation
- Ching CB. Non-antibiotic approaches to preventing pediatric UTIs: a role for D-mannose, cranberry, and probiotics? Current Urology Reports. 2022 Apr;23(6):113-127.
- Williams G, Hodson EM, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database of Systematic Reviews. 2019 Feb;2(2):CD001532.
- Brownlee EM, Blore C, Wragg R, Patel M, McCarthy L. D-mannose reduces the risk of UTI in complex paediatric urology patients. Archives of Pediatrics. 2020 May;5(1):180.
Image credits: Adobe Stock (header); Nationwide Children’s (Dr. Ching portrait)
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