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Case Study: Diaper Drama ​~home edition

Part I - Is this Normal?
Leia and Jeff were so excited to welcome their new baby girl into the
world. Little Marina weighed 8 pounds and was healthy at birth. Leia was
a little nervous to take Marina home, she was a new mother, but she had
been reading lots of new books on parenting and babies. She was
expecting to be woken up at night for feedings and diaper changes, but
she felt ready. She had already subscribed to a diaper service that would
deliver and clean cloth diapers. Leia felt that cloth was better for the
environment than disposable diapers.

After six weeks at home, Leia was not feeling as confident as she was when
she left the hospital. Her once happy baby was now fussy all the time and
was running a fever. She was still using the cloth diapers which were
getting cleaned on schedule, but Leia noticed that Marina had developed a
red rash around her genitals.

Leia called the pediatric nurse who suggested that Leia should use a diaper cream and switch to disposable
diapers, that Marina just had a basic diaper rash from her skin staying moist. The pediatric nurse told her to
give Marina children’s tylenol for the fever.

Leia consulted her baby manuals and was not convinced that this was a normal diaper rash. Jeff brought
home disposable diapers to see if that helped. After a few days using the cream and the disposable diapers,
the rash looked even worse than before. Leia called the doctor’s office and scheduled an appointment.

When Doctor Well checked Marina out, he confirmed that the rash was just a diaper rash and even suggested
Leia wasn’t changing her diapers enough. He prescribed a different cream for the rash and told her to
continue the treatments and administer tylenol for fever. Doctor Well asked if Leia was feeling okay herself
and that maybe he should refer her to a mental health specialist.

Leia was angry when she left the office, it was like the doctor was blaming her for her baby having the rash.
She also didn’t feel as if the doctors were taking things seriously. She really felt there was something more
going on with Marina.

Leia’s mother suggested that she let Marina go without a diaper for a few hours a day. That was something
they used to do back in the old days when they didn’t have the fancy medicine. Leia kept a strict routine of
diaper changing, ointments, and leaving the diaper off. The rash did seem to get better, but then Leia noticed
that Marina’s urine had a strange smell. Marina cried constantly, and would not eat. Leia decided she
needed a second opinion.

Leia found a doctor nearby who specialized in pediatric urology managed to get an appointment.

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Questions

1. What symptoms has Marina exhibited over the first months of her life?

2. How did Leia treat Marina’s symptoms?

3. Do you think Leia’s choice of diapers was causing the problem? Why or why not?

4. Why was Marina angry when she left Doctor Well’s office?

5. What is a pediatric urologist?

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Part II – Diagnosing Marina
At the new office, the nurse weighed and measured Marina, then took her​ ​temperature and reviewed her
symptoms with Leia. Doctor Renali then came in to evaluate Marina. He requested a urine​ ​sample, which
can be difficult to obtain from pediatric patients. He explained to Leia how they could get the urine sample,

There are a couple of techniques to gather specimens from infants. In the “clean-catch” technique, a
container is held at ready. You wait for the child to urinate and catch the urine. Sometimes urination can be
encouraged by rubbing the abdomen with a cold cloth.

Urine can also be collected with a ​catheter.​ In this procedure, the catheter is inserted through the urethra
and threaded into the bladder to collect urine. The doctor opted to do the catheter technique so the results
could be immediately obtained. One disadvantage is that infants must stay still and it can cause discomfort.

Leia decided to have the urine taken by catheter so that they could get the results right away. Marina had to
be held very still while the catheter was inserted into the urethra. It was difficult for Leia to watch, but she
was determined to get answers.

6. What are the advantages and disadvantages of using the clean-catch technique?

7. What are the advantages and disadvantages of the catheter technique?

8. There are other ways that urine is collected from infants. Suggest a creative way that you might collect urine from a
baby. No wrong answers, think like an engineer.

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Part III - Further Tests
After confirming that Marina had a urinary infection, Dr. Renali decided to begin administering antibiotics and gave
Marina an injection to get her started. She would then get a prescription to take a strong dose of antibiotic over the
next week. He also wanted other tests performed to determine if there were other causes for the infection.

The doctor also ordered an IVP, or an ​intravenous pyelogram​, used to detect abnormalities. This procedure uses an
injection of a contrast material placed in the bloodstream. This allows the organs of the urinary system to be seen as
bright white on the film. Normally, these structures would not be visible and you would only see the bones, not soft
tissue.

This X-ray image would show the kidneys, bladder, and ureters.

Normal Marina

9. Why is a contrast dye needed to see the structures?

10. Examine the image carefully. What do you notice about Marina’s x-ray. What is abnormal there? Use anatomical
terms to describe the abnormality.

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Part IV - Treatment Options
By the end of the week both tests had been completed and the family was
back at the pediatrician’s office for a consultation. The tests had revealed a
diagnosis of a ​bilateral duplicate collection system​ in the left kidney. This is
also called an ​ectopic ureter​. In some cases, the additional ureter causes no
problems, but in other cases, urine does not drain properly, which leads to
urinary tract infections.

We can fix the problem through surgery, through a procedure called a

nephrectomy.

Dr. Renali explained further: “In this surgery the upper part of the kidney
which contains the ectopic ureter is removed. This stops the flow of urine
there and reduces the chance of infection. The kidney will continue to
function even though part of it has been removed.

Leia frowned, she really didn’t want her baby to have surgery or any of her
kidney to be removed. “Are there any other options?”

​ rophylactic​ antibiotics that she will

Dr. Renali nodded, we can start her on p
take to prevent further infections. This is a low grade antibiotic that she will
take daily. Sometimes, as they grow, the problem becomes less severe as
the ureter lengthens and the kidney gets larger..

11 What is an ectopic ureter and why does it cause problems?

12. What is the difference between the antibiotics injected to address the current infection, and prophylactic
antibiotics?

13. What is a nephrectomy?

14. Which option would you choose if you were Leia: a medical intervention or a surgical intervention? Defend your
choice.

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