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Pediatric Kidney Stones

  • If your child has had kidney stones, you know how upsetting they can be. No parent wants to watch her child suffer—and passing a kidney stone can be extremely painful.

    The good news is that there are some basic things you can do to reduce the chances of your child developing kidney stones.

    If your child needs treatment, you’re in the right place. The Kidney Stone Program at Boston Children’s Hospital has expert doctors and innovative techniques to help your child pass the stone with a minimum of pain.

    Here’s what you need to know about kidney stones:

    • While kidney stones are still relatively uncommon in children, the number of cases is growing.
    • Kidney stones are small, hard deposits of mineral and acid salts formed within the urinary tract. There are many different kinds of stones, with calcium, oxalate, uric acid and phosphate being the most common components.
    • They can obstruct the drainage of urine and frequently cause intense pain.
    • Most of the time, stones are found in the kidney or ureter (the tube that connects the kidney with the bladder).
    • Key symptoms are pain accompanied by blood in the urine. Some children may have nausea and vomiting.
       
    • Many stones pass all by themselves, without treatment; others will need to be removed, which can often be done using a noninvasive method.

    How Boston Children's Hospital treats kidney stones

    Children’s has established a pediatric Kidney Stone Program, because more children are developing kidney stones. We see children who’ve had kidney stones and those who are at risk for developing them.

    At our innovative program, your child will see both a pediatric urologist and a pediatric nephrologists at the same appointment. This multidisciplinary approach allows for direct collaboration between the two specialists to optimize your child’s care and work together to develop a treatment plan—in real time.

    We can treat stones in several ways, depending on the size, location, number and composition of the stones. In nearly all children, we can treat these stones with noninvasive or minimally invasive surgical techniques; in rare instances, we can use very robotic surgery techniques to remove the stones.

    The best treatment is prevention. Your child will receive a metabolic evaluation to determine if he has risk factors for future kidney stones. We then prescribe individualized treatment plans to prevent new stones from forming, and monitor your child with urine and blood tests and sometimes ultrasound exams.


    Kidney stones: Reviewed by Bartley Cilento, MD, MPH.
    © Children’s Hospital Boston, 2010

    Boston Children's Hospital
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  • It can be upsetting to see your child suffering from kidney stones. It can also be frustrating if your child has had multiple kidney stones and you’re having trouble figuring out what’s causing them. Read on to learn more about kidney stones and stone disease — and what they mean for your child.

    What do the kidneys do?

    The kidneys are the body's filtering system. They help control water levels and eliminate excess minerals and waste products through urine.

    What are kidney stones?

    Kidney stones are small deposits of minerals and salts that build up within the kidneys.

    Why are kidney stones a problem?

    They can get lodged in the urinary tract and obstruct the flow of urine. Although most stones won’t cause long-term damage to your child, passing kidney stones can be extremely painful.

    What is the long-term outlook for my child?

    It depends on what’s causing your child to develop the stones. Some children pass a stone, change their diet and hydration patterns and never have another stone again. Others have trouble changing their hydration and eating habits and will probably develop more stones.

    Rarely, a child may have an underlying medical condition that causes the body to develop stones; in this case, your child may have to struggle with stones for the rest of her life.

    How common are kidney stones? 

    Stones are not common in children, but they're getting more so.

    Some children who form urinary stones have an underlying abnormality of the urinary tract. These can include obstructions of the kidney and ureter (the tube that connects the kidney with the bladder) or diseases such as spina bifida.

    However, most children with stones have normal urinary tract anatomy.

    We believe that the increase in kidney stones may reflect lifestyle factors such as childhood obesity, diets with excess salt and not drinking enough water.

    At what age do children typically form stones?

    Stones can form in children of any age, but we generally see school-aged children and older. We also see premature babies whose medications throw off the balance of minerals in their urine and lead to kidney stone formation.

    Are kidney stones more common in boys or girls?

    Boys are slightly more likely to develop kidney stones.

    Do environmental conditions affect stone formation?

    Yes. We see more cases in the summer and fall when children tend to be more active, sweat more and are more prone to dehydration.

    The highest concentration of Americans with kidney stones come from what we refer to as the "Stone Belt" in the southeastern states. This is probably due to the warm weather in those states, which can cause mild dehydration.

    Symptoms

    What are the symptoms of kidney stones?

    Symptoms may vary from none, in the case of “silent stones,” (stones that are still in the kidney and have not moved to the ureter) to severe pain due to urinary obstruction.

    Here’s a list of the most common symptoms of stone disease:

    • pain in the abdomen, flank (side), back, or groin
    • blood in the urine
    • frequent urination
    • nausea and/or vomiting

    Keep in mind that kidney stones affect different children in different ways.

    Any child with pain accompanied by blood in the urine — even if it’s just a little bit — should be evaluated by a doctor.

    Causes

    What causes kidney stones?

    Kidney stones form when there is too much of the mineral ingredients of the stone and not enough water in the urine.

    This can occur either because there is an abnormally high mineral content in the urine, or the urine is too concentrated because of dehydration.

    Some rare stone diseases can result from inborn metabolic problems, which means that your child has a genetic condition that causes his body to make these stones. A family history of kidney stones predisposes other members of the family to have stones.

    Children who can’t move for long periods of time (in traction after surgery, for example) may also be susceptible to stones, because when bones are inactive, they’re unable to regenerate themselves properly, which results in calcium being flushed into the system.

    Questions to ask your doctor

    You and your family are key players in your child’s medical care. It’s important that you share your observations and ideas with your child’s health care provider and that you understand your provider’s recommendations.

    If your child is suffering from kidney stones and you’ve set up an appointment, you probably already have some ideas and questions on your mind. But at the appointment, it can be easy to forget the questions you wanted to ask. It’s often helpful to jot them down ahead of time so that you can leave the appointment feeling like you have the information you need. You may want to suggest that your child write down what he wants to ask his health care provider, too.

    Some of the questions you may want to ask include:

    • Can my child pass these stones on his own?
    • What are our treatment options?
    • What sort of dietary changes do we need to make?
    • What can we do to encourage our child to drink more water?
    • Where can we go for further information?

    Keep in mind that your doctor will want to ask you some questions, too. These can include the following:

    • Is this your child’s first stone?
    • Is there a history of stone disease in the family?
    • How much water does your child drink each day?
    • What’s your child’s diet like?

    FAQ

    Q: Why are kidney stones a problem?

    A: They can get lodged in the urinary tract and obstruct the flow of urine. Although most stones won’t cause long-term damage to your child, passing kidney stones can be extremely painful.

    Q: What causes kidney stones?

    A: Kidney stones form when there is too much of the mineral ingredients of the stone and not enough water in the urine. This can occur either because there is an abnormally high mineral content in the urine, or the urine is too concentrated because of dehydration.

    Some rare stone diseases can result from inborn metabolic problems, which means that your child has a genetic condition that causes his body to make these stones. A family history of kidney stones predisposes other members of the family to have stones.

    Children who can’t move for long periods of time (in traction after surgery, for example) may also be susceptible to stones, because when bones are inactive, they’re unable to regenerate themselves properly, which results in calcium being flushed into the system.

    Q: How common are kidney stones? 

    A: Stones are not common in children, but they're getting more so.

    Some children who form urinary stones have an underlying abnormality of the urinary tract. These can include obstructions of the kidney and ureter (the tube that connects the kidney with the bladder) or diseases such as spina bifida.

    However, most children with stones have normal urinary tract anatomy. We believe that the increase in kidney stones may reflect lifestyle factors such as childhood obesity, diets with excess salt and not drinking enough water.

    Q: What are the symptoms of kidney stones?

    A: Symptoms may vary from none, in the case of “silent stones,” (stones that are still in the kidney and have not moved to the ureter) to severe pain due to urinary obstruction.

    Here’s a list of the most common symptoms of stone disease:

    • pain in the abdomen, flank (side), back, or groin
    • blood in the urine
    • frequent urination
    • nausea and/or vomiting

    Keep in mind that kidney stones affect different children in different ways.

    Any child with pain accompanied by blood in the urine — even if it’s just a little bit — should be evaluated by a doctor.

    Q: How are kidney stones diagnosed?

    A: Our doctors can tell if your child has a kidney stone by looking at his urinary tract with ultrasound or a CT scan.

    Ultrasound is our first choice of diagnostic because there’s no radiation exposure. If the ultrasound is inconclusive — or if your child’s doctor has any questions about it — we might do a CT scan. A CT scan can also be used to help your child’s doctor locate the exact position and size of the stone for surgical planning.

    Q: How are kidney stones treated?

    A: The best treatment will depend on the size, location, number and composition of your child's stone(s). In many cases, stones can be passed spontaneously without any treatment — in fact, children can pass stones that are relatively large compared to those that adults can pass.

    Your child's doctors may prescribe certain medications that have been shown to increase the chance of a stone passing spontaneously.

    Q: What if my child can’t pass the stone himself?

    A: Sometimes it is necessary to remove the stones if warranted by your child's condition and symptoms. It also makes sense sometimes to remove a growing stone even if it is causing no symptoms, rather than waiting until it is very large.

    The choice of technique depends upon the location, size and type of stone, as well as your child's anatomy. Methods include, the following, which are described in the Treatment & Care section:

    • extracorporeal shock wave lithotripsy (ESWL)
    • percutaneous nephrolithotomy (PCNL)
    • ureteroscopy
    • open stone surgery

    Q: What is the long-term outlook for my child?

    A: It depends on what’s causing your child to develop the stones. Some children pass a stone, change their diet and hydration patterns and never have another stone again. Others, however, have trouble changing their hydration and eating habits and will probably develop more stones.

    Rarely, a child may have an underlying medical condition that causes the body to develop stones; in this case, your child may have to struggle with stones for the rest of her life.

    Q: How do I make sure my child doesn't get more stones?

    A: Here’s a list of some basic things you can do to decrease your child’s chances of developing kidney stones:

    • Encourage your child to drink plenty of water, not only when he is thirsty, but through the day. Keeping hydrated is extremely important.
      • An excellent way to determine if your child is properly hydrated is by checking the color of his urine; if it’s clear, he’s adequately hydrated, but if it’s yellow, he’s dehydrated.
      • Many sport drinks have added sodium, so be sure to check the label before drinking them and avoid drinks with high amounts of sodium. Water is always the best way to stay hydrated and decrease your child’s chances of developing stones.
      • Citrate is generally good to have in the urine. We encourage children to drink lemonade because it may be a source of natural citrate.
    • Avoid salty foods like chips, French fries, processed meats, canned soups, prepackaged meals and high-fat items. To cut salt intake, leave the saltshaker off the kitchen table and do not add salt to food while cooking.
    • Focus on providing a healthy diet high in fruits and vegetables, and be sure to include the recommended daily allowance of protein, calcium and vitamin D.
    • Exercise, exercise, exercise! Although fit children can develop kidney stones, many experts believe obesity may be related to higher incident rates. Make sure your child keeps hydrated while exercising.
    • If there is a family history of kidney stones, pay extra attention to diet, exercise and water consumption.
  • The first step in treating your child is forming an accurate and complete diagnosis.

    Our doctors can tell if your child has a kidney stone by looking at his urinary tract with ultrasound or a CT scan.

    Ultrasound is our first choice of diagnostic because there’s no radiation exposure. Our trained ultrasound technicians can often find the stone that’s causing your child trouble.

    If the ultrasound is inconclusive — or if your child’s doctor has any questions about it — we might do a CT scan.

    This is a non-invasive procedure that uses x-ray equipment and powerful computers to create detailed, cross-sectional images of your child's urinary tract. A CT scan can help your child’s doctor locate the exact position and size of the stone for surgical planning.

    What should we expect during our visit to the Kidney Stone Program?

    During your appointment, you and your child will meet with a pediatric urologist and a pediatric nephrologist for a physical exam and discussion of your child’s health, including a review of current prescribed and over-the-counter medications and a detailed history of your child’s diet and fluid intake.

    • Please be sure to bring a detailed list of all of your child’s medications, including over-the-counter medications. If it’s more convenient, you may bring the medications themselves instead of making a list.

    • If your child passes a stone, try to recover it, place it in a plastic bag and bring it to your appointment so that we can send it out for chemical analysis.

    Several tests are also performed during the visit. These may include:

    • analysis of urine to assess for factors that contribute to stone formation, such as increased levels of calcium in the urine

    • blood tests to look for other risk factors

    • chemical analysis of the stone (if it has passed or has been removed) to identify the type of stone. This can provide important clues about why it formed.

    • evaluation for inherited disorders to look at risk factors (such as rare inherited disorders)

    Once the tests are completed, you may be asked to return for a follow-up appointment.

    How long does the appointment take?

    Your first appointment usually takes two hours. If we need to perform diagnostic imaging as discussed above, it can add some time to your visit.

    After we complete all necessary tests, our experts meet to review and discuss what they have learned about your child's condition. Then we will meet with you and your family to discuss the results and outline the best treatment options.

  • Knowing that your child is suffering from kidney stones can be upsetting. But you can rest assured that you're in the right place. At Boston Children's Hospital, we're known for our science-driven approach—we're home to the most extensive research enterprise located in a pediatric hospital in the world, and we've partnered with a number of top biotech and health care organizations—but our physicians never forget that your child is a child, and not just another patient.

    How are kidney stones treated?

    The best treatment will depend on the size, location, number and composition of your child's stone(s). In many cases, stones can be passed spontaneously without any treatment — in fact, children can pass stones that are relatively large compared to those that adults can pass.

    Your child's doctors may prescribe certain medications that have been shown to increase the chance of a stone passing spontaneously.

    What if my child can't pass the stone himself?

    Sometimes it is necessary to remove the stones if warranted by your child's condition and symptoms. It also makes sense sometimes to remove a growing stone even if it is causing no symptoms, rather than waiting until it is very large.

    The choice of technique depends upon the location, size and type of stone, as well as your child's anatomy. Methods include, the following, which are further described below:

    • extracorporeal shock wave lithotripsy (ESWL)
    • percutaneous nephrolithotomy (PCNL)
    • ureteroscopy
    • open stone surgery

    ESWL

    The most common and least invasive way of treating stones, ESWL uses a special machine called a “lithotripter” to send shock waves through the skin into your child's body.

    The lithotripter focuses the shock waves at the precise point where the stone is located, in much the same way that a magnifying lens can focus sunlight to create intense heat. This causes the stone to break into small fragments. Many shock waves are applied slowly, often several thousand, over about 20 minutes. The pieces will then pass in the urine over the following days.

    • When the shock waves enter the skin, they are not focused, so they do no damage to the skin or internal organs. However, there can be some discomfort with this procedure.  In older children, sedation can be used to control discomfort, but in small children, general anesthesia is used.
    • After treatment, it may take up to three months for all fragments to pass, depending upon the position of the stone.
    • The overall success rate of ESWL is about 85 percent. Stones in the lower pole of the kidney are less likely to pass. Very hard stones, such as those made of cystine or certain kinds of calcium stones, may not fragment very well.

    Ureteroscopy

    This technique uses a small scope passed up through the urethra into your child's bladder, and from there up into one or both ureters (the tubes that connect the kidney with the bladder) and kidneys.

    Digital cameras attached to the scope allow doctors to see the stones and remove them with a variety of specially designed instruments.

    • Ureteroscopy is done under general anesthesia.
    • The success rate is very high, upwards of 95 percent. Success rates are lower for large stones, which may require multiple treatments, and in children whose urinary anatomy makes it difficult to get the scope up to the stone.

    PCNL

    PCNL is used to treat large kidney stones, and employs a needle that goes through the skin and into the kidney, under ultrasound or x-ray guidance.

    An instrument is then passed into the kidney to allow direct examination, fragmentation and removal of the stone.

    • PCNL is done under general anesthesia.
    • A kidney drainage tube is usually left in place for two to four days.
    • PCNL is particularly useful if your child has a hard or large stone that might not fragment with ESWL or has abnormal kidney anatomy.
    • A special, small access sheath permits access to the kidney for stone removal in small children.

    Open stone surgery

    Years ago, almost all stones required open surgery for removal. With advances in technology, however, most stones can now be treated with a less invasive approach, but open stone surgery is still needed occasionally in children with unusual anatomy or other specific conditions.

    How do I make sure my child doesn't get more stones?

    Effective prevention depends largely upon why the stones are forming. A metabolic evaluation of your child is necessary, in consultation with a pediatric nephrologist, to identify risk factors for stone formation.

    This evaluation includes:

    • detailed questions about your child's medical history, diet and fluid intake
    • review of current prescribed and over-the-counter medications
      • Please be sure to bring a detailed list of all of your child's medications, including over-the-counter medications. If it's more convenient, you may bring the medications themselves instead of making a list.
    • physical exam
    • a urine test to look for factors that contribute to stone formation, such as increased levels of calcium in the urine
    • blood tests to look for other risk factors
    • analysis of the stone (once it is passed or removed) to identify its composition, which can provide important clues about why it formed.
      • If your child passes a stone, try to recover it, place it in a plastic bag and bring it to your appointment so that we can send it out for chemical analysis.
    • questions about family history, since some inherited disorders can increase the risk of kidney stones

    After this metabolic evaluation is completed, your doctor will better understand what is causing the stones — and how best to prevent your child from developing more stones.

    Here's a list of some basic things you can do to decrease your child's chances of developing kidney stones:

    • Encourage your child to drink plenty of water, not only when he is thirsty, but through the day. Keeping hydrated is extremely important.
      • An excellent way to determine if your child is properly hydrated is by checking the color of his urine; if it's clear, he's adequately hydrated, but if it's yellow, he's dehydrated.
      • Many sport drinks have added sodium, so be sure to check the label before drinking them and avoid drinks with high amounts of sodium. Water is always the best way to stay hydrated and decrease your child's chances of developing stones.
      • Citrate is generally good to have in the urine. We encourage children to drink lemonade because it may be a source of natural citrate.
    • Avoid salty foods like chips, French fries, processed meats, canned soups, prepackaged meals and high-fat items. To cut salt intake, leave the saltshaker off the kitchen table and do not add salt to food while cooking.
    • Focus on providing a healthy diet high in fruits and vegetables, and be sure to include the recommended daily allowance of protein, calcium and vitamin D.
    • Exercise, exercise, exercise! Although fit children can develop kidney stones, many experts believe obesity may be related to higher incident rates. Make sure your child keeps hydrated while exercising.
    • If there is a family history of kidney stones, pay extra attention to diet, exercise and water consumption.

    What kind of treatment plan will the doctor prescribe?

    It varies based on the cause of the stones, but some common ingredients are listed below:

    • Your child's doctor will prescribe high fluid intake and a low-salt diet to reduce the chances of kidney stone recurrence.
    • The nephrologist may prescribe medications to help prevent stones from forming, such as medications that lower the levels of calcium in the urine.

    If your child has an inherited condition that leads to kidney stones, doctors will create an individualized plan of care based on the nature and symptoms of the disorder.

    Follow-up care

    After a child has his first stone and we've completed our initial evaluation, we like to see her twice a year. We check to see how she's drinking, monitor her symptoms and do follow-up urine and blood tests. We also check for development of new stones by follow-up ultrasound.

    Coping and support

    We understand that you may have a lot of questions when your child is diagnosed with kidney stones. Will these stones go away on their own? What do we do next? We've tried to provide some answers to those questions in the following pages, but there are also a number of other resources to help you and your family through this time.

    Patient education: From your first office visit through the entire diagnosis and treatment process, our nurses will be available to help answer any questions you may have. They will also reach out to you by phone, continuing the care and support you received while at Children's.

    Parent to parent: Want to talk with someone whose child has been treated for kidney stones? We may be able to put you in touch with other families whose children have been treated at Children's.

    Social work: Our clinical social workers have helped many other families in your situation. Your social worker can offer counseling and assistance with issues such as coping with your child's diagnosis, stresses relating to coping with illness and dealing with financial difficulties.

    Visit our For Patients and Families site for all you need to know about:

    • Getting to Children's
    • Accommodations
    • Navigating the hospital experience
    • Other resources that are available for your family
  • Research: Rise in kidney stones in kids

    Confirming anecdotal reports of doctors, researchers at Boston Children's Hospital found a tripling of kidney stones in children at pediatric hospitals across the country in the last decade.

    "If you look at the raw numbers, the upward trend goes through the roof," says Caleb P. Nelson, MD, MPH, co-director of the Children's Kidney Stone Program. "The increase is not so dramatic when you adjust for hospital volume, but it is still there." The proportion of kidney stones among all patients at children's hospitals increased about 10 percent a year, from about 18.4 per 100,000 patients in 1999 to 57.0 per 100,000 in 2008, showed a study (Journal of Urology, September).

    Although on the upswing, kidney stones in children remain relatively uncommon, about half the rate of appendicitis, the researchers calculated. "We don't have a good handle on why it may be going up," says Dr. Nelson, who notices his patients tend to be healthy-weight teens who may not drink sufficient water or who may have a family history of kidney stones. Studies in adults have implicated obesity and dietary salt, both of which are on the rise in children.

    More information: childrenshospital.org/stone

    Boston Children’s Hospital is the world’s largest research program at a pediatric institution, and we’re known for pioneering new treatments. A large part of our success comes from our commitment to research—and to advancing the frontiers of what’s possible in transplants through our innovative approach.

    While kidney stones are still relatively uncommon in children, the number of cases is growing. In response, Boston Children's Hospital has established the Pediatric Kidney Stone Program to care for children with kidney stones, those who've previously had them and those who are at risk for developing them.

    At our innovative center, your child will see both a pediatric urologist and a pediatric nephrologist at the same appointment. This multidisciplinary approach allows for direct collaboration between the two specialists to optimize your child’s care and work together to develop a treatment plan — in real time.

    Minimizing radiation exposure

    As part of your child's medical care at Children's, he might need to undergo an imaging study or scan to diagnose or help treat his stone disease. You may have read about the potential risk derived from radiation from imaging tests. We take radiation exposure from diagnostic imaging very seriously and our professionals go to great lengths to ensure that these tests are performed with the lowest possible radiation exposure to patients and families.

    We routinely follow three steps to reduce the risk to children and families:

    1. Studies that involve radiation are only used when they are deemed the most appropriate test for a particular patient. Diagnostic examinations that do not involve ionizing radiation, like ultrasound, are substituted for examinations using ionizing radiation, when appropriate. In addition, steps are taken to reduce the need for multiple studies involving radiation.

    2. When an x-ray or CT scan is performed, our techniques are designed to ensure that the radiation dose is reduced to the amount needed to provide a diagnostic quality examination.

    3. The imaging equipment is properly calibrated and optimized for the special imaging needs of your child. This helps ensure the best possible result and greatest safety at the lowest necessary radiation level.

    Physicians, technologists, medical physicists and radiation safety professionals all play a role in assuring the best diagnostic image quality while minimizing radiation exposure to your child.

    The professionals that oversee the use of ionizing radiation at Children's are leading national and international efforts toward radiation dose reduction through programs such as the “Image Gently” campaign, which aims to keep the medical use of radiation as safe as possible for children. Learn more about these efforts.

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