UTI and watchful waiting: the courage to do nothing.

In this issue of Pediatrics, Nelson and colleagues present a retrospective cross-sectional study of children ,60 months of age who underwent renal and bladder ultrasound (RBUS) and voiding cystourethrogram (VCUG). Like other studies of this topic, this is a retrospective analysis of data captured through routine care, but it is probably the largest and most well-conducted study of its kind. Their findings are consistent with most earlier work, and their conclusions valid: RBUS is a lousy screen for vesicoureteral reflux (VUR). Because the new American Academy of Pediatrics (AAP) guidelines recommend routine RBUS after the first febrile urinary tract infection (UTI), the authors make the point that a negative RBUS should not be interpreted as ruling out VUR or other conditions detectible on VCUG. This raises an important point. The AAP guideline, in fact, recommends watchful waiting (for a second UTI), not RBUS, as the screening test for high-grade VUR.