Kidney Stones in Kids and Teens

Podcast Transcript

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

Dr. Richard So, MD:

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Lynn Woo, MD:

Hi there. Welcome back to Little Health, a Cleveland Clinic Children's podcast where we talk about common health concerns in kids in a way that's practical, reassuring, and easy to understand. I'm Lynn Woo, one of the pediatric urologists at Cleveland Clinic Children's, and hoping to highlight a topic you may not think really affects kids all that much, and that's kidney stones.

Dr. Lynn Woo, MD:

In today's episode, we're gonna talk about pediatric kidney stones, signs, symptoms, when to seek care, and what treatment looks like, and most importantly, how to prevent stones. Joining us today is my friend and colleague, Dr. John Weaver. He's a board certified pediatric urologist, surgeon, and researcher, who works closely with children and their families dealing with all sorts of urinary tract problems. Dr. Weaver, thanks so much for being here today.

Dr. John Weaver, MD:

Thank you for having me.

Dr. Lynn Woo, MD:

A lot of people seem surprised when they learn that kids can actually get kidney stones too, but would you agree this is one of those things that shows up on the consult list pretty regularly now?

Dr. John Weaver, MD:

Yeah, it's definitely not rare in pediatrics anymore. I think most of us are seeing it more routinely, even in young children, but especially in adolescents.

Dr. Lynn Woo, MD:

I'll ask you more about that worrisome trend in a bit, but first, let's start with some basics. When we say kidney stones, what are we actually talking about?

Dr. John Weaver, MD:

It's essentially a concentration problem in the urine. Urine is, which is produced by the kidney. When urine becomes too concentrated, minerals like calcium and oxalate can crystallize and form a stone.

Dr. Lynn Woo, MD:

And so why would a stone in your kidney necessarily be a problem?

Dr. John Weaver, MD:

So a stone sitting quietly in the kidney may not cause any symptoms. It's when it starts to move or blocks the flow of urine from the kidney that the patient can develop symptoms.

Dr. Lynn Woo, MD:

So earlier you mentioned that stones are becoming more frequent in kids. Just how often do you think we're seeing it now?

Dr. John Weaver, MD:

More than we used to. It's still less common than adults, but the trend is clearly increasing. Over the past couple decades, the incidence in children has gone up, particularly in teenagers. In a busy pediatric practice, it's something you expect to see, not something unusual anymore.

Dr. Lynn Woo, MD:

So what do you think is driving that?

Dr. John Weaver, MD:

There's multiple factors, but the biggest factors are pretty straightforward. Low fluid intake, high-sodium diets, kids are often not drinking enough water and their d- diets tend to be more processed. There are also metabolic contributors in some patients and a family history can play a role as well.

Dr. Lynn Woo, MD:

All right. So you were talking about some of the symptoms when the stones are moving or when they're blocking. Let's talk about how kids actually show up. How do they present? Because it may not always be the typical picture that people expect.

Dr. John Weaver, MD:

Right. Some kids have pretty classic flank pain or back pain, but a lot don't. What we actually see in a lot of children is just abdominal pain. That's pain in the belly and sometimes it's hard to localize. They might have nausea, vomiting, sometimes blood in the urine, or just a kid who's clearly uncomfortable and not acting like themselves.

Dr. Lynn Woo, MD:

And so does it sometimes happen where it gets evaluated as something else or we think they're coming in with something else?

Dr. John Weaver, MD:

All the time, especially in younger kids. It can look like GI issues before stones even come up as a consideration in the workup.

Dr. Lynn Woo, MD:

So what are the big risk factors that you think about?

Dr. John Weaver, MD:

The biggest one is low fluid intake, and that's probably number one, so drink a lot more water, a high-salt diet, family history, and then some kids underlying metabolic factors.

Dr. Lynn Woo, MD:

So if a child comes in and they've got symptoms making us worried about a stone, what does that evaluation and workup generally look like?

Dr. John Weaver, MD:

We usually start with a urinalysis. Sometimes blood work and an ultrasound. That's our first line imaging test in kids. We try to avoid CT unless the ultrasound isn't definitive, but the clinical picture is still concerning.

Dr. Lynn Woo, MD:

And so what are you looking for on that urine sample or urinalysis?

Dr. John Weaver, MD:

On the urine sample, we're looking to see if there's blood in the urine. We're looking for signs of infection. We're looking to see if there's crystals and multiple other factors.

Dr. Lynn Woo, MD:

Why do you try to start with ultrasound? And are there specific things you're looking for in addition to finding the actual stone?

Dr. John Weaver, MD:

Yeah. We start with ultrasounds because they're simple. They're a pain-free study and what we're looking at, we're trying to see, are there two kidneys? Is there hydronephrosis that's a swelling or dilation of the kidney that might be a sign of obstruction from a kidney stone? We look for the location of the stone and the size of the stone.

Dr. Lynn Woo, MD:

And you had mentioned doing a CAT scan. How does that compare to an ultrasound?

Dr. John Weaver, MD:

So CT scans are also pain-free, but they give more details regarding the location of, and the size of the stone.

Dr. Lynn Woo, MD:

That sounds great. Why wouldn't I want that as first-line?

Dr. John Weaver, MD:

They do require radiation though, which we try to avoid as much as possible in children.

Dr. Lynn Woo, MD:

All right, so let's talk about management. What can someone expect if their child is trying to actively pass a kidney stone?

Dr. John Weaver, MD:

So most kids can be managed conservatively. You just, you know, give them fluids, a nausea control, and pain control, and sometimes medications to help passage. In some patients though, surgical treatment needs to be considered.

Dr. Lynn Woo, MD:

And you had mentioned earlier looking at the size of the stone on some of the x-ray studies. How big of a factor is the size of a stone? Is that really the main determining factor of whether a child's going to need surgery or not?

Dr. John Weaver, MD:

Size is a factor, yes. But deciding on surgery is not that simple. We look at size, location, symptoms, whether the stone is moving, whether there's infection. There's no single cutoff where we say a certain size always needs surgery. It's really about the overall clinical picture of the patient.

Dr. Lynn Woo, MD:

All right. So when would you actually start thinking about doing something procedurally or recommending that a surgery is going to be necessary?

Dr. John Weaver, MD:

So if there's persistent pain, inability to tolerate symptoms, really large stones or failure to pass over time, or especially obstruction with infection, that's when we intervene.

Dr. Lynn Woo, MD:

And so what if we do need to intervene? What does that surgery look like?

Dr. John Weaver, MD:

Most of what we do is minimally invasive. It's called ureteroscopy is the most common surgical approach and that's where we go up into the bladder and ureter with a very small scope to break up and remove the stone. There's also another option called shockwave lithotripsy that we use in selected cases. Rarely do larger stones require more involved procedures.

Dr. Lynn Woo, MD:

And do these generally require like full general anesthesia?

Dr. John Weaver, MD:

They do require full anesthesia, but one nice fact about the ureteroscopy and the shockwave lithotripsy is that there's no incisions that are made as a part of those procedures. They're completely minimally invasive and our scopes go through existing orifices.

Dr. Lynn Woo, MD:

And do kids tend to recover pretty quickly?

Dr. John Weaver, MD:

Yeah. Yeah. Kids, you know, depending on the case and, and the severity and the size of the stone, it's variable, but in general, kids do very well after these procedures and go home the same day and oftentimes do very well.

Dr. Lynn Woo, MD:

So once the patient passes their stone or ends up having surgery to treat it, then what are the next steps?

Dr. John Weaver, MD:

So if the patient can collect the stone, they should save it and bring it in for analysis. In surgery, we'll have some, some of the fragments, so additional testing can be done by the lab to determine the type of stone.

Dr. Lynn Woo, MD:

And so beyond managing that first or that initial stone episode, we've also got to think about why it formed in the first place.

Dr. John Weaver, MD:

Especially for first time stones in younger kids or any recurrent stone formers, we'll often do a metabolic evaluation. That involves doing blood work, urine studies, and sometimes even a 24-hour urine collection.

Dr. Lynn Woo, MD:

So that's where looping in our colleagues in pediatric nephrology becomes really important.

Dr. John Weaver, MD:

Our pediatric nephrology team helps guide the metabolic workup and long-term prevention strategies. This is a shared approach, especially for kids who are at risk of forming more stones. We work with nephrology a lot, not just for kidney stones, but for many patients with underlying problems involving the kidneys.

Dr. Lynn Woo, MD:

So let's finish up with prevention. What actually works?

Dr. John Weaver, MD:

Again, uh, the biggest thing is hydration. You should drink enough water to keep your urine very light yellow to almost clear color. I find this rule to be more helpful than a fixed number of glasses a day, but if you do need a target, I'd say for young kids, they should drink more than one liter of water per day. Teens should aim for greater than two liters and for adults, new guidelines show that even greater than two and a half liters per day.

Dr. Lynn Woo, MD:

That's great.

Dr. John Weaver, MD:

Beyond that, lowering sodium intake can be really key. We ingest a lot more salt than we're probably aware of. Try to read labels and, and you'll be surprised. In general, aim to keep your sodium less than 2,000 milligrams per day. For reference, a single slice of pepperoni pizza could have up to 1,000 milligrams of sodium.

Dr. John Weaver, MD:

Also, it might seem counterintuitive, but don't restrict calcium, although a lot of these stones are made out of calcium. Ironically, limiting calcium can actually lead to more stones and harm your child's bone health. And then we'll talk about citrate. So increasing citrate, which is a natural stone inhibitor, might also be helpful. You can get this from eating citrus fruits. Adding lemon to your water can be a double duty way to decrease the risk of forming more stones.

Dr. John Weaver, MD:

In general, keeping a balanced diet is the best rule. Limit soda and sugary beverages maintain a healthy weight and a healthy lifestyle. Obesity and insulin resistance are associated with developing stones, so avoid those at all costs. And some kids whose urinary parameters can't be improved with diet alone, targeted prescription therapy may be recommended based on their workup and that will be prescribed in conjunction with our nephrology colleagues.

Dr. Lynn Woo, MD:

So Dr. Weaver, since we're talking about balanced diets, what about the keto diets or the high protein diets that we hear so much about?

Dr. John Weaver, MD:

So keto diets are generally high protein diets. They can place some patients at increased risk of stones. Some kids, uh, do need to be on keto diets because of other medical concerns. So when that is the case, it's more important than ever to work with our colleagues in nephrology and those patients may be recommended to drink even higher volumes of water than, than what we described previously.

Dr. Lynn Woo, MD:

And I know we keep talking about the importance of hydration, but what about when it's summertime or you're living in a particularly hot or dry climate? How does that affect your recommendations for hydration?

Dr. John Weaver, MD:

Certainly. So, you know, high temperatures, warm climates can certainly cause children to become more dehydrated. So in those situations, it's more important than ever to drink high volumes of water, probably drink more than, you know, the recommended amount that we mentioned earlier and really kind of analyze the color of the urine in those cases and make sure that we're getting to a very, like, light straw yellow urine to maintain hydration because we can see increased risk of stone formation in those climates.

Dr. Lynn Woo, MD:

That's great advice. I feel like just really pushing the water intake with kids these days is a big deal.

Dr. John Weaver, MD:

Absolutely.

Dr. Lynn Woo, MD:

Dr. Weaver, I know we're really pushing these fluids. Do you have any recommendations or strategies you could recommend to a parent in order to encourage or remind their child to be keeping up with the water intake?

Dr. John Weaver, MD:

So interestingly, there have been studies recently done on the impact of smart water bottles that, you know, connect to your phone via Bluetooth and, and can k- kind of keep track of and send reminders regarding how much fluid intake you've done throughout the day and remind you to keep increasing fluids if you've been low throughout the day. So that is something new that has been analyzed recently and is currently ongoing but could be very beneficial.

Dr. Lynn Woo, MD:

Yeah, I think kids definitely will respond to anything that's potentially linked to an electronic device or that gives them regular prompts. I know there's some apps that you can also download these days that can interface with the watch, you know, or your phone to help them track fluid intake. I think nowadays the water bottles are also pretty cute, so going with your child to pick out a cute one may also encourage them to keep that with them or get it out on a regular basis to remember to drink.

Dr. John Weaver, MD:

Yeah, absolutely. There's certainly, you know, flashy water bottles out there that children would love to purchase and then also if you have any questions with the app, they probably will know better and, and know how to, uh, download it and, and work it. So, uh, they'll, they'll be there.

Dr. Lynn Woo, MD:

Definitely true. <laugh> Definitely true.

Dr. Lynn Woo, MD:

That's really great advice. So it may seem obvious, but why are we making such a big deal about evaluation after the stone event? Like, why are we really trying to emphasize prevention?

Dr. John Weaver, MD:

Yeah. I mean, for anyone who's ever experienced the pain of passing a stone or who's needed surgery to treat kidney stones, they can probably tell you it's something they wouldn't wish on their worst enemy. But from a clinical standpoint, about a third to maybe half of kids who form one kidney stone will go on to have another, especially if we don't address the underlying risk factors, which is why we have to take that first stone pretty seriously and recommend a pretty thorough evaluation.

Dr. Lynn Woo, MD:

So to sum it up, kidney stones in kids, they're not rare, but they're very treatable and in many cases, future stones can be prevented with some of the advice shared today. If your child has persistent abdominal pain, blood in their urine, or symptoms that just don't add up, it's definitely worth getting evaluated. And as always, our team at Cleveland Clinic Children's, the pediatric urologists, and the pediatric nephrologists, we'll work closely together to take care of your child. Thank you so much for sharing your time and expertise today, Dr. Weaver.

Dr. John Weaver, MD:

Thanks for having me today.

Dr. Lynn Woo, MD:

We hope today's conversation helped you feel better supported and prepared. If you'd like to schedule an appointment with Dr. Weaver or another pediatric urologist at Cleveland Clinic Children's, please call 216.444.5600. That's 216.444.5600. Thanks again for listening today's episode of Little Health.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the Little Health Tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.