Background
Ellie Raymore is a 3-year-old girl who loves playing with her dolls and sitting on her mother9s lap
while being read to. She lives with her adoptive parents, Sandy and Eric Raymore, and is their first
and only child. They are in the process of adopting a child from Guatemala at the present time.
Sandy and Eric received little information regarding the prenatal care Ellie9s biological mother
received but were informed her mother was 17 years old when she delivered Ellie. The biological
father9s information is unknown. Ellie was in four different foster homes for the first 4 months of
her life and was then placed in Sandy and Eric9s home at about 5 months of age as a foster child.
Her adoption was finalized when she was 16 months of age.
Ellie has adjusted well since she was placed in the Raymore9s home. In the first few months,
she did not gain weight as well as she should have, but by the age of about 11 to 12 months, she
began to gain weight and grew in length. Ellie was not a good sleeper, only sleeping for 2 to 3
hours at a time when she first came to the Raymore9s house. Again, however, by about the age of
12 months, she had developed a consistent sleeping pattern and was more consolable and playful
during the day. Since coming to the Raymore9s home, Ellie has been receiving regularly scheduled
well-care visits at the pediatrician9s office and is up to date on all her immunizations.
However, Ellie was diagnosed with grade 3 vesicoureteral reflux at the age of 11 months
following a second urinary tract infection (UTI) within a 2-month period, which led her
pediatrician to suspect vesicoureteral reflux (Fig. 4.1). To diagnose Ellie, the pediatrician ordered
several tests and procedures, including a voiding cystourethrogram, a renal ultrasound, and
laboratory tests such as blood urea nitrogen, creatinine, and renal function tests. Ellie takes a
prophylactic antibiotic, sulfamethoxazole and trimethoprim (Bactrim), once a day to reduce the
chances she will get a UTI.
,
, Figure 4.1. Vesicoureteral reflux, graded according to severity. In grade 1 vesicoureteral
reflux, urine backs up into the ureter but does not dilate it. In grade 2, urine backs up into the
ureter and renal pelvis but does not dilate them. In grades 3 to 5, urine backs up into the ureter,
renal pelvis, and calyces and increasingly dilates them. Modified with permission from Marino, B.
S., & Fine, K. S. (2013). Blueprints pediatrics (6th ed., Fig. 17.1). Philadelphia, PA: Wolters
Kluwer Health/Lippincott Williams & Wilkins.
Sandy and Eric have had a lot to learn about UTIs and vesicoureteral reflux (Box 4.1). When
Sandy explains to family members what vesicoureteral reflux is, she tries to keep it simple.
Essentially, she tells people, Ellie9s urine flows backward instead of forward. Urine goes back into
her ureters and possibly into her kidneys. This puts Ellie at high risk for UTIs, renal scarring,
and pyelonephritis. If UTIs are not caught and treated quickly, Ellie could have permanently
damaged kidneys because of repeated bouts of pyelonephritis.
Sandy and Eric enjoy watching Ellie grow and develop. Just recently, Ellie mastered a few
puzzles and is so proud of herself she jumps up and down and claps her hands every time she tells
someone about her puzzles. She recently started dressing herself in the mornings and changing
into her pajamas without help in the evening. She has also mastered riding her tricycle but takes
her helmet off when Sandy and Eric are not looking. Despite her parents9 many attempts at
explaining why the helmet is important, Ellie still takes the helmet off. The rule at the Raymore
house is that you have to wear a helmet when riding a bicycle or tricycle. Sandy and Eric model
this behavior when they ride bicycles. Eric has begun taking the tricycle away from Ellie if she
takes her helmet off. Ellie gets frustrated, cries, and throws a temper tantrum each time the tricycle
is taken away. The <fit-throwing= (as Eric refers to the episodes) or temper tantrums are concerning
to Sandy. She believes Ellie should be out of this phase.
Box 4.1 Vesicoureteral Reflux
Vesicoureteral reflux occurs primarily in infants and young children but can be seen in adults.
Vesicoureteral reflux can be primary or secondary. Primary vesicoureteral reflux is more
common and is caused by a congenital defect in the functional valve between the bladder and
the ureter that normally closes to prevent urine from flowing back into the ureter. The exact
cause of vesicoureteral reflux is unknown, but it is thought to have a genetic component
because the defect runs in families. Often, depending on the severity, as the child grows, the
ureters grow longer and become straighter, which then improves valve function. Children
diagnosed with grade 1 or 2 vesicoureteral reflux often outgrow it and have normal flow of urine.
Children diagnosed with grade 3, 4, or 5 vesicoureteral reflux may have life-long reflux issues,
requiring them to take prophylactic antibiotics, undergo annual testing for renal disease, and
even have one or more surgeries to help reduce or correct the reflux severity. Secondary
vesicoureteral reflux is caused by an obstruction or malfunction in the urinary tract, most
commonly due to repeated infections that lead to scarring (National Institute of Diabetes and
Digestive and Kidney Disorders, 2017).
Ellie has met several other milestones recently, as well (Growth and Development Check 4.1).
She has been potty-trained since she was 28 months. She no longer has nighttime accidents now,
either. Ellie likes to play in groups and seems to understand the meaning of <mine,= <his,= and
<hers.= She shares without prompting about 50% of the time she plays with children her age. Sandy
is able to leave Ellie with family and familiar people as well as day care workers without signs of
separation anxiety. Sandy has noticed that Ellie has begun running <like a normal kid= instead of
being so wobbly like when she was a 2-year-old. Every day, it seems, a bit more of Ellie9s
