Audrey Rhee, MD, FACS, FAAP, is a board-certified pediatric urologist. After finishing medical school at Albert Einstein College of Medicine in the Bronx, and completing her residency at Medical College of Georgia in Augusta, GA, Dr. Rhee narrowed her field of focus to pediatrics and went on to practice at Riley Children’s Hospital and Cleveland Clinic. She was in practice for 11 years, when she decided she wanted to live in a warmer climate and reconnect with North Carolina friends. At WakeMed, Dr. Rhee has found just what she was seeking.

“I have been thrilled to find a great practice model with a partner and strong team at WakeMed.” shares Dr. Rhee. “I love working here and digging into my passion for pediatric urology. Pediatric urology presents the opportunity to provide care across the discipline — in the pediatric form. Even better, taking care of children means the scope of my work includes families, so I am greatly involved in family-directed care. In this vein, I offer family education in lifestyle choices that may impact a child’s health, particularly when it comes to kidney stones.”

Dr. Rhee has significant experience with kidney stones in children and has performed many stone removals (lithotripsy).

Kidney stones in kids on the rise

When it comes to children, stomachaches will happen, but caregivers may not always recognize the difference in a run-of-the-mill tummy ache versus an emergent need. Since kidney stone numbers in children have grown steadily larger over the last several years, it’s important that caregivers understand the possible signs in children.

The symptoms of kidney stones in children

Here are signs to help parents and caregivers stay on alert for possible stones.

• Vomiting
• Fever
• Genetic risk factors (run in families)
• Overweight
• Pain with urinating
• Blood in urine
• Certain medications
• Consumption of processed foods

What to watch for

“One of the biggest reasons for the jump in numbers of kids and teens, other than medical conditions, is not drinking enough water,” says Dr. Rhee. “There are many drinks far more appealing than water, including soda, sweet tea and flavored sports drinks. These kinds of beverages are marketed very well towards families. With these tempting alternatives, why would a child choose water? Flavored beverages taste and look better.

“Yet, the preferred drinks are problematic. Tea, for example, has a lot of oxalate in it, and oxalate-rich foods are stone formers. Soda and sports drinks have a high volume of salt which also fuel stone formation.”

It’s important that caregivers attend to a child’s habits to prevent kidney stones from developing.

Beyond a lack of water, other contributing factors to the formation of kidney stones include processed foods — which are often laden with salt.

How kidney stones form

It’s estimated that ten percent of Americans will develop a kidney stone in their lifetime. Kidney stones are comprised of tiny crystals. These solid masses may form one at a time, or several may form all at once, causing pain in the kidney or ureter.

Typically, the kidneys filter and clean the blood, removing waste through urine. This urine passes from the two kidneys through tubes (ureters) to the bladder. In some cases, often due to a high mineral salt concentration, small crystals can form. In many instances, the stones are small enough to pass through and be eliminated without any pain. In other cases, they are too large to pass through the tubes and become lodged, producing significant pain, nausea, vomiting, blood in the urine and fever/chills. If this happens, intervention is necessary to prevent kidney damage or infection and to relieve pain, nausea and/or vomiting if they cannot pass the stone on their own.

Why movement makes a difference

While children are not more susceptible to stones than adults, the modern-world transition to a more sedentary lifestyle certainly contributes to the increasing numbers in children. Sitting for long periods of time is not great for the kidneys and increases the odds of developing kidneys stones. Regular activity improves kidney function by expanding the renal blood vessels. Individuals with low levels of physical activity and long periods of sedentary behavior [increase the] odds of developing [kidney issues].

Dr. Rhee explains, “Today’s children are more likely than prior generations to deal with a high body mass index (BMI). Being overweight, making less healthy food and beverage choices and sitting on devices for extended periods of time, contribute to the increasing numbers in children.”

How kidney stones are discovered

Kids will present with abdominal pain, flank pain, nausea, vomiting and/or blood in urine. In addition to labs and a physical exam, the imaging modality is usually an ultrasound, but can also be computed tomography scan (CT) or magnetic resonance imaging (MRI) scans.

If a kidney stone is diagnosed in a pediatric patient, the stone (if available) is sent to the lab for chemical analysis and a urine sample is collected then sent to a lab to test the mineral content: the amount of each mineral in the urine and the amount of urine produced. This is used to evaluate for metabolic disorders, such as tubular acidosis, cystic diseases of the kidneys and barters disease, which impact how the body processes salt increasingly the likelihood of stone formation.

Dr. Rhee notes, “It’s rare for me to find a metabolic disorder, but almost every patient I’ve seen has a low volume of urine. If you’re not making enough urine, you’re probably not taking in enough fluid.

Fluids help flush minerals through the urinary system, so dehydration is associated with developing kidney stones.

How to figure out a child’s daily water needs

Determining how much water a child should drink is not an exact science. Adults are encouraged to drink at least half their body weight in water each day. However, children may need more water if they are naturally active, spend time out in the North Carolina sunshine or play sports.

To make it simple, Dr. Rhee says, “If your urine is dark, you should drink more water. Urine should be a very light yellow.”

Adding acidity to water with a little lemon is also helpful.

“The majority of stones are referred to as calcium oxalate stones and some of the acidity in lemonade (from the citrate) can help counteract the formation of those stones. We will tell patients who form stones to take potassium citrate. This is excreted into the urine and will decrease the number of stones. However, some children don’t like taking potassium citrate because they are big pills and don’t taste good. Simply adding lemon to their water, while not as good as potassium citrate, can help in the prevention of stones.”

If you suspect your child has kidney stones

Children with suspected kidney stones should be seen by their physician, who will order an ultrasound and labs to look for signs of stones and obstructions. To minimize exposure to radiation, a computerized tomography (CT) scan or other imaging tests are best reserved for when absolutely necessary.

Caregivers may schedule with a child’s primary pediatric provider. Many insurances will also allow parents to schedule directly with pediatric urology.

Learn more about WakeMed Pediatric Urology.

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About Audrey Rhee, MD, FACS, FAAP

Dr. Audrey Rhee is a board-certified pediatric urologist who specializes in medical and surgical treatments in pediatric urology. Dr. Rhee received her medical degree from Albert Einstein College of Medicine in Bronx, New York. After completing her residency in surgery and urology at the Medical College of Georgia in 2010, Dr. Rhee went on to complete a fellowship in pediatric urology at James Whitcomb Riley Hospital for Children in Indianapolis. Dr. Rhee joins WakeMed from the Cleveland Clinic Foundation.

Dr. Rhee approaches each patient individually, focusing on their specific needs and what treatment option works best for them. Outside of work, she enjoys spending time with her family, exploring outdoor activities, reading and playing tennis.