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Three Part Question

In a [child] does the [avoidance of bubble bath] help to [prevent urinary tract infections]?

Clinical Scenario

Bubble baths are common products used by parents. Medical professionals, from students to consultants, can be heard across clinics throughout the country, advising parents to avoid the use of bubble bath to help prevent another urinary tract infection in their child.
In our simple survey we could not find any labels on bubble baths intended for children or babies that reinforced this advice. Are we, as general paediatricians, providing unsubstantiated advice to our patients and parents?

Search Strategy

Primary sources: Medline 1965 to present
Embase: same search strategy—no additional papers
Secondary sources: Cochrane, Clinical Evidence—none.
(urinary tract infection) AND (bubble bath) OR (soap)—none; search of (bubble bath) OR (soap).

Search Outcome

Search results: no papers for combined search; 28 articles for (bubble bath) search, 4 relevant. Manual searching led to 3 further relevant papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Marshall S, 1965	Single case: 2 year old boy	(level IV)	Effect of bubble bath on irritative symptoms of lower urinary tract	Avoidance of bubble bath led to symptom resolution. Reintroduction of bubble bath 1 week later led to symptom recurrence within 12 h	Anecdotal evidence. Author's son (case) compared to twin brother (control) as shared baths. Supported anecdotal evidence of 2 cases (no details). Author advises to ascertain history of product use
Simmons R, 1955,	280 adult females with vulovaginitis	Descriptive study (level V)	Relative incidence of aetiological factors in vulvovaginitis	41% cases attributed to detergent/soap (bubble bath and bath salt) use. Avoidance of products caused symptom improvement	Adult patients all attending a private clinic. ?confounding factors (did review Candida albicans, Trichomonas vaginalis, atrophy, and allergens). Did not look at urinary tract infections. Authors' conclusion: "to warn patients against use of soaps"
Bass HN, 1968	16 children (4.5–10 y) details of only 4 cases given	(level V)	Effect of bubble bath on irritative symptoms of lower urinary tract	Resolution of symptoms with bubble bath avoidance and recurrence with reintroduction. One child had meatal stenosis—although exact aetiology unknown, bubble bath reported as "most likely agent responsible"	First study published with children; only 4 cases discussed All children already diagnosed as having urethral/bladder irritation attributable to regular bubble bath use. ?biased data. Urine cultures negative—did not look at urinary tract infections. Advise to enquire about bubble bath use
Heller RH, 1969	50 premenarcheal girls (12 days to 13.5 y), 21 controls	Age matched case-control study (level III)	Aetiological factors in vulvovaginitis in premenarcheal girls	Specific aetiology found in 2/3 patients. Toxic-allergic reaction to bubble bath found to be most common cause for vulvitis (8 girls, all with symptom resolution on discontinuing bubble bath)	7 of the 8 girls that used bubble bath were daughters of "medical or paramedical personnel". Results show majority of cases caused by infectious agents if vaginal discharge present
Roberts HJ, 1973	10 adult women cases, only 2 cases discussed	Case study (level V)	Acute or recurrent urethral bladder irritation precipitated by bubble bath	Cessation of bubble bath with "little or no change in therapy" led to symptom subsidence. "Majority" of patients remained "free of urinary tract symptoms" over observed time	Author coined term "bubble bath cystitis" in 1967. 7 patients had overt or chemical diabetes mellitus. Many assumptions stated: "the urethritis and cystitis caused by bubble bath irritants undoubtedly predisposes tissues to complications of a chronic manner". Also comments on possible role of bubbles in transferring bacteria. Several anecdotal comments about physicians children affected
Paradise et al, 1982	54 premenarcheal girls (5 months to 12 y)	Age matched case-control prospective study (level III)	Aetiological factors in vulvovaginitis in premenarcheal girls with and without discharge	A specific diagnosis could be made for 59% of patients. Chemical irritants caused symptoms in only 2 girls (one used uncommon brand of bubble bath and other used home-made lye soap)	Unselected population. Results with regard to aetiology of vulvovaginitis in parallel to Heller study. In contrast to Heller, chemical irritants caused genital symptoms in only 2 girls. Did not look at urinary tract infection
West et al, 1998	16 adults (25–47 y)	(level V)	To compare irritancy of 9 children's liquid bubble baths via skin patch tests (erythema, scaling, and fissuring)	Bubble baths vary in ability to cause irritation. The higher number of surfactants in a product influences its irritancy potential	Study used higher concentration of 5% to elicit enough of a response to ensure valid comparison (the recommended concentration is 1% in solution). Thus using the modified patch test greatly amplifies the irritant response that would be expected with brief intermittent exposure in a normal bath

Comment(s)

Generations of general paediatricians have advised parents to avoid the use of bubble bath in order to prevent urinary tract infections. Indeed this advice is echoed by websites that parents may access for further information, such as BUPA and the National Kidney Foundation. Our search revealed little evidence to support the avoidance of bubble baths to prevent urinary tract infections. Studies found showed that bubble bath is indeed an irritant to the urinary tract of children. Different brands of children's bubble bath lead to variable irritancy potential. A United States Food & Drug Administration (FDA) three year cumulative adverse reaction rate for bath products indicated that the reaction rate for all bath products was between 1 and 3 per million units sold. However, this is a reported rate and is likely to be higher if families were surveyed. Vaginal irritation from surfactant exposure in baths was a concern of the FDA at one point and led to the warning on all foaming bath products (especially bubble baths for children). This warning reads: "Caution: use only as directed. Excessive use or prolonged exposure may cause irritation to skin and urinary tract. Discontinue use if rash, redness or itching occurs. Consult your physician if irritation persists. Use under adult supervision." There were no studies found looking at the effectiveness of avoiding bubble bath in the prevention of urinary tract infection. However it is still plausible that irritation may increase the frequency of urinary tract infections. Should we then avoid bubble baths completely? Generally, parents and children enjoy the feeling and fragrance of bubbles in their baths. Also, the ease of use, attractive packaging, and formulations can aid in training children to bathe regularly.

Clinical Bottom Line

A common sense approach is advised in the lack of conclusive evidence. The avoidance of bubble bath may help to prevent conditions with presentations similar to lower urinary tract infections (e.g. vulval irritation) rather than urinary tract infections themselves. There is a paucity of evidence with regard to the effects of bubble bath on recurrent urinary tract infections. (Grade D) We believe that the enjoyment of bubble baths outweighs the limited evidence of their proposed harm. (Grade D)

References

1. BUPA [Online]Health Information Team http://www.bupa.co.uk/health_information/ (Accessed) 04/10/06)
2. National Kidney Federation. [Online]Children with recurrent urinary tract infections. A guide for families. http://www.kidney.org.uk/kids/uti/index.html (Accessed 04/10/06)
3. The Food and Drug Administration. Regression line and other pertinent statistical data based on cosmetic product experience information voluntarily by some cosmetic firms under 21 CFR 730 for the years 1987–1990. Washington, DC:FDA 1990.
4. Anon. Cosmetic product warning statements. Establishment of effective data for label caution requirement on children's foaming detergent bath products. Federal Register 1986;108:20471.
5. Marshall S. The effect of bubblebath on the urinary tract. J Urol 1965;93:112.
6. Simmons R. Acute vulvovaginitis caused by soap products. Am J Obstet Gynaecol 1955;6:447–8.
7. Bass HN. Bubble bath as an irritant to the urinary tract of children. Clin Paediatr (Phila) 1968;7:174.
8. Heller RH, Joseph JM, Davis HJ. Vulvovaginitis in the premenarchal child. J Paediatr 1969;74:370.
9. Roberts HJ. Bubble bath cystitis and J Fla Med Assoc 1973;60:31–5.
10. Paradise JE, Campos JM, Friedman HM, et al. Vulvovaginitis in premenarchal girls: clinical features and diagnostic evaluation. Pediatrics 1982;70:193–8.
11. West NY, Fitzpatrick JE, Jackson EM. Comparison testing of the irritancy of children's liquid bubble bath using a modified human repeat insult patch test. Am J Contact Dermat 1998;9:212–15.