We appreciate the thoughtful response to our study findings and agree that the medical community should re-evaluate the American Academy of Pediatrics guidelines for febrile urinary tract infections. While the guidelines rely on the use of renal and bladder ultrasound findings to determine the need for VCUGs, several previous investigations have shown that ultrasound findings are a poorly predictive of VCUG abnormalities. Hoberman et al determined that identification of urinary tract dilation on renal ultrasound following the first febrile urinary tract infection had only a 10% sensitivity and 40% positive predictive value for detection of vesicoureteral reflux on VCUG among 302 children. 1 Hoberman A Charron M Hickey RW Baskin M Kearney DH Wald ER Imaging studies after a first febrile urinary tract infection in young children. N. Engl. J. Med. 2003; 348: 195-202 Crossref PubMed Scopus (562) Google Scholar These results were corroborated by Juliano et al, who reported evidence of dilating vesicoureteral reflux among 23/84 children with a normal renal ultrasound. 2 Juliano TM Stephany HA Clayton DB et al. Incidence of abnormal imaging and recurrent pyelonephritis after first febrile urinary tract infection in children 2 to 24 months old. J. Urol. 2013; 190: 1505-1510 Crossref PubMed Scopus (40) Google Scholar A larger study by Logvinenko et al revealed that renal ultrasound had a sensitivity of only 32% for detecting grade 3-5 vesicoureteral reflux among nearly 4000 patients. The group concluded that ultrasound was a poor screening tool for diagnosis of high-grade vesicoureteral reflux. 3 Logvinenko T Chow JS Nelson CP Predictive value of specific ultrasound findings when used as a screening test for abnormalities on VCUG. J Pediatr Urol. 2015; 11 (e171-177): 176 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The use of renal ultrasound findings to guide VCUG administration, therefore, should be called into question. It is perhaps for this reason that guideline adherence did not improve vesicoureteral reflux detection among children aged 2-24 months in our patient cohort.