Haematuria in children

Haematuria in childhood is caused by a spectrum of disease in children similar to the spectrum in adults.

Healthy children can have occasional red cells in the urine but persistent microscopic haematuria is considered significant if there are > 10 red cells/high power field in at least 3 fresh samples collected a minimum of 1 week apart (1).

Suggested initial investigations in primary care (2)

• urine dipstick testing to confirm the presence of haematuria
• in well infants, discoloration of nappy material may mimic blood, so confirm this by collecting a clean catch sample.
• early morning urine albumin to creatinine ratio (ACR) if dipstick testing shows proteinuria;
• baseline blood tests (urea, creatinine, electrolytes) and calculate glomerular filtration rate (GFR)

Summary key points (2):

• visible haematuria in children can be caused by many individually rare conditions; a small number of investigations can help to identify those which require urgent action
  
• isolated non-visible haematuria is common and usually transient; the yield from investigations is very low
  • if non-visible haematuria and clinical features of urinary tract infection, send a urine culture and treat as a urinary tract infection
  • a clinically well child with persistent, isolated non-visible haematuria and with normal blood pressure and blood and urine tests can be referred to an outpatient clinic with appropriate safety-netting and primary care monitoring
    
• ongoing symptomatic visible haematuria should be referred urgently for hospital investigation
  • refer all patients with visible haematuria to a general paediatrician
    • most children with normal initial investigations will not have further episodes of visible haematuria
    • suggested other indications for referral include:
      • persistent proteinuria, defined as ACR >3 mg/mmol on a morning urine sample
      • recurrent visible haematuria without a cause
      • any abnormal results from investigations
      • patients with suspected infection with Schistosoma haematobium based on travel or migration history.
      • non-visible haematuria with proteinuria should be referred for hospital investigation

Reference

1. Smith G. Guidelines for the management of a child with haematuria. Children’s Kidney Centre University Hospital of Wales. February 2020.
2. Godse A, Tse Y, Kokumo A, Harkensee C. Haematuria in childrenBMJ 2024; 387 :e072501