Haematuria in Children - draft

Overview

The page below is aimed at guiding clinicians in primary care and has been written with the help of local secondary care paediatric nephrologists. Comprehensive guidance is also provided by the Bristol Royal Hospital for Children and designed for use in secondary care as follows: 

• Haematuria in Children (1) 
• Henoch Schonlein Purpura (HSP) (4)

Definitions

Visible (macroscopic) haematuria (VH) -  is where the urine is visibly discoloured. As little as 1 mL of blood per litre of urine can produce a visible change in the urine colour (2).

Non - visible (microscopic) haematuria (NVH)  -  Regard 2 out of 3 positive reagent strip tests as confirmation of persistent invisible haematuria after exclusion of a UTI (3). Avoid testing after vigorous exercise. 

In addition, children may be symptomatic or asymptomatic and may have proteinuria or isolated haematuria without proteinuria.

Refer to the clinical guidance on Haematuria in Children (1) for a full list of causes. 

Pseudohaematuria - there can also be red urine or a positive urine dip caused by conditions other than blood in the urine - see details below.

Assessment in primary care

Haematuria should be confirmed by dipstick test and/or microscopy to rule out non haematuria causes.

Non-haematuria (pseudohaematuria) causes of red urine/positive dipstick include:

• Food - Beetroot, food dyes, berries containing anthocyanins like blueberries or raspberries  - dipstick negative
• Drugs- Metronidazole, nitrofurantoin, doxorubicin, rifampicin - dipstick negative.
• Metabolites - e.g. porphyrins, urate crystals, tyrosinosis
• Haemoglobin due to haemolysis - dipstick positive, microscopy negative.
• Myoglobin due to rhabdomyolysis - dipstick positive, microscopy negative

Visible (macroscopic) Haematuria (VH)

• Exclude UTI or vigorous exercise as cause of VH.
• Consider referral to paediatric ED or USC referral - see red flag section below for details.

Non-Visible (microscopic) Haematuria (NVH)

In the majority of children with NVH the cause is benign and resolves spontaneously. However, investigations in primary care to exclude underlying causes are advised as below:

• Examination - Weight and height, temperature, abdominal exam for masses or tenderness of renal angles, external genitalia for other sources of blood,  oedema, skin rash, joint swelling.
• Urine dip for protein and send for protein: creatinine ratio if positive.
• Blood pressure check - see  the Henoch- Schonlein Purpura paediatric guidelines (4) which includes an appendix on pages 10-11 with normal blood pressure measurements by sex, age and height for children.

If examination and investigations are normal then isolated asymptomatic non-visible haematuria can be monitored in primary care:

• Repeat urinalysis twice 2-3 weeks apart (without exercise).
• If positive but no other indications for referral then check urine and blood pressure every 6 months in the 1st year.
• Refer to paediatric nephrologist if: Proteinuria and/or hypertension develops during monitoring or NVH persists for 6-12 months.

Red Flags

Refer to Paediatric ED for same day assessment children with:

• Visible haematuria associated with trauma.
• Palpable abdominal mass or unexplained enlarged abdominal organ (with or without visible haematuria)

Refer via Children & Young People – USC (2WW) pathway (see section 7- Wilms tumour) for children with:

• Unexplained visible haematuria confirmed on dipstick test and/or microscopy where UTI or trauma has been excluded. 

When to Refer

Refer to paediatric nephrology via eRS if:

• NVH with elevated protein:creatinine ratio and/or high blood pressure (BP charts for children can be found on pages 11 and 12 of the Henoch Schonlein Purpura In Childhood document (4)).
• NVH with persistent haematuria (1+ or above on samples 2-3 weeks apart) and proteinuria (1+ or above) on dipstick test.
• NVH where proteinuria and/or hypertension develops during monitoring or Haematuria persists for 6-12 months.

Referral is not required for:

• Haematuria (visible or non-visible) secondary to UTI which resolves with treatment.
• Haematuria (visible or non-visible) after vigorous exercise and no red flags (see red flag section below) and which resolves on repeat urine dip (no set time frame for repeat urine dip but local specialists advise 1-2 weeks).
• Isolated non-visible haematuria/proteinuria that resolves on repeat test 2-3 weeks apart.
• Isolated non-visible haematuria without elevated protein:creatinine ratio or high blood pressure. See also monitoring in primary care below*.

*Monitoring in primary care

• Persistent NVH in the absence of proteinuria or high blood pressure can be followed up annually with repeat testing for haematuria, proteinuria or albuminuria, GFR and blood pressure monitoring. This should continue for as long as the haematuria persists (3). Local nephrologists advise that it is reasonable to manage this group of children in primary care, but the above checks would need to take place in primary care on at least an annual basis. Consider referral if NVH continues for 6-12 months or refer to the guidelines set out above.

Referral

If indicated, then refer via eRS to paediatric nephrology.

There is no formal advice and guidance service for paediatric nephrology but discuss with on call team via BRCH switch if immediate or urgent concerns.

Resources

(1) Haematuria in Children provided by Bristol Royal Hospital for Children.

(2) Haematuria, management and investigation in Paediatrics (scot.nhs.uk)

(3) Chronic kidney disease: assessment and management | Guidance | NICE - in particular sections 1.1.17-19

(4) Henoch-Schonlein Purpura (Remedy BNSSG ICB)

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