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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

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Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

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With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Haematuria, management and investigation in Paediatrics (145)

Objectives

1. To define microscopic and macroscopic haematuria
2. To understand the non haematuria causes for discoloured urine
3. An overview of the causes of microscopic and macroscopic haematuria, their clinical features and investigation
4. Red flags to look for in patients with haematuria

Scope

Children presenting with haematuria.

Audience

The following guideline has been developed in conjunction with clinicians based at the Renal Unit at the Royal Hospital for Children, in Glasgow. They are based on current evidence and best practice relating to the management and investigation of haematuria. They are for the use of any clinicians caring for children with haematuria, including general paediatricians, GPs and other specialists. 

This clinical guideline adheres to the principles outlined in the criteria in the AGREE (Appraisal of Guidelines, Research and Evaluation for Europe) guideline appraisal instrument and the NHSGGC Clinical Guideline Framework.

Definition

Microscopic haematuria is the presence of five red blood cells/mm3 in uncentrifuged urine (1) or 5 red blood cells per high powered field (2). Persistent microscopic haematuria is three samples with this number of RBC’s taken at least a week apart, not after exercise. There is no published data detailing the amount of RBCs seen on microscopy for each dipstick result 0, trace, 1+, 2+, 3+, however 2+ or greater on repeated is regarded as significant.

Population studies of school aged children suggest that about 1% have two or more dipsticks positive for microscopic haematuria, but this only persists at six months in a third (3-5).

Macroscopic haematuria 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 (6).

  • Blood that is glomerular in origin can be cola coloured, due to longer contact with the acidic urine causing the haem pigment to be oxidized to a methaem derivative (1). Dysmorphic red blood cells and acanthocytes can be seen on microscopy
  • Lower urinary tract blood will be red or pink coloured and may be at the beginning or end of micturition.

 

Table 1: Non haematuria causes for red or brown urine

Substance

Cause

Urine Dipstick

Haemoglobin 

Haemolysis

Positive

Myoglobin

Rhabdomyolysis

Positive

Food

Beetroot, food dyes, berries containing anthocyanins like blueberries or raspberries 

Negative

Drugs

Metronidazole, nitrofurantoin, doxorubicin, rifampicin

Negative

Inborn errors of metabolism

Porphyria, tyrosinaemia

Negative

Urate Crystals

Concentrated urine in neonates

Negative 

Reproduced from 15 minute consultation on microscopic haematuria in children article

Table 2: Causes of both microscopic and macroscopic haematuria

Aetiology

Relevant history and examination

Investigations

Urinary tract infection

Depends on ag; dysuria, frequency, fever, vomiting, off feeds

Urine dipstick

Urine microscopy, culture and sensitivity

Irritation to the meatus or perineum

History and examination

Nil

Adenovirus haemorrhagic cystitis

Symptoms of upper respiratory tract infection (URTI) with episodes of haematuria

Respiratory viral screen including adenovirus

Tumour (Wilms)

Asymptomatic abdominal mass (commonly), abdominal pain, hypertension, fever. Associated with overgrowth syndromes, Bloom's syndrome, Denys-Drash syndrome or WAGR 

USS abdomen

Nephrolithiasis

Renal colic may be absent, dysuria, incidental finding on imaging, passage of stones

USS abdomen then

abdominal xray as first line investigations

Glomerulonephritis including post infectious GN, HSP GN, membranoproliferative GN

History of cola coloured urine, odema, oliguria, hypertension, proteinuria, impaired renal function.  Haematuria onset 7-10 days post URIT in postinfectious GN. 
Rash and joint swelling/pain in HSP. 

ASOT, antiDS DNA, throat swab, U&E, FBC, C3,C4, IgGs, ANCA

(see glomerulonephritis protocol)

IgA nephropathy

Haematuria onset 1-3 days after URTI in Ig A nephropathy

High serum IgA may be suggestive, but no definitive test other than biopsy

Focal segmental glomerulosclerosis (FSGS)

FSGS usually presents with proteinuria that may become nephrotic range

Urine PCR

Alport syndrome (COL4A5, COL4A3, COL4A4 mutations)

Persistent microscopic haematuria +/- macroscopic haematuria. There may be proteinuria, renal impairment, deafness, ophthalmological abnormalities  

Genetic testing (discuss with genetics or nephrology)

Sickle cell trait/disease

Family history. Due to haemoglobin S polymerization and erythrocyte sickling within the renal medulla (7).

Hb electrophoresis

Clotting abnormalities

Relevant history and family history, petechiae, bruising

FBC and clotting as initial steps

Trauma

Relevant history and examination. Note, undiagnosed structural can be diagnosed if bleeding occurs with only mild trauma

May need USS

Exercise

Microscopic and macroscopic haematuria can be seen with vigorous exercise

Nil

Haemolytic uraemic syndrome

Bloody diarrhoea, oliguria, history of infectious contact, pallor. 

Stool culture, U&E, FBC

GN, Glomerulonephritis; ASOT, antistreptolysin O titre; U&E, urea and electrolytes; FBC, full blood count; USS, ultrasound; Hb, haemoglobin; HSP, henoch schonlein purpura; FSGS, focal segmental glomerulosclerosis; PCR, protein creatinine ratio.

Table 3: Microscopic haematuria only 

Aetiology

Relevant history and examination

Investigations

Thin basement membrane disease (COL4A3, COL4A4) also called ‘benign recurrent haematuria’

Persistent or intermittent microscopic haematuria, benign. Thought of as ‘carrier’ form of Alport syndrome.

Nil required

Structural abnormalities e.g. horseshoe kidneys

Asymptomatic, abdominal pain, UTIs

USS kidneys, ureters, bladder

Hypercalciurea

Many causes, hypercalcicurea may be present with or without hypercalcaemia

Urine calcium/creatinine ratio

Drug or toxin ingestion

Aspirin, sulphonamide, lead, tin, amitriptyline, chlorpromazine, ritonavir, carbon monoxide, mushrooms, phenol (7). See toxbase for management

Urine drug screen

 

The majority of patients with microscopic haematuria have a benign cause that resolves spontaneously. In symptomatic patient, the symptoms may give a clue to the diagnosis. In a study of 228 patients with asymptomatic macroscopic haematuria, 36% had no cause identified, 22% had hypercalciuria, 16% had IgA nephropathy, 7% had post streptococcal glomerulonephritis, 2% had other glomerulopathies including thin TBM disease, 2% had congenital anomalies, 1% had sickle cell trait (8).

Investigations

Microscopic haematuria only

Isolated microscopic haematuria is common and only requires investigation if persistent.

Investigate for specific pathologies as per clinical features; ensure that patient has blood pressure measured. In patients with asymptomatic persistent haematuria:

  • Urine microscopy 
  • Urine calcium/creatinine ratio 
  • Dipstick testing of the immediate family

If microscopic haematuria is still present 6 months later, consider checking U&E, FBC and ultrasound kidney, ureters and bladder.

Macroscopic haematuria

Investigate for specific pathologies as per clinical features; ensure that patient has blood pressure measured. If asymptomatic; 

  • Urine microscopy for presence of RBCs
  • Urine culture
  • Urine protein creatinine ratio
  • U&E, FBC, clotting, LFTs
  • Urine calcium/creatinine ratio
  • Renal USS
  • Urine analysis of family members

Box 1: Red flag features

What are the red flag features to look out for? Consider discussion with nephrologist

  • Abnormal renal function
  • Proteinuria 2+ or more on the dipstick, please send a urine protein/creatinine ratio
  • Signs of fluid overload: peripheral oedema, ascites, elevated JVP, pulmonary oedema
  • Hypertension
  • Persistent frank/macroscopic haematuria with no cause identified after baseline investigations

Key points

  1. Haematuria should be confirmed by microscopy to rule out non haematuria causes
  2. The majority of persistent microscopic haematuria is benign and resolves spontaneously 
  3. Red flag symptoms include; persistent frank haematuria, hypertension, abnormal renal function, proteinuria and signs of overload. Patients with these features should be discussed with a nephrologist (after baseline investigations). 

Editorial Information

Last reviewed: 16/12/2019

Next review date: 31/10/2025

Author(s): Dr Rebecca Dalrymple, Paediatric Registrar & Dr Ian Ramage, Consultant Paediatric Nephrologist.

Version: 4

Approved By: Paediatric & Neonatal Clinical Risk & Effectiveness Committee

Document Id: 145

References
  1. Avner ED, Harmon WE, Niaudet P, Nyoshikawa. Pediatric nephrology 6th Ed. 2009 Springer publishers. Volume one. P 477-478
  2. Diven SC, Travis LB. A practical primary care approach to haematuria in children. PediatrNephrol 2000: 14; 65-72
  3. Dodge WF, West EF, Smith EH. Proteinuria and hematuria in schoolchildren: epidemiology and early natural history. J Pediatr 1976; 88:327.
  4. Vehaskari VM, Rapola J, Koskimies O, et al. Microscopic hematuria in school children: epidemiology and clinicopathologic evaluation. J Pediatr 1979; 95:676.
  5. Iitaka K, Igarashi S, Sakai T. Hypocomplementaemia and membranoproliferative glomerulonephritis in school urinary screening in Japan. PediatrNephrol 1994; 8:420.
  6. Wald R. Urinalysis in the diagnosis of renal disease. Curhan GC and Forman JP (Eds). Up to date article. Updated Sept 2016. Accessed November 2016
  7. Mina R, Brunner HI.  Pediatric lupus – are there differences in presentation, genetics, response to therapy and damage accrual compared with adult lupus. Rheum Dis Clin N Am 2010; 36: 53-80 
  8. Bergstein J, Leiser J, Andreoli S. The clinical significance of asymptomatic gross and microscopic hematuria in children. Arch Pediatr Adolesc Med. 2005;159(4):353.