Reasoning GP · Algorithm · 1-page summary
Haematuria in children
For: children with visible or dipstick haematuria in primary care. Not for: adults (use the haematuria algorithm); antibiotic choice for UTI (use the UTI in children protocol); suspected cancer at other sites (use the paediatric cancer referral algorithm).
Core rule: always measure BP and quantify protein. Haematuria with proteinuria, hypertension, oedema or reduced urine output is nephritis until proven otherwise. An abdominal mass or unexplained visible haematuria may be Wilms tumour: consider a 48-hour referral.
0Stop — call 999 now — do not wait for microscopy, ultrasound or bloods
- Nephritis or AKI and clinically unstable: severe hypertension with neurological or cardiopulmonary symptoms, respiratory compromise, altered consciousness → 999
- Significant trauma (road traffic collision, fall from height) with haematuria and instability or suspected internal bleeding → 999 emergency trauma assessment.
- IgA vasculitis (HSP) with scrotal pain or swelling → immediate surgical assessment for torsion; 999 if immediate transfer cannot be arranged. Ultrasound must not delay it.
- HSP with severe abdominal pain, bloody stool and vomiting (intussusception) and unstable → 999.
1Triage — visible or dipstick, and what comes with it
| Finding | Next step |
|---|---|
| Visible + AKI, oedema | Or oliguria or severe hypertension → Same-day hospital |
| Visible, unexplained | Or abdominal mass → consider very urgent referral, ≤48 h (NICE NG12) |
| Dipstick only | Confirm on repeat ± microscopy; one positive is not persistent. Brown or cola + protein = glomerular. |
| Red, no red cells | Beetroot, rifampicin, myoglobin, haemoglobin, menstrual contamination |
2Screen — one row is enough
- Nephritic or nephrotic syndrome, oliguria, rising creatinine, severe hypertension, significant oedema → Same-day hospital
- Abdominal mass, unexplained enlarged organ or unexplained visible haematuria → consider very urgent paediatric referral ≤48 h. Examine once; do NOT palpate repeatedly.
- HSP rash + haematuria → Urgent paediatrics. Severe abdominal pain or GI bleeding → Same-day paediatric surgeons.
- Recent sore throat (1–3 weeks) or impetigo (3–6 weeks): PSGN → paediatric assessment; nephritic features → Same-day
- Under 3 months with suspected UTI → Same-day, immediate paediatric referral.
- Trauma with significant mechanism → Same-day hospital (999 if unstable).
3Assess — only once blocks 0–2 are answered
☐ Repeat dipstick ± microscopy ☐ BP by age, sex and height ☐ uPCR if protein positive ☐ Culture if UTI possible ☐ Creatinine and electrolytes if proteinuria, hypertension, oedema, visible haematuria or systemic illness ☐ Oedema, purpura, hearing, family history. Not routine for isolated microscopic haematuria: USS, FBC, antibody panels.
4Classify — only if the screen is negative
- IgA nephropathy — visible haematuria with or 1–3 days after a URTI.
- PSGN — 1–3 weeks after sore throat; low C3; self-limiting.
- HSP nephritis — purpura on buttocks and legs, arthritis, abdominal pain; renal signs may appear late.
- UTI — only on a properly collected sample with symptoms; recheck after treatment.
- Hypercalciuria or stones — isolated microscopic haematuria, colic → spot urine calcium:creatinine ratio.
- Alport or thin basement membrane — persistent haematuria + family history of kidney failure or deafness.
- Uncertain — say so; exercise-related haematuria is a diagnosis of exclusion.
5Treat today — doses: NICE/SPC, BNFC, local formulary
- UTI: clean-catch urine before antibiotics; treat per NG224.
- HSP, mild or no renal signs: fluids; NSAID only if no renal, GI or other contraindication; no routine prednisolone.
- Hypercalciuria: cut excess salt, cola and sugary drinks; normal fluids; do NOT restrict calcium.
- PSGN: antibiotics treat active strep infection only; fluids, salt and BP managed by paediatrics.
6Refer routinely
- Persistent proteinuria or hypertension, recurrent visible haematuria, suspected PSGN, IgA or Alport, family history → Urgent paediatric nephrology.
- Stone with colic, hydronephrosis or renal mass on USS → paediatric urology. Sickle cell → haematology.
- Isolated microscopic haematuria, normal BP, protein, renal function and family history → Routine GP recall: BP, dipstick, uPCR, creatinine yearly.
7Never reassure by
- A urine result without a BP and a protein check.
- Blaming a UTI without a properly collected sample, or visible haematuria that persists after treatment.
- Calling visible haematuria exercise-related before other causes are excluded.
- Waiting for microscopy before referring obvious nephritis.
- Calling HSP scrotal pain orchitis: torsion must be excluded immediately.
- A clear urine early in HSP: keep urine and BP checks for at least 6 months.
8Safety-net — say it, then document it
999 “Call 999 if your child is struggling to breathe, becomes very drowsy or confused, or collapses.”
Same day “Go to A&E straight away if they have severe tummy pain, vomit blood, have blood in their poo, cannot walk, or have pain in the testicle. Contact us the same day if they pass much less urine or get a puffy face.”
Routine “Keep the booked urine and blood pressure checks, even if your child seems well.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
True haematuria confirmed; pigment and contamination excluded
BP by age, sex and height, and uPCR recorded
Cause named or uncertainty stated; recall coded
Safety-net given
Summary of the full Reasoning GP haematuria in children algorithm, which holds the detail, history, examination, investigations, specific causes and evidence. Sources: NICE NG12 (updated April 2026), NG224; BAPN haematuria guidance; RCPCH HSP guideline; KDIGO IgA nephropathy 2021. Clinical reference — follow local paediatric nephrology and urology pathways and check doses in the current BNFC.