How should a 7-year-old child presenting with hematuria be evaluated and managed?

Evaluation of a 7-Year-Old with Hematuria

For a 7-year-old child presenting with blood in the urine, start with a thorough history focusing on recent infections, family history of kidney disease or hearing loss, trauma, and urinary symptoms, then obtain a urinalysis with microscopy to confirm true hematuria (≥3 RBCs/HPF) and differentiate glomerular from non-glomerular causes—most children with isolated microscopic hematuria require only observation, while gross hematuria or concerning features warrant renal ultrasound. 1, 2, 3

Initial History and Physical Examination

Critical historical elements to elicit:

• Recent streptococcal pharyngitis or skin infection (7-21 days prior suggests post-infectious glomerulonephritis) 4
• Family history of kidney disease, hearing loss, or hematuria (raises concern for Alport syndrome or thin basement membrane nephropathy) 1, 3, 5
• Recent trauma, even minor (anomalous kidneys are vulnerable) 1, 3
• Strenuous exercise (can cause transient hematuria) 2, 3
• Dysuria, frequency, fever (suggests urinary tract infection) 3, 6
• Flank or abdominal pain (consider stones or mass) 3, 6
• Rash, joint pain, or edema (Henoch-Schönlein purpura) 3, 5
• Sickle cell disease or bleeding disorders 3, 4

Physical examination priorities:

• Blood pressure measurement (hypertension suggests glomerulonephritis) 3, 4
• Palpate for abdominal masses (Wilms tumor, though rare with isolated hematuria) 1, 3
• Assess for rash, arthritis, or edema 3
• Check for costovertebral angle tenderness 3
• Document height and weight (chronic disease indicators) 3

Laboratory Evaluation

Urinalysis with microscopy is the cornerstone of evaluation:

• Confirm ≥3 red blood cells per high-power field to establish true hematuria 2, 3
• Examine for dysmorphic RBCs (>80% indicates glomerular source) and red cell casts (pathognomonic for glomerulonephritis) 1, 3, 4
• Assess proteinuria with spot urine protein-to-creatinine ratio (>0.5 g/g suggests glomerular disease) 2, 4
• Check for white blood cells and bacteria (urinary tract infection) 3, 6
• Tea-colored or cola-colored urine strongly suggests glomerular bleeding 1, 2

Additional laboratory tests based on findings:

• Spot urine calcium-to-creatinine ratio to evaluate for hypercalciuria (common cause of pediatric hematuria) 1, 3
• Serum creatinine and BUN if glomerular disease suspected 3, 4
• Complete blood count if chronic disease or coagulopathy suspected 3
• Complement levels (C3, C4) if post-infectious glomerulonephritis suspected (C3 falls acutely, normalizes by 8 weeks) 4, 5

Risk Stratification and Imaging Decisions

Isolated Microscopic Hematuria (No Proteinuria, Normal Blood Pressure)

For an otherwise well child with isolated microscopic hematuria, NO imaging is required initially. 1, 2, 3 A large study of 325 pediatric patients found no clinically significant findings on renal ultrasound or voiding cystourethrography in this population. 3 These children can be managed with:

• Baseline evaluation to exclude infection, hypercalciuria, and familial hematuria 4, 7
• Clinical observation with repeat urinalysis 4, 7
• Avoid CT, MRI, or VCUG—these expose the child to unnecessary risk without benefit 3

Critical pitfall: Isolated microscopic hematuria is very rarely the presenting scenario of Wilms tumor; brief, self-limited findings should not trigger oncologic concerns. 3

Gross (Visible) Hematuria

Renal and bladder ultrasound is the first-line imaging modality for all children with gross hematuria. 1, 2, 3 Ultrasound effectively evaluates for:

• Structural abnormalities (cysts, obstruction, congenital anomalies) 1, 3
• Nephrolithiasis (though sensitivity for ureteral stones is limited) 1, 3
• Renal or bladder tumors (rare but important) 1, 3
• Kidney size and echogenicity (enlarged echogenic kidneys suggest acute glomerulonephritis) 1, 3

Plain radiography may be performed concurrently to detect radiopaque stones. 3

Hematuria with Proteinuria

The combination of hematuria and proteinuria requires rapid systematic evaluation, generally including nephrology referral and often renal biopsy. 4, 5 The exception is clear post-streptococcal glomerulonephritis, which can be managed conservatively with monitoring for resolution over 6-12 months. 4

Painful Hematuria (Suspected Urolithiasis)

• Start with renal and bladder ultrasound 1, 3
• If ultrasound is negative but clinical suspicion remains high, consider low-dose CT (sensitivity and specificity >90% for stone detection) 3
• CT is particularly useful if stone detection would change management 1, 3

Traumatic Hematuria

Contrast-enhanced CT of abdomen and pelvis is indicated when: 1, 3

• Macroscopic hematuria is present after trauma 1, 3
• ≥50 RBCs/HPF with hypotension or concerning mechanism 3
• Blood at urethral meatus with pelvic fracture (50% incidence of genitourinary injury) 3

Isolated microscopic hematuria without clinical findings of visceral trauma does not need emergency investigation. 1, 3

Hematuria with Palpable Abdominal Mass

This scenario requires urgent ultrasound evaluation—it fundamentally changes the clinical picture from isolated hematuria. 3 Ultrasound confirms renal origin, assesses the contralateral kidney, evaluates for IVC involvement, and determines tumor size. 3 After ultrasound confirms a renal mass, proceed urgently to chest CT for staging and consider contrast-enhanced abdominal CT or MRI to define local extent and vascular invasion. 3

Nephrology Referral Indications

Refer to pediatric nephrology when:

• Proteinuria with protein-to-creatinine ratio >0.5 g/g 2, 4
• Dysmorphic RBCs >80% or red cell casts present 1, 3, 4
• Elevated serum creatinine or declining renal function 3, 4
• Hypertension accompanying hematuria 3, 4
• Family history suggesting hereditary nephropathy (Alport syndrome, thin basement membrane disease) 3, 5
• Persistent hematuria with proteinuria requiring renal biopsy 4, 5

Common Pitfalls to Avoid

• Do not perform advanced imaging (CT, MRI, VCUG) for isolated, transient microscopic hematuria in an otherwise well child—this exposes the child to unnecessary radiation and invasive procedures without diagnostic benefit. 1, 3
• Do not assume isolated microscopic hematuria indicates Wilms tumor—malignancy is exceedingly rare as a cause of isolated hematuria in children. 1, 3
• Do not skip family screening—obtaining urine samples from parents and siblings helps identify benign familial hematuria and thin basement membrane nephropathy. 3, 5
• Do not rely on standard light microscopy alone—phase contrast microscopy is required to properly assess for dysmorphic RBCs. 8
• Do not delay imaging when an abdominal mass is palpable—this requires urgent ultrasound evaluation regardless of the degree of hematuria. 3

Expected Outcomes

After complete work-up, 34-80% of children with microscopic hematuria have no identifiable cause; these patients can be managed with clinical observation without further invasive testing. 3 Post-streptococcal glomerulonephritis, when clearly documented, shows gradual resolution of hypertension, hematuria, and proteinuria over 6-12 months in children. 4