Paediatrics — Paediatric Renal Disease and Febrile Seizures, NMC MBBS licence examination syllabus (Nepal Medical Council).
A puffy-faced child and a child passing dark urine have different diseases, and a dipstick tells you which in thirty seconds.
Two children arrive on the same morning. One has swollen eyelids that the family assumed was an allergy. The other has passed urine the colour of strong tea.
These are the two great glomerular presentations of childhood, and they separate cleanly — provided you know what question to ask of the urine.
The glomerulus is a filter. It can fail in two ways, and they produce opposite pictures.
Nephrotic syndrome — the filter is leaky. The barrier that normally retains protein lets it through. So protein pours into the urine, blood albumin falls, and fluid leaves the circulation into the tissues. The result is oedema, classically noticed first as puffy eyes in the morning, because loose periorbital tissue swells easily when the child has been lying flat.
Nephritic syndrome — the filter is inflamed. Inflammation damages the glomerular capillaries, so blood appears in the urine, and filtration itself is impaired. Urine output falls, fluid is retained, and blood pressure rises.
The bedside discriminator is the urine itself. Frothy urine loaded with protein and no blood points to nephrotic; dark, smoky or tea-coloured urine with blood points to nephritic. A urine dipstick is the cheapest test in medicine and it separates these two immediately — so a child with unexplained oedema gets a dipstick before anything else is arranged.The good news first: in young children, nephrotic syndrome usually responds well to corticosteroids, and most children do not need a kidney biopsy before treatment is started — the response to treatment is itself informative.
But the complications are where children are actually harmed, and both follow from the same fact: the kidney is not selectively losing albumin. It is losing proteins.
Post-infectious glomerulonephritis classically follows a streptococcal throat or skin infection — but with a latent period of days to weeks, by which time the original infection has resolved.
Why does that matter practically? Because the family sees no connection. The sore throat got better; the child is now unwell with something apparently unrelated. Unless you ask specifically about a recent sore throat or skin infection, the history is not volunteered.
What actually endangers the child is not the visible haematuria. It is the hypertension and fluid overload: severely raised blood pressure can cause encephalopathy and seizures, and fluid retention can cause pulmonary oedema. The dramatic symptom is the dark urine; the dangerous problem is the blood pressure.
So measure the blood pressure in every child with dark urine or oedema. It takes a minute, it is frequently omitted in children, and it identifies the complication that does the harm.Most children recover completely with supportive management — controlling blood pressure and fluid balance while the kidney recovers on its own.
An older child with a urinary infection complains of pain on passing urine. A baby cannot. So the infection presents as fever with no obvious source, vomiting, poor feeding, irritability, faltering growth, or — in a newborn — prolonged jaundice.
None of those points at the urinary tract, which is why urinary infection is among the most commonly missed serious bacterial infections in small children.
The practical rule that follows: in a febrile young child with no obvious source of infection, test the urine. This is not a refinement; it is the step that finds the diagnosis.
And it matters beyond the current illness. Repeated infection reaching the upper tract can scar a growing kidney, and that scarring is permanent — potentially contributing to hypertension and impaired renal function much later. This is why a urinary infection in a child is taken more seriously than the same infection in an adult, and why some children are investigated afterwards for an underlying structural or reflux problem.
Imaging protocols after childhood urinary infection differ substantially between national guidelines and are revised, so none is given here — follow your local guidance. One universal point does apply: collect the sample properly. A contaminated specimen produces a result that cannot be interpreted, leading either to a missed diagnosis or to a child treated for an infection they never had.
A febrile seizure is a seizure occurring with fever in a young child, without central nervous system infection or another identifiable cause. Every part of that definition is doing work, particularly the exclusion.
The question is always: is this meningitis? A child who has a seizure with a fever has meningitis until you have satisfied yourself otherwise. Reaching for the label "febrile seizure" first — because it is common and reassuring — is exactly how meningitis is missed.Features that should increase concern rather than settle it:
Once meningitis and other causes have been excluded, the message to the family is genuinely reassuring: a simple febrile seizure is frightening to witness but does not damage the brain, and the great majority of children never have another.
No age range or duration thresholds are given in this chapter deliberately. Sources differ on both, and a child falling just outside a memorised range risks being wrongly reassured — which is precisely the error this chapter exists to prevent.
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