From the Guidelines
The best initial treatment for epistaxis in a pediatric patient is to have the child sit down and continuously hold the lower third or soft portion of the nose pinched closed to help the blood clot, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This approach is supported by the most recent and highest quality study, which emphasizes the importance of nasal pressure alone in the vast majority of cases, including 20% of cases managed in EDs. The child should be instructed to breathe through their mouth and spit out any blood, and lean forward to prevent blood from entering the airway or stomach. Key considerations for treatment include:
- Applying firm and continuous pressure to the soft part of the nose
- Having the child sit upright and lean forward
- Instructing the child to breathe through their mouth and spit out any blood
- Avoiding the child tilting their head backward, which can cause blood to flow down the throat It is essential to note that ongoing epistaxis can lead to anemia and shock due to blood loss, as highlighted in the 2024 guidelines 1. If bleeding persists, additional interventions such as nasal saline sprays or petroleum jelly may be considered, but the primary approach should focus on applying nasal pressure. Seeking medical attention is crucial if bleeding doesn't stop after 20 minutes of pressure, if nosebleeds are frequent, or if they're accompanied by other symptoms like easy bruising or prolonged bleeding elsewhere.
From the Research
Treatment Options for Pediatric Epistaxis
- First aid measures such as external pressure and ice packing can be effective in stopping epistaxis in children, with a success rate of 65-75% 2
- Topical agents like oxymetazoline can also be used to stop bleeding, with a success rate of 65-75% 2
- Cauterization, either chemical or electrocautery, can be used to control bleeding, with silver nitrate coagulation being preferred over electrocoagulation 3, 4
- Nasal packing can be applied using non-absorbable or absorbable materials, with newer hemostatic materials being more effective and having fewer complications 2
- Endoscopic ligation of arteries or endoscopic cauterization can be used in more severe cases, with a success rate of 97% and 80% respectively 2
- Embolization can be used in intractable cases, with a success rate of 80% 2
Management Strategies
- Mucosal hydration, cautery, and first aid advice are the fundamentals of management 4
- Raising awareness of simple management strategies among parents and primary care physicians can significantly reduce associated quality of life issues 4
- Antiseptic cream can be used in cases of non-active bleeding in children, and in those with recurrent idiopathic epistaxis, to avoid further nasal cavity trauma 5
- Local treatments are usually easy to perform, but physicians have to ponder their indications depending on the possible complications in order to inform parents and to know pediatric epistaxis specificities 5
Considerations
- Hemorrhagic diathesis needs to be kept in mind as a potential cause of epistaxis in children 3
- Digital trauma, foreign bodies, and nasal colonization with Staphylococcus aureus have been suggested as specific nosebleed factors in children 5
- Rare aetiologies such as juvenile nasopharyngeal angiofibroma appear later during adolescence 5
- Quality of life can be significantly affected in cases of recurring epistaxis, with primary parental concerns being fear of excessive blood loss and the stress of soiled bedclothes and night wear 4