What is the treatment for epistaxis (nose bleeds) in pediatric patients?

Treatment of Epistaxis in Pediatric Patients

For most pediatric patients with epistaxis (nosebleeds), initial treatment should involve having the child sit with their head slightly forward while pinching the soft portion of the nose for 10-15 minutes, which is often sufficient to control bleeding. 1

Initial Management

1. Proper positioning and direct pressure:

   • Position the child sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach
   • Apply direct pressure by pinching the soft lower third of the nose continuously for 10-15 minutes
   • Instruct the child to breathe through their mouth and spit out any blood 1

2. Anterior rhinoscopy:

   • After bleeding stops or slows, perform anterior rhinoscopy to identify the bleeding site
   • Remove any blood clots that may be present to better visualize the nasal cavity 2
   • In young children, an otoscope can be used to visualize the anterior nasal cavity 2

Treatment Based on Identified Bleeding Site

Once the bleeding site is identified, choose appropriate interventions:

For Anterior Bleeding (90-95% of cases):

1. Topical vasoconstrictors:

   • Apply oxymetazoline or phenylephrine to the bleeding site
   • Success rate: 65-75% of cases resolve with vasoconstrictor application 1
   • For children 6-12 years: 2-3 sprays in each nostril, not more often than every 10-12 hours, maximum 2 doses in 24 hours
   • For children under 6 years: consult a physician for proper dosing 3

2. Nasal cautery:

   • Anesthetize the bleeding site with topical lidocaine or tetracaine
   • Apply cautery only to the active bleeding site
   • Electrocautery is more effective than chemical cautery (silver nitrate), with fewer recurrences (14.5% vs 35.1%) 1, 4
   • Avoid bilateral septal cautery to minimize risk of septal perforation 1

3. Prevention of recurrence:

   • After bleeding stops, apply moisturizing/lubricating agents (petroleum jelly)
   • Consider humidification and saline sprays 1

For Persistent or Recurrent Bleeding:

1. Nasal endoscopy:

   • Perform or refer for nasal endoscopy to identify the bleeding site
   • Particularly important for recurrent bleeding despite prior treatment 2
   • Can identify bleeding sites in 87-93% of cases 1

2. Nasal packing:

   • For ongoing active bleeding not controlled by the above measures
   • Use resorbable packing for patients with suspected bleeding disorders 2
   • Options include petroleum jelly gauze, PVA nasal tampons (Merocel), or newer hemostatic materials 4

Special Considerations

1. Foreign body assessment:

   • Consider nasal foreign bodies in children with unilateral epistaxis, rhinorrhea, or foul smell
   • Epistaxis is the presenting symptom in 7% of patients with nasal foreign bodies
   • Bleeding occurs in 30% of cases with nasal foreign bodies 2
   • Disk batteries require urgent removal as they can cause tissue necrosis within hours 2

2. Screening for underlying conditions:

   • Assess for nasal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds (possible hereditary hemorrhagic telangiectasia) 2
   • Consider bleeding disorders in children with severe, recurrent, or difficult-to-control epistaxis 2

3. Patient education:

   • Educate patients and caregivers about preventive measures, home treatment, and indications to seek additional medical care 2
   • Teach proper nasal hygiene to prevent picking and trauma

When to Refer to a Specialist

• Recurrent episodes of epistaxis despite appropriate treatment
• Suspicion of posterior bleeding (more rare in children)
• Concern for underlying pathology (tumor, vascular malformation)
• Bleeding that cannot be controlled with first-line measures
• Suspected bleeding disorder

Common Pitfalls and Caveats

• Don't tilt the head backward during bleeding as this can cause blood to flow into the pharynx and potentially be aspirated 1
• Don't pack both sides of the nose simultaneously in young children who are obligate nasal breathers
• Don't miss nasal foreign bodies in young children with unilateral epistaxis
• Don't apply bilateral cautery as this increases risk of septal perforation 1
• Don't forget to remove nasal packing if non-resorbable material is used, and provide clear instructions to parents about timing of removal 2

By following this algorithmic approach to pediatric epistaxis, most cases can be effectively managed with simple measures, reducing morbidity and improving quality of life for affected children.