What are the causes and management of epistaxis (nosebleeds) in pediatric patients?

Causes and Management of Pediatric Epistaxis (Nosebleeds)

The most effective first-line treatment for pediatric nosebleeds is having the child sit with their head slightly forward while pinching the soft portion of the nose continuously for 10-15 minutes. 1, 2

Common Causes of Pediatric Nosebleeds

Nosebleeds in children have a bimodal age distribution, with high frequency in children under 10 years and later in adults. Pediatric epistaxis is typically anterior in origin (90-95% of cases) and usually benign 1, 2.

Most Common Causes:

• Digital manipulation (nose picking) - most frequent cause in children 3
• Dry nasal mucosa - from dry heat, abrupt temperature changes 4
• Environmental factors - low humidity, heated indoor air 2
• Upper respiratory infections - colds, allergies, sinus disease 4
• Trauma - minor nasal trauma 3

Less Common Causes:

• Bleeding disorders - hemophilia, von Willebrand disease 3
• Medications - anticoagulants or antiplatelet drugs 1, 3
• Anatomical abnormalities - septal deviation, vascular malformations 2
• Systemic diseases - hypertension (rare in children) 1

Management Algorithm

1. Initial Management (First Aid)

• Position the child sitting upright with head tilted slightly forward 1, 2
• Apply direct pressure by pinching the soft lower third of the nose continuously for 10-15 minutes 1
• Instruct the child to breathe through the mouth and spit out any blood 1
• Apply ice to the bridge of the nose (though evidence for effectiveness is limited) 1

2. When to Seek Medical Attention

• Bleeding that continues after 15 minutes of continuous pressure 1
• Child becomes lightheaded from blood loss 1
• Nosebleed associated with trauma, especially with nasal deformity 1
• Child is taking anticoagulant/antiplatelet medications or has a bleeding disorder 1
• Recurrent or severe epistaxis 1

3. Medical Management

• Examination to identify bleeding site (anterior vs posterior) 1, 2
• Vasoconstrictor application (oxymetazoline or phenylephrine) with 65-75% success rate 2
• Cauterization options:
  • Silver nitrate (75% concentration preferred over 95% - more effective and less painful) 5
  • Electrocautery for persistent cases (fewer recurrences than chemical cautery) 2
• Nasal packing if bleeding persists despite above measures 1
  • Resorbable packing preferred for patients with suspected bleeding disorders or on anticoagulants 1

4. Prevention of Recurrence

• Apply moisturizing/lubricating agents to prevent recurrence 2
• Humidification and saline sprays to maintain nasal moisture 2
• Teach children to avoid nose picking and trauma 3
• Address underlying causes (allergies, infections) 4

Special Considerations

• Bilateral cautery should be avoided to prevent septal perforation 2
• Posterior epistaxis (5-10% of cases) is rare in children but more serious, often requiring hospitalization and specialized treatment 1, 4
• Hemorrhagic diathesis should be considered in severe or recurrent cases 3
• Most pediatric epistaxis cases (approximately 43-50%) can be managed without invasive therapy 3

When to Refer to an Otolaryngologist

• Severe, recurrent, or posterior epistaxis 1
• Failed initial management attempts 1
• Suspected underlying pathology 2
• Non-cooperative children who may require procedural sedation 3

Remember that while nosebleeds can be frightening for children and parents, they are rarely life-threatening and most can be successfully managed with proper first aid techniques and appropriate medical care when necessary 3, 6.