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

Treatment of Epistaxis in Pediatric Patients

The first-line treatment for epistaxis in pediatric patients should include firm sustained compression to the lower third of the nose for 10-15 minutes, followed by application of topical vasoconstrictors such as oxymetazoline if bleeding persists. 1

Initial Management Algorithm

Step 1: First Aid Measures

• Apply firm, sustained compression to the lower third of the nose for 10-15 minutes
  • This is the most basic and effective first-line treatment
  • Have the child sit upright and lean slightly forward to prevent blood from flowing down the throat
  • Apply pressure by pinching the soft part of the nose against the septum
  • Maintain continuous pressure without releasing to check if bleeding has stopped

Step 2: Topical Vasoconstrictors

• If bleeding persists after compression, apply topical vasoconstrictors:
  • Oxymetazoline (65-75% success rate) 1, 2
  • 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 3
  • For children under 6 years: consult a physician for appropriate dosing 3

Step 3: Visualization and Cauterization

• If bleeding site is clearly visible:
  • Chemical cauterization with silver nitrate (78% of pediatric cases may require this) 4
  • Use cauterization with caution to avoid septal damage 1
  • Electric cautery is more effective with fewer recurrences (14.5% vs 35.1%) compared to chemical cauterization 2

Step 4: Advanced Interventions

• For persistent bleeding:
  • Consider topical tranexamic acid (TXA) application
    • Studies show TXA stops bleeding within 10 minutes in 71% of patients vs 31.2% with nasal packing 5
    • Lower rebleeding rates (4.7% vs 11%) compared to nasal packing 5
  • Nasal packing options if other methods fail:
    • Non-absorbable materials (petroleum jelly, BIPP gauze)
    • Absorbable materials (Nasopore)
    • Hemostatic materials (Surgicel, Floseal) 2

Prevention of Recurrence

• Nasal moisturization with saline gel or spray 1-3 times daily 1
• Humidification in dry environments
• Avoidance of digital trauma (nose picking) and vigorous nose blowing 1
• Antiseptic cream for recurrent idiopathic epistaxis 6

Special Considerations in Pediatric Patients

• Most pediatric nosebleeds originate from the anterior septum (Little's area), unlike in adults 6
• Common causes specific to children:
  • Digital trauma (nose picking)
  • Nasal foreign bodies
  • Rhinitis
  • Crusting
  • Nasal colonization with Staphylococcus aureus 6

When to Refer to Specialist Care

• Posterior epistaxis
• Bleeding not controlled with anterior measures
• Recurrent epistaxis despite treatment
• Suspected underlying pathology requiring endoscopic evaluation 1
• Significant impact on quality of life (affects 10% of cases) 4

Warning Signs Requiring Immediate Attention

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 1

Epistaxis in children is typically more benign than in adults, but proper management is essential to prevent complications and reduce stress for both children and parents. The American Academy of Otolaryngology-Head and Neck Surgery guidelines emphasize a stepwise approach, starting with simple compression and escalating to more invasive interventions only when necessary 1.