Laboratory Tests and Management Strategies for Children with Nosebleeds
For most children with nosebleeds (epistaxis), laboratory testing is not routinely indicated unless there are specific risk factors or concerning clinical features. 1, 2
Initial Assessment
- Children aged 3 years and older with nosebleeds should undergo anterior rhinoscopy to identify the source of bleeding after removal of any blood clots 1
- Nasal foreign bodies should be considered in children with unilateral epistaxis, rhinorrhea, or foul smell (present in approximately 7% of nasal foreign body cases) 1
- Clinicians should inquire about the use of intranasal medications, particularly nasal corticosteroids, which can increase the risk of nosebleeds (relative risk 2.74) 1
When to Consider Laboratory Testing
Laboratory tests should be considered in children with:
- Severe epistaxis (duration >30 minutes in a 24-hour period) 2, 3
- Recurrent bilateral nosebleeds without apparent seasonal pattern 4
- Nosebleeds combined with other bleeding symptoms (skin, gum, etc.) 5
- Family history of bleeding disorders 3
- Nosebleeds requiring multiple medical interventions (cauterizations, packings) 3
Recommended laboratory tests when indicated:
- Complete blood count with platelet count and mean platelet volume 3
- Coagulation studies: prothrombin time, activated partial thromboplastin time, thrombin time 3
- Bleeding time assessment 3
- Von Willebrand factor antigen and ristocetin cofactor, factor VIII coagulant 3
- Platelet aggregation studies 3
Management Strategies
First-Line Treatment
- Firm compression of the lower part of the nose for 10-15 minutes with the head slightly tilted forward 2, 6
- Instruct the child to breathe through the mouth and spit out any blood rather than swallowing it 2, 6
- This approach alone resolves the majority of epistaxis episodes in children 2, 6
For Persistent Bleeding
- Apply topical vasoconstrictors such as oxymetazoline or phenylephrine after clearing clots from the nose 2, 6
- These agents resolve 65-75% of persistent nosebleeds 2
- For recurrent or difficult-to-control bleeding, referral for nasal endoscopy should be considered 1
Prevention of Recurrence
- Nasal mucosal hydration with saline nasal sprays and humidifiers 2, 7
- Application of petroleum jelly or other emollients to prevent nasal dryness 2, 8
- Patient and caregiver education about preventive measures and home treatment 2
Special Considerations
- In children with severe or recurrent epistaxis, studies have found underlying hemostatic disorders in up to 57.9% of cases 3
- Specific conditions detected in these cases include von Willebrand's disease, Bernard-Soulier syndrome, autoimmune thrombocytopenic purpura, and Rendu-Osler-Weber disease 3
- For children requiring cautery, 75% silver nitrate is preferable to 95% as it is more effective in the short term and causes less pain 7