What to do for a 5-year-old with a headache and epistaxis (nose bleed)?

Management of a 5-Year-Old with Headache and Epistaxis

For a 5-year-old presenting with headache and epistaxis, first manage the nosebleed with proper nasal compression for 10-15 minutes while seated upright with head tilted slightly forward, then evaluate for underlying causes of both symptoms. 1, 2

Initial Management of Epistaxis

• Position the child sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2
• Apply firm sustained compression to the soft lower part of the nose (anterior nasal septum) for 10-15 minutes without interruption 1, 3
• Have the child breathe through the mouth and spit out any blood rather than swallowing it 2
• If bleeding persists after initial compression, clean the nasal cavity of clots and apply a topical vasoconstrictor such as oxymetazoline or phenylephrine (2 sprays in the bleeding nostril) 4, 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 3

Prevention of Recurrent Epistaxis

• Once bleeding has stopped, apply petroleum jelly to the nasal mucosa to prevent recurrence 4, 2
• Recommend regular use of saline nasal sprays to keep the nasal mucosa moist 3, 2
• Consider using a humidifier, especially in dry environments 4

Evaluation of Headache with Epistaxis

• While epistaxis and headache occurring together is uncommon in children, it has been reported in approximately 1.1% of pediatric migraine cases 5
• Evaluate for warning signs that may indicate more serious conditions:
  • Fever, neck stiffness, or neurological deficits may suggest meningitis or other intracranial pathology 6
  • Persistent or severe headache unresponsive to simple analgesics 7
  • Nocturnal headaches or headaches that wake the child from sleep 6

Treatment of Headache

• For mild to moderate headache without concerning features, administer weight-appropriate ibuprofen as first-line treatment 7
• If headache persists or is severe, consider acetaminophen as an alternative 7
• Ensure the child is well-hydrated and rests in a quiet, dark environment 7

When to Seek Further Medical Attention

• If epistaxis does not stop after 15 minutes of continuous pressure 3
• If the child experiences dizziness due to blood loss 3
• If bleeding is severe (duration >30 minutes over a 24-hour period) 3
• If headache is accompanied by:
  • Fever and neck stiffness 6
  • Focal neurological deficits 6
  • Persistent vomiting 7
  • Altered mental status 6

Special Considerations

• In infants and very young children, nasal bleeding is unusual and may warrant further investigation, particularly to rule out non-accidental injury 8
• For children with recurrent epistaxis and headaches, consider referral to pediatric otolaryngology and neurology for further evaluation 5

Common Errors to Avoid

• Insufficient compression time: compression must be maintained for at least 10-15 minutes without checking if the bleeding has stopped 4, 9
• Incorrect head position: tilting the head backward can cause blood to flow into the throat and potentially lead to aspiration 2, 9
• Neglecting prevention: not treating underlying nasal mucosa dryness can lead to recurrent episodes 4