What is the management of recurrent epistaxis (nosebleeds) in children?

Management of Recurrent Epistaxis in Children

For children with recurrent epistaxis, begin with nasal moisturization using petroleum jelly or saline sprays applied 1-3 times daily, and if a specific bleeding site is identified on anterior rhinoscopy, proceed with silver nitrate cautery using 75% concentration rather than 95% as it is more effective and less painful. 1, 2

Initial Assessment

When evaluating a child with recurrent nosebleeds, perform anterior rhinoscopy to identify the bleeding source, as most pediatric epistaxis (approximately 78%) originates from Kiesselbach's plexus on the anterior nasal septum 3, 4. Document specific risk factors including:

• Digital trauma (nose picking) and vigorous nose blowing 5, 1
• Dry nasal mucosa and environmental factors 5, 4
• Rhinitis or allergic conditions 4
• Use of anticoagulant or antiplatelet medications 1
• Family history of recurrent bilateral nosebleeds (suggesting hereditary hemorrhagic telangiectasia) 1

Perform nasal endoscopy or refer to a specialist if bleeding has a posterior flow pattern or if unilateral bleeding with nasal obstruction is present, as this may indicate juvenile nasopharyngeal angiofibroma in adolescent males. 3

First-Line Preventive Treatment

The cornerstone of management for recurrent pediatric epistaxis is nasal mucosal hydration, which resolves up to 65% of cases 6:

• Apply petroleum jelly (Vaseline) or saline gel to the anterior nasal septum 1-3 times daily, particularly before bedtime 1, 3
• Use regular saline nasal sprays to maintain mucosal moisture 5, 1
• Consider bedside humidification during sleep 5, 3

These simple measures are highly effective yet frequently underutilized—only 30% of caregivers apply appropriate first aid measures initially 4.

Acute Episode Management

For active bleeding episodes, instruct patients and caregivers to:

• Apply firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward 1, 7
• Breathe through the mouth and spit out blood rather than swallowing it 5, 7
• After compression, clean the nasal cavity of clots and apply topical vasoconstrictor (oxymetazoline or phenylephrine) spray 1, 3

This approach stops bleeding in 65-75% of cases 1.

Nasal Cautery When Indicated

If a specific bleeding site is identified and preventive measures fail, nasal cautery should be performed 1, 3:

• Use 75% silver nitrate rather than 95% concentration—it achieves 88% complete resolution at two weeks compared to 65% with 95% silver nitrate (P = 0.01), and causes significantly less pain (mean pain score 1 versus 5, P = 0.001) 2
• Apply local anesthetic before cautery 2
• Restrict cautery only to the active bleeding site 7
• Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 1

Silver nitrate cauterization is preferred over electrocoagulation in children 8.

Red Flags Requiring Specialist Referral

Certain presentations warrant urgent otolaryngology consultation:

• Unilateral bleeding with nasal obstruction in adolescent males (concern for juvenile nasopharyngeal angiofibroma) 3
• Bilateral recurrent bleeding with visible telangiectasias on nasal or oral mucosa (hereditary hemorrhagic telangiectasia) 3
• Bleeding refractory to initial local measures 5
• Posterior epistaxis not visible on anterior rhinoscopy 5

Consider hematologic testing using standardized bleeding questionnaires when frequency, duration, or severity suggests underlying coagulopathy 6.

Patient and Caregiver Education

Educate families about preventive measures, home treatment, and indications to seek additional medical care, as recurrent epistaxis significantly affects quality of life in 10% of cases, with primary parental concerns being fear of excessive blood loss and stress of soiled bedclothes. 5, 4

Specific instructions should include:

• Avoiding digital trauma and forceful nose blowing for at least one week after treatment 3
• Proper first aid technique (pinching lower third of nose for full 15 minutes) 5
• When to seek emergency care (bleeding not controlled after 15 minutes of compression) 5

Follow-Up and Documentation

Document the outcome of intervention within 30 days to assess treatment effectiveness. 5, 1, 3

Common Pitfalls

The most significant pitfall is inadequate initial management—only 30% of caregivers apply appropriate first aid measures 4. Additionally, clinicians often overlook the effectiveness of simple nasal moisturization, which can resolve the majority of cases without need for invasive procedures 6. Finally, using 95% silver nitrate instead of 75% concentration results in both decreased efficacy and increased pain in children 2.