What is the treatment for pediatric epistaxis?

Treatment for Pediatric Nosebleed (Epistaxis)

The first-line treatment for pediatric nosebleed is firm sustained compression to the lower third of the nose for 5 minutes or longer, with the child sitting upright and head tilted slightly forward. 1, 2

Immediate First-Line Management

Positioning and Compression

• Position the child sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 2, 3
• Have the child breathe through the mouth and spit out any blood rather than swallowing it 2
• Apply firm, continuous pressure by pinching the soft lower third of the nose for at least 5 minutes, preferably 10-15 minutes without checking if bleeding has stopped 1, 2
• This compression technique alone stops bleeding in the majority of pediatric cases 1, 2

Critical Pitfall to Avoid

• Do not tilt the head backward—this is a common error that can cause blood to flow into the throat and stomach 2
• Do not check if bleeding has stopped before the full 10-15 minutes of compression 2
• Do not insert tissues or cotton into the nostrils 2

Second-Line Treatment (If Bleeding Persists After Compression)

Topical Vasoconstrictors

• Clear any blood clots from the nose first 2, 3
• Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine (2 sprays in the bleeding nostril) 2, 3
• For children 6 years and older: oxymetazoline can be used with 2-3 sprays per nostril, not more often than every 10-12 hours 4
• For children under 6 years: consult a physician before using oxymetazoline 4
• This approach resolves 65-75% of nosebleeds that don't stop with compression alone 2, 3

Third-Line Treatment (If Bleeding Still Persists)

Cauterization

• If a bleeding site is clearly visible on anterior rhinoscopy, cauterization should be performed 1
• Bipolar electrocautery is preferable to chemical cautery (silver nitrate) as it is less painful and more effective 1
• If chemical cautery is used, 75% silver nitrate is superior to 95% silver nitrate—it achieves 88% complete resolution versus 65%, and causes significantly less pain (mean pain score 1 versus 5) 5
• Cautery should be performed with direct visualization using a headlight, nasal speculum, and suction 1
• Avoid bilateral septal cautery simultaneously as this increases risk of septal perforation 1

Prevention of Recurrence

Nasal Moisturization

• Apply petroleum jelly (Vaseline) or other moisturizing/lubricating agents to the anterior nasal septum to prevent recurrence 1, 2, 6
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist 2, 3
• Use a humidifier in the home, especially in dry environments 2

Antiseptic Cream for Recurrent Cases

• For children with recurrent idiopathic epistaxis, antiseptic cream (0.5% neomycin + 0.1% chlorhexidine/Naseptin) can be applied regularly to prevent recurrence 5, 7
• This is particularly useful in children with nasal colonization by Staphylococcus aureus, which is a specific risk factor in pediatric epistaxis 7

When to Seek Emergency Medical Attention

Red Flags Requiring Immediate Evaluation

• Bleeding does not stop after 15 minutes of continuous proper compression 2, 3
• Child experiences dizziness, weakness, or lightheadedness suggesting significant blood loss 2, 3
• Child has a history of bleeding disorders or is taking anticoagulant medications 2, 6
• Bleeding is severe (duration >30 minutes over a 24-hour period) 3
• Signs of hemodynamic instability such as tachycardia or hypotension 3

Special Pediatric Considerations

Age-Specific Factors

• Epistaxis in children typically originates from the anterior septum (Kiesselbach's plexus), unlike adults where posterior bleeding is more common 1, 7
• Children under 3 years of age may require different management approaches as guidelines focus primarily on children 3 years and older 2
• Mean age of pediatric epistaxis presentation is 7.5 years, with 57% being male 1
• Three out of four children experience at least one episode of epistaxis in childhood 1

Pediatric-Specific Causes

• Digital trauma (nose picking), crusting, foreign bodies, and nasal colonization with Staphylococcus aureus are specific pediatric risk factors 7
• Dry nasal mucosa from low humidity, allergies, or upper respiratory infections are common triggers 8, 9
• Rare causes like juvenile nasopharyngeal angiofibroma should be considered in adolescent males with recurrent severe epistaxis 8, 7

Advanced Management (Rarely Needed in Children)

Indications for ENT Referral

• Document factors that increase bleeding frequency: personal/family history of bleeding disorders, use of anticoagulant medications, or intranasal drug use 1, 6
• Perform nasal endoscopy if bleeding is difficult to control, there is concern for unrecognized pathology, or recurrent bleeding despite prior treatment 6
• Only 6.9% of pediatric epistaxis cases presenting to emergency departments require procedures beyond simple compression and topical agents 1
• For persistent bleeding uncontrolled by compression, vasoconstrictors, and cautery, consider nasal packing (though this is uncommon in children) 1
• Surgical arterial ligation or endovascular embolization is extremely rare in pediatric cases and reserved for refractory posterior bleeding 1