What is the management of epistaxis (nosebleed) in children?

Management of Epistaxis in Children

First-Line Treatment: Direct Nasal Compression

The American Academy of Otolaryngology-Head and Neck Surgery recommends firm sustained compression to the lower third of the nose for 10-15 minutes without interruption as the first-line treatment, which stops bleeding in the majority of pediatric cases. 1

• Position the child sitting upright with head tilted slightly forward (never backward) to prevent blood from entering the airway or causing aspiration 2, 1
• Apply firm, continuous pressure by pinching the soft lower third of the nose for at least 10-15 minutes without checking if bleeding has stopped, as premature release prevents adequate clot formation 2, 1
• Have the child breathe through the mouth and spit out any blood rather than swallowing it 1
• Never tilt the head backward, as this increases aspiration risk and obscures assessment of bleeding severity 2
• Do not insert tissues or cotton into nostrils, as removal disrupts clot formation 2

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after 10-15 minutes of proper compression, the American Academy of Otolaryngology-Head and Neck Surgery recommends topical vasoconstrictors 1:

• Clear blood clots from the nose first, then apply oxymetazoline or phenylephrine (2 sprays in the bleeding nostril) 2, 1
• This resolves 65-75% of nosebleeds that don't stop with compression alone 2, 1, 3

Third-Line Treatment: Cauterization

If a bleeding site is clearly visible on anterior rhinoscopy after failed compression and vasoconstrictors, the American Academy of Otolaryngology-Head and Neck Surgery recommends cauterization 1:

• Bipolar electrocautery is preferable to chemical cautery (silver nitrate) as it is more effective and less painful 1
• However, if silver nitrate is used, 75% silver nitrate is significantly more effective than 95% (88% vs 65% complete resolution at two weeks) and causes less pain (mean pain score 1 vs 5) 4
• Only 6.9% of pediatric epistaxis cases presenting to emergency departments require procedures beyond simple compression and topical agents 5, 1

Special Pediatric Considerations

The American Academy of Otolaryngology-Head and Neck Surgery notes important pediatric-specific factors 1:

• Epistaxis in children typically originates from the anterior septum (Kiesselbach's plexus), making it easier to manage than posterior bleeds 1
• Mean age of presentation is 7.5 years, with 57% being male 5, 1
• Three out of four children experience at least one episode of epistaxis in childhood 1
• Children under 3 years may require different management approaches as guidelines focus primarily on children 3 years and older 1

Prevention of Recurrence

The American Academy of Otolaryngology-Head and Neck Surgery recommends preventive measures 1:

• Apply petroleum jelly (Vaseline) or other moisturizing agents to the anterior nasal septum regularly 1
• Use saline nasal sprays to keep nasal mucosa moist 1

When to Seek Emergency Medical Attention

The American Academy of Otolaryngology-Head and Neck Surgery recommends emergency evaluation if 1:

• Bleeding does not stop after 15 minutes of continuous proper compression 1
• The child experiences dizziness, weakness, or lightheadedness suggesting significant blood loss 1

Red Flags Requiring Further Investigation

Document and investigate the following risk factors 1, 6:

• Personal or family history of bleeding disorders (hemorrhagic diathesis) 1, 6
• Use of anticoagulant medications or medications interfering with hemostasis 1, 6
• History of trauma beyond simple digital manipulation 6
• Perform nasal endoscopy if bleeding is difficult to control or there is concern for unrecognized pathology 1

Advanced Management (Rarely Needed)

Surgical arterial ligation or endovascular embolization is extremely rare in pediatric cases and reserved for refractory posterior bleeding 1:

• Posterior epistaxis accounts for only 5-10% of all nosebleeds and is more common in older patients, not children 5, 7
• If nasal packing becomes necessary, use resorbable materials 2

Common Pitfalls to Avoid

• Avoid insufficient compression time (<10 minutes) or repeatedly checking if bleeding has stopped 2
• Avoid aggressive nasal packing or cautery initially until coagulation status is clarified, as these may be contraindicated in underlying bleeding disorders 2
• In most pediatric cases, careful instruction of patients and relatives concerning nasal mucosal care is sufficient 6