What is the treatment for epistaxis (nosebleed) in pediatric patients?

Treatment of Epistaxis in Pediatric Patients

The first-line treatment for pediatric epistaxis is firm, sustained compression of the soft lower third of the nose for 10-15 minutes with the child sitting upright and head tilted slightly forward, which stops bleeding in 60-80% of cases. 1

Immediate First-Line Management

• Position the child sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1, 2
• Instruct the child to breathe through the mouth and spit out any blood rather than swallowing it 1, 3
• 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 of pressure is a common pitfall 4, 1, 2
• This compression technique alone resolves the majority of anterior epistaxis cases in children 1, 5

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after 10-15 minutes of proper compression:

• Clear any blood clots from the nose by gentle nose blowing or suction 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) - 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2
• This approach resolves 65-75% of nosebleeds that don't stop with compression alone 1, 6

Third-Line Treatment: Cauterization

If bleeding continues despite compression and vasoconstrictors:

• Perform anterior rhinoscopy to identify the bleeding site after clot removal 2
• If a bleeding site is clearly visible on the anterior septum, cauterization is indicated 1
• Chemical cautery with silver nitrate is preferred over electrocautery in pediatric patients because it is less painful and more appropriate for children 7
• Critical pitfall to avoid: Never perform bilateral simultaneous septal cautery as this significantly increases the risk of septal perforation 2
• Electrocautery has fewer recurrences (14.5%) compared to chemical cauterization (35.1%) in adults, but silver nitrate is still preferred in children due to better tolerability 7, 6

Fourth-Line Treatment: Nasal Packing (Rarely Needed)

Only 3.9-6.9% of pediatric epistaxis cases require nasal packing 5, 8:

• Nasal packing is indicated when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, for life-threatening bleeding, or when a posterior bleeding source is suspected 4, 2
• For all pediatric patients, use resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) rather than non-resorbable materials to reduce trauma during removal 4, 5
• This is especially critical for patients with suspected bleeding disorders or those on anticoagulation/antiplatelet medications 4

Prevention of Recurrence

• Apply petroleum jelly (Vaseline) to the anterior nasal septum regularly to prevent dryness and recurrence 1, 3
• Use saline nasal sprays regularly to keep nasal mucosa moist 1, 3
• Use a humidifier in the child's room to prevent dry mucosa 3
• Educate parents and children to avoid nose-picking behavior, which is a common trigger 3

When to Seek Emergency Medical Attention

• Bleeding does not stop after 15 minutes of continuous proper compression 1, 3
• The child experiences dizziness, weakness, or lightheadedness suggesting significant blood loss 1, 3
• Recurrent unilateral persistent bleeding, which may indicate underlying pathology such as foreign body or nasal mass 3
• Personal or family history of bleeding disorders or coagulation abnormalities 3, 8

Special Pediatric Considerations

• Epistaxis in children typically originates from the anterior septum (Kiesselbach's plexus), making it more accessible and easier to treat than posterior bleeds 1
• The mean age of pediatric epistaxis presentation is 7.5 years, with 57% being male 1
• Pediatric epistaxis is significantly less severe than adult epistaxis, with fewer cases requiring hospitalization (3.9%) or surgical intervention 5
• Common triggers in children include digital manipulation (nose-picking), dry air, allergies, and upper respiratory infections 7, 9
• Children under 3 years of age may require different management approaches and lower threshold for specialist referral due to cooperation difficulties 1

Advanced Management (Extremely Rare in Children)

• Only 2-7% of pediatric cases require surgical intervention 5, 8
• For persistent or recurrent bleeding not controlled by packing, evaluate for surgical arterial ligation (endoscopic sphenopalatine artery ligation) or endovascular embolization 2
• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 2, 6
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% 2, 6

Risk Factors Requiring Special Attention

• Bleeding disorders or family history of bleeding disorders - these children have higher risk of severe epistaxis requiring factor replacement or transfusion 8
• Anticoagulation or antiplatelet medication use - associated with severe epistaxis 8
• Recent nasal procedures within 30 days - associated with severe epistaxis 8
• Bleeding duration over 30 minutes prior to arrival - associated with both moderate and severe epistaxis 8
• Prior ED visit within 72 hours - associated with moderate epistaxis 8

Common Pitfalls to Avoid

• Checking if bleeding has stopped before the full 10-15 minutes of compression - this is the most common error and leads to treatment failure 4
• Performing bilateral septal cautery simultaneously, which risks septal perforation 2
• Using non-resorbable packing in children when resorbable materials are safer and equally effective 5
• Routinely performing endoscopic examination or coagulation tests unless there is history of recurrent epistaxis, known coagulopathy, or anticoagulation therapy 5

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