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

Management of Epistaxis in Pediatric Patients

For children with active nosebleed, immediately apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped—this single intervention resolves the vast majority of pediatric epistaxis cases. 1, 2

Initial Assessment and Triage

When a child presents with epistaxis, first distinguish whether prompt management is needed by assessing: 1

• Active bleeding duration >30 minutes suggests moderate-to-severe epistaxis requiring immediate intervention 3
• Hemodynamic stability: Check for tachycardia, syncope, orthostatic hypotension, dizziness, or weakness 1, 2
• Bleeding from both nostrils or mouth suggests posterior source requiring urgent care 1
• History of bleeding disorders, anticoagulation use, or recent nasal surgery increases severity risk 1, 3

Most pediatric epistaxis (>90%) is mild, anterior in origin from Kiesselbach's plexus, and self-limited. 1, 4, 5 The mean age of presentation is 7.5 years, with 57% being male, and three out of four children experience at least one episode. 1, 4

Step-by-Step Treatment Algorithm

Step 1: Proper Nasal Compression (First-Line)

Position the child sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach. 2, 6 Have the child breathe through their mouth and spit out any blood rather than swallowing it. 2, 6

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. 1, 2, 4 This is the single most important intervention—premature release of pressure before the full 10-15 minutes is the most common error leading to treatment failure. 2

Step 2: Topical Vasoconstrictors (Second-Line)

If bleeding persists after proper compression, apply topical vasoconstrictor spray (oxymetazoline or phenylephrine): 2, 4, 6

• Clear any blood clots from the nose first 2
• Apply 2 sprays into the bleeding nostril 2, 6
• Follow with another 5-10 minutes of firm compression 2, 6
• This stops bleeding in 65-75% of cases that don't respond to compression alone 2, 4, 7

Step 3: Cauterization (Third-Line)

If a bleeding site is clearly visible on anterior rhinoscopy after Steps 1-2 fail: 2, 8

• Anesthetize the bleeding site first 1
• Chemical cautery with silver nitrate is preferred over electrocautery in children as it is less painful and easier to perform 8, 9
• Restrict cautery application only to the active or suspected bleeding site 1
• Note: Cauterization should only be performed if the bleeding site is clearly visible; "acrobatic" cauterization in uncooperative children can cause further trauma 9

Step 4: Nasal Packing (Fourth-Line)

Nasal packing is indicated when: 2

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors
• Life-threatening bleeding is present
• Posterior bleeding source is suspected

Use resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) rather than non-resorbable materials in children, especially those with bleeding disorders or on anticoagulation. 1, 2, 5 Absorbable packs offer advantages over non-absorbable packs by avoiding the need for removal and reducing patient discomfort. 5

Prevention of Recurrence

After the acute episode resolves: 2, 4, 6

• Apply petroleum jelly (Vaseline) or other lubricating agents to the anterior nasal septum daily 2, 6
• Use saline nasal sprays regularly to keep nasal mucosa moist 2, 4, 6
• Use a humidifier in the child's bedroom, especially during winter months or in dry climates 4, 6
• Discourage nose picking (digital trauma is the most common cause in children) and keep fingernails trimmed 4, 9
• Avoid nose blowing, strenuous activity, and heavy lifting for at least one week after any intervention 4

When to Escalate Care

Seek emergency medical attention or specialist referral if: 2, 4

• Bleeding does not stop after 15 minutes of continuous proper compression 2
• Child experiences dizziness, weakness, or lightheadedness suggesting significant blood loss 2
• Recurrent nosebleeds occur more than once weekly despite preventative measures 4
• Family history of bleeding disorders or child bruises easily 4
• Unilateral foul-smelling discharge suggesting nasal foreign body 4

Special Pediatric Considerations and Pitfalls

Common pitfall: Checking if bleeding has stopped before completing the full 10-15 minutes of compression—this is the most frequent error and leads to treatment failure. 2

Avoid placing tissues or cotton inside the child's nose as they can be aspirated. 4

Only 6.9% of pediatric epistaxis cases presenting to emergency departments require procedures beyond simple compression and topical agents, with 93.5% of those requiring only simple anterior control. 1, 2, 4 Surgical arterial ligation or endovascular embolization is extremely rare in children and reserved for refractory posterior bleeding. 2

Do not routinely perform endoscopic examination or coagulation tests unless there is history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or suspicion of juvenile nasopharyngeal angiofibroma (which appears during adolescence). 5, 9

For children with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, assess for nasal and oral mucosal telangiectasias to diagnose hereditary hemorrhagic telangiectasia (HHT). 1