What lab work should be done for a 6-year-old patient with recurrent epistaxis?

Laboratory Workup for Recurrent Epistaxis in a 6-Year-Old

In most 6-year-old children with recurrent epistaxis, routine laboratory testing is not indicated unless specific historical or clinical features suggest an underlying bleeding disorder. 1, 2

When Laboratory Testing is NOT Needed

• Three out of four children experience at least one episode of epistaxis, and most cases are benign anterior bleeds from digital trauma, nasal inflammation, or crusting. 1
• The majority of pediatric epistaxis cases (93.5%) require only simple anterior control measures without any laboratory investigation. 1
• Standard coagulation screening tests (PT, aPTT, platelet count) are insufficient to diagnose most relevant bleeding disorders in children with epistaxis and should not be ordered routinely. 3

Red Flags Requiring Laboratory Investigation

Order laboratory testing when any of these features are present:

Severity Indicators

• Bilateral nosebleeds occurring frequently (multiple episodes per year) with prolonged duration suggest possible von Willebrand disease or other coagulopathy. 2, 4
• Severe epistaxis requiring multiple cauterizations or nasal packing warrants hematologic workup. 4
• Significant blood loss affecting iron metabolism (anemia symptoms). 4
• Epistaxis that is difficult to control with standard first-line measures. 5

Associated Bleeding History

• Personal or family history of bleeding disorders (easy bruising, prolonged bleeding from minor cuts, excessive bleeding with dental procedures or surgery). 5, 6
• Bleeding from multiple sites (gums, GI tract, joints). 3

Physical Examination Findings

• Visible nasal or oral mucosal telangiectasias suggesting Hereditary Hemorrhagic Telangiectasia (HHT). 5
• Petechiae, purpura, or other signs of systemic bleeding disorder. 3

Specific Laboratory Tests to Order

When testing is indicated based on the above criteria, order this comprehensive panel:

Primary Hemostasis

• Complete blood count with platelet count and mean platelet volume 4
• Bleeding time (though less commonly used now) 4
• Platelet function testing/aggregation studies 4

von Willebrand Disease Screening (Most Important)

• von Willebrand factor antigen 4
• von Willebrand factor ristocetin cofactor activity 4
• Factor VIII coagulant activity 4

Von Willebrand disease is the most frequent congenital bleeding disorder (prevalence ~1%) and epistaxis is its cardinal symptom. 3

Secondary Hemostasis

• Prothrombin time (PT) 3, 4
• Activated partial thromboplastin time (aPTT) 3, 4
• Thrombin time 4
• Plasma fibrinogen level 4
• Factor XIII level (often missed by routine screening but found in 6% of epistaxis patients in one study) 3

Key Evidence on Testing Yield

• In children with mild epistaxis, only 10.3% have laboratory abnormalities, whereas in severe epistaxis, 57.9% have abnormalities with specific diagnoses in 31.6%. 4
• A prospective study of hospitalized epistaxis patients found bleeding disorders in 13%, including von Willebrand disease in 8% and Factor XIII deficiency in 6%. 3
• The prevalence of bleeding disorders in patients with epistaxis is significantly higher than in the general population. 3

Clinical Decision Tool

Use a standardized bleeding questionnaire to guide testing decisions, evaluating:

• Frequency of episodes 2
• Duration of each episode 2
• Bleeding site (unilateral vs bilateral) 2
• Seasonal correlation 2
• Severity (amount of blood, need for intervention) 2

Critical Pitfall to Avoid

Do not order routine coagulation studies (PT, aPTT, platelet count alone) as screening tests—they miss the most common bleeding disorders causing epistaxis in children, particularly von Willebrand disease and Factor XIII deficiency. 3 If you suspect a bleeding disorder, order the comprehensive panel above or refer to pediatric hematology.