What to do for a 7-year-old child with intermittent epistaxis (nosebleeds) for the past month?

Management of a 7-Year-Old with Intermittent Nosebleeds for One Month

For a 7-year-old with one month of intermittent epistaxis, perform anterior rhinoscopy (using an otoscope in young children) to identify the bleeding source, educate parents on proper nasal compression technique (10-15 minutes to the lower third of the nose), and initiate aggressive nasal moisturization with petroleum jelly and saline sprays. 1, 2

Initial Assessment and Common Causes

Digital trauma and nasal mucosal irritation are the most frequent causes in otherwise healthy children, typically affecting the anterior nasal septum. 2 The one-month duration warrants clinical evaluation rather than phone management alone.

Key History Elements to Obtain:

• Unilateral versus bilateral bleeding - unilateral bleeding raises concern for foreign body (occurs in 7% of cases with 30% having bleeding) or, in adolescent males, juvenile nasopharyngeal angiofibroma 2
• Associated symptoms - foul smell suggests nasal foreign body, nasal obstruction may indicate structural issues 2
• Medication use - intranasal corticosteroids increase nosebleed risk 2.74-fold 1
• Family history of bleeding disorders - warrants coagulation studies 2
• Environmental factors - dry climate, low humidity, nose picking 3

Physical Examination Approach

The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present). 1 In young children, use an otoscope for visualization. 1, 2

What to Look For:

• Bleeding site on anterior septum (most common location) 2
• Septal deviation or perforation 1, 2
• Nasal foreign bodies - critical to identify, especially disk batteries which can cause tissue necrosis and septal perforation in as little as 3 hours 2
• Masses or lesions - though rare, nasal malignancies can present with epistaxis 2
• Mucosal telangiectasias - suggests hereditary hemorrhagic telangiectasia (HHT), especially with bilateral recurrent bleeding or positive family history 2, 3

Immediate Management and Parent Education

First-Line Treatment:

Apply firm sustained compression to the lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 3, 4 The patient should:

• Sit with head slightly forward to prevent blood from flowing into airway or stomach 4
• Breathe through mouth and spit out blood rather than swallowing it 4
• Avoid checking if bleeding stopped during the compression period 4

If Bleeding Persists After 15 Minutes:

• Clean nasal cavity of blood clots by gentle nose blowing 3, 4
• Apply topical vasoconstrictor (oxymetazoline 0.05%, 2-3 sprays per nostril) 3, 4
• Resume firm compression for another 5-10 minutes 4

Prevention Strategy - The Cornerstone of Management

Aggressive nasal mucosal moisturization is the cornerstone of prevention for recurrent epistaxis. 3 This includes:

• Petroleum jelly applied to nasal mucosa once bleeding stops 3, 4
• Saline nasal sprays used regularly to keep nasal mucosa moist 3, 4
• Humidifier use in the home environment 4, 5
• Avoid nose picking, rubbing, or vigorous nose-blowing for at least 7-10 days 4

When to Escalate Care

Indications for Nasal Endoscopy:

Refer to a clinician who can perform nasal endoscopy for recurrent nasal bleeding despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. 1 Nasal endoscopy localizes the bleeding site in 87-93% of cases. 2, 4

Red Flags Requiring Urgent Evaluation:

• Unilateral epistaxis with nasal obstruction - concern for tumor or foreign body 2
• Severe or bilateral recurrent episodes with bruising or petechiae - obtain coagulation studies with hematology referral 2
• Adolescent male with unilateral, unprovoked, profuse epistaxis - mandatory examination for juvenile nasopharyngeal angiofibroma 2
• Hemodynamic instability or life-threatening bleeding - requires immediate intervention 4

Cautery Considerations

If a specific bleeding site is identified on anterior rhinoscopy, 75% silver nitrate is preferable to 95% silver nitrate as it is more effective (88% vs 65% complete resolution at two weeks) and causes less pain. 6 However, avoid bilateral simultaneous septal cautery as it increases the risk of septal perforation. 4

Common Pitfalls to Avoid

• Do not check if bleeding has stopped during the initial 10-15 minute compression period - this disrupts clot formation 4
• Do not overlook nasal foreign bodies - always examine carefully, especially with unilateral symptoms 2
• Do not continue intranasal corticosteroids if present - these significantly increase epistaxis risk 1, 3
• Do not assume all recurrent epistaxis is benign - unilateral bleeding warrants thorough evaluation 2

Follow-Up

Routine follow-up is recommended to assess for complications and recurrent bleeding, with documentation of outcomes within 30 days. 4 This allows assessment for underlying conditions when treatments are ineffective or bleeding recurs. 4