What is the appropriate evaluation and management of epistaxis in a pediatric patient?

Management of Pediatric Epistaxis

Immediate First-Line Treatment

Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking for cessation—this single maneuver resolves the vast majority of anterior epistaxis in children. 1, 2

• Position the child seated with head tilted slightly forward to prevent blood from entering the airway or stomach 2
• Instruct the child to breathe through the mouth and spit out blood rather than swallow it 2
• Premature release of pressure is the most common cause of treatment failure 2
• Compression alone is sufficient in the majority of pediatric cases, as most bleeding originates from the anterior septum (Kiesselbach's plexus) 1, 3

When Compression Fails: Add Topical Vasoconstrictors

If bleeding persists after 15 minutes of proper compression, apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) and resume firm pressure for another 5–10 minutes. 2

• Vasoconstrictors stop bleeding in 65–75% of emergency department cases 2
• These agents are appropriate for children over 6 years of age 3
• Before using vasoconstrictors, obtain baseline blood pressure, as approximately one-third of epistaxis patients have undiagnosed hypertension 2
• Avoid prolonged or repeated use to prevent rhinitis medicamentosa 2

Identifying the Bleeding Source

After achieving hemostasis, remove blood clots by suction or gentle nose blowing, then perform anterior rhinoscopy to identify the bleeding site. 1, 4

• Most pediatric nosebleeds originate from Little's area on the anterior septum 4, 3
• Common pediatric-specific causes include digital trauma (nose picking), crusting, nasal foreign bodies, and Staphylococcus aureus colonization 3
• Nasal endoscopy is indicated when anterior rhinoscopy fails to identify the source, bleeding is difficult to control, or there is concern for foreign body or tumor 1
• Nasal endoscopy localizes the bleeding site in 87–93% of cases 1, 2

Critical Red Flags Requiring Endoscopy

• Unilateral epistaxis with nasal obstruction or foul smell suggests nasal foreign body—delay in diagnosis can cause septal perforation, especially with disk batteries (tissue necrosis can occur in as little as 3 hours). 1
• Adolescent males with unilateral, unprovoked, profuse epistaxis require examination of the posterior nasal cavity to exclude juvenile nasopharyngeal angiofibroma. 1

Definitive Treatment for Identified Bleeding Site

When a focal bleeding point is identified, treat with chemical cautery using 75% silver nitrate—this is preferred over electrocautery in children. 5, 6

• Anesthetize the site with topical lidocaine before cautery 1
• Apply cautery strictly to the active bleeding point only 1
• Never perform bilateral simultaneous septal cautery—this markedly increases the risk of septal perforation. 1, 2
• Silver nitrate cautery is preferred over electrocoagulation in pediatric patients due to better tolerability 5
• In one pediatric series, 78% of children required silver nitrate cautery while 22% needed only reassurance and advice 6

Alternative for Non-Active Bleeding or Recurrent Idiopathic Epistaxis

For children with recurrent epistaxis but no active bleeding at examination, apply antiseptic cream (such as mupirocin) to the anterior nasal mucosa—this is easier and safer than cautery in uncooperative children. 3

• Antiseptic cream addresses Staphylococcus aureus colonization, a specific pediatric risk factor 3
• This approach avoids potential trauma from "acrobatic" cauterization in young children 3

Prevention of Recurrence

After bleeding stops, apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and prevent recurrence. 2, 6

• Use saline nasal sprays frequently throughout the day 2
• Recommend a humidifier in dry environments, as dry heat creates fragile, hyperemic nasal mucosa 2, 7
• Instruct parents and children to avoid nose picking, vigorous nose blowing, and nasal manipulation for at least 7–10 days 2
• Mucosal hydration is the cornerstone of prevention in pediatric epistaxis 6

When to Proceed to Nasal Packing

Nasal packing is indicated only when bleeding persists after 15–30 minutes of proper compression combined with vasoconstrictors, or when life-threatening hemorrhage is present. 2, 4

• Only 6.9% of children presenting to emergency departments require procedural control, with 93.5% of these being simple anterior epistaxis control 1
• For children on anticoagulants or with bleeding disorders, use only resorbable packing materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 2, 4
• Surgery is rarely needed in children; when required, it is mainly due to noncooperation 5

Documentation and Risk Stratification

Document personal and family history of bleeding disorders (von Willebrand disease, hemophilia, thrombocytopenia), as hemorrhagic diathesis is a potential cause of pediatric epistaxis. 4, 5

• Record any anticoagulant or antiplatelet medication use 4
• Note intranasal drug use, including topical corticosteroids and nasal decongestant overuse 8
• Discontinue intranasal corticosteroids in children with recurrent epistaxis, as they increase bleeding risk with a relative risk of 2.74. 8

Indications for Specialist Referral

Refer to otolaryngology when bleeding persists despite appropriate packing, recurrent bleeding occurs despite correct local treatment, or more than 3 recent episodes have occurred. 2, 4

• Refer for evaluation of surgical arterial ligation or endovascular embolization when persistent bleeding is not controlled by packing or cautery 2, 8
• Refer adolescent males with unilateral profuse epistaxis for evaluation of juvenile nasopharyngeal angiofibroma 1
• Screen for hereditary hemorrhagic telangiectasia (HHT) in children with recurrent bilateral nosebleeds or family history of recurrent nosebleeds 8, 4

Common Pitfalls in Pediatric Epistaxis

• Do not skip clot removal before visualization—this prevents accurate identification of the bleeding source. 4
• Do not check for bleeding cessation during the initial 10–15 minutes of compression—premature release causes treatment failure. 2
• Do not overlook nasal foreign bodies in children with unilateral epistaxis and foul smell—epistaxis is the presenting symptom in 7% of foreign body cases. 1
• Do not use non-resorbable packing in children with bleeding disorders or on anticoagulation. 4
• Do not perform bilateral septal cautery simultaneously. 1, 2

Parental Education and Quality of Life

Educate parents on proper first aid measures, as only 30% of caregivers apply appropriate initial management. 6

• Primary parental concerns include fear of excessive blood loss and stress of soiled bedclothes 6
• Children are most affected by negative impact on sporting activity 6
• Reassure parents that epistaxis in children is seldom serious, though it can be troublesome and alarming 6, 3
• Provide clear instructions on when to return: bleeding persisting after 15 minutes of proper compression, bleeding duration exceeding 30 minutes over 24 hours, or signs of hemodynamic instability 2, 4