What is the appropriate assessment and management of epistaxis in a 9‑year‑old child?

Assessment and Treatment of Nosebleeds in a 9-Year-Old

For a 9-year-old with nosebleeds, immediately apply firm continuous pressure to the soft lower third of the nose for 10-15 minutes with the child sitting upright and head tilted slightly forward—this stops bleeding in 60-80% of cases. 1

Immediate Management of Active Bleeding

First-Line Treatment: Nasal Compression

• Position the child sitting upright with head tilted slightly forward to prevent blood from entering the airway 1
• Apply firm, sustained compression by pinching the soft lower third of the nose (not the bony bridge) for a full 10-15 minutes without checking if bleeding has stopped 2, 1
• Instruct the child to breathe through their mouth and spit out blood rather than swallow it 1
• The most common error is releasing pressure prematurely to check if bleeding stopped—this leads to treatment failure 3

If Bleeding Continues After 15 Minutes

• Clean the nasal cavity of clots and apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, then resume firm compression for another 5-10 minutes 3
• This combination stops bleeding in 65-75% of cases that don't respond to compression alone 3

Assessment After Bleeding Control

Anterior Rhinoscopy (Mandatory)

• Perform anterior rhinoscopy on all patients after removing any blood clot to identify the bleeding source 2, 4
• Use an otoscope for visualization in young children 4
• Look specifically for: septal deviation, perforation, telangiectasias, masses, and foreign bodies 4
• Most pediatric epistaxis originates from the anterior nasal septum (Kiesselbach's area) due to digital trauma and mucosal irritation 4, 5

Key History Elements

• Document any medications (aspirin or other anticoagulants are rare but critical in children) 2, 4
• Ask about personal history of bleeding other than nosebleeds or family history of bleeding disorders 2, 4
• Assess for associated symptoms: unilateral nasal obstruction, rhinorrhea, foul smell (suggests foreign body in 7% of cases) 4
• Determine severity: bleeding duration >30 minutes, bilateral bleeding, or >3 recent episodes warrant prompt evaluation 2

When to Obtain Laboratory Testing

Laboratory evaluation is NOT routine for simple anterior epistaxis in otherwise healthy children. 6

Indications for Coagulation Studies

• Positive family history of bleeding disorders (hemophilia, von Willebrand disease) 4
• Severe or bilateral recurrent episodes 4
• Associated bruising, petechiae, or other bleeding manifestations suggesting immune thrombocytopenia 4
• History of significant bleeding after medical procedures 4

Laboratory Panel When Indicated

• Complete blood count (CBC) with differential to evaluate platelet count and anemia 4
• Coagulation studies (PT/PTT) to screen for coagulation factor deficiencies 4

When to Perform Nasal Endoscopy

Nasal endoscopy is indicated for recurrent unilateral bleeding or bleeding despite prior treatment—it localizes the bleeding site in 87-93% of cases. 4

Specific Indications

• Recurrent unilateral persistent bleeding (may indicate underlying pathology) 4, 1
• Failure to identify bleeding source on anterior rhinoscopy 4
• Adolescent males with unprovoked, profuse epistaxis (rule out juvenile nasopharyngeal angiofibroma, which occurs in 60-76% with this presentation) 4
• Suspected posterior bleeding source 4

Treatment for Recurrent Epistaxis

If Bleeding Site is Visible

• Chemical cauterization with silver nitrate is preferred over anterior packing or electric cauterization 7, 6
• Anesthetize the bleeding site first and restrict cautery application only to the active or suspected site(s) 2
• Chemical cauterization was performed in 39.3% of pediatric cases in recent studies 6

Prevention of Recurrence

• Apply petroleum jelly to the anterior septum to prevent dryness 1
• Use saline nasal sprays regularly to maintain mucosal humidity 1
• Use a humidifier in the room to prevent dry mucosa 1
• Avoid nose-picking behavior and vigorous nose-blowing for at least 7-10 days 3

For Recurrent Epistaxis with Allergies

• Combination of intranasal corticosteroids and oral antihistamines achieves 60% resolution rate (versus 40% with intranasal corticosteroids alone or 20% with antihistamines alone) 1
• Intranasal corticosteroids are more effective because they reduce mucosal inflammation and itching/rhinorrhea that trigger nose-picking behavior 1

Red Flags Requiring Immediate Referral

Emergent Evaluation Needed

• Active bleeding with hemodynamic instability or airway compromise 2
• Bleeding duration >30 minutes over 24 hours 2
• Bleeding from both nostrils or from the mouth 2
• Signs of acute hypovolemia (tachycardia, syncope, orthostatic hypotension) 2
• Dizziness, weakness, or lightheadedness indicating significant blood loss 1

Specialist Referral Indicated

• Recurrent unilateral persistent bleeding 1
• History of personal or family coagulation disorders 1
• Failure of conservative management 7
• Adolescent males with profuse, unprovoked epistaxis (mandatory examination of posterior nasal cavity and nasopharynx to rule out juvenile nasopharyngeal angiofibroma) 4

Common Pitfalls to Avoid

• Do not obtain routine imaging (CT or plain films) for uncomplicated epistaxis—it does not contribute to diagnosis 4
• Do not perform routine coagulation tests unless there is history of recurrent epistaxis, known coagulopathy, or suspicion of bleeding disorder 6
• Anterior packing is rarely needed in children (only 3.9% of cases) and should be reserved for failure of compression and cauterization 6
• Nasal endoscopy is not mandatory for simple anterior epistaxis but should be performed for recurrent or unilateral bleeding 4, 6