Epistaxis (nosebleeds) in children

What is epistaxis? How common is it?

Epistaxis is simply the medical term used to describe a nosebleed. The origin of the word is Greek. It is an uncommon condition in infants and young children but very common in children ages 3-8 years.
Obviously, it occurs more frequently in the winter months, as a result of the cold and dry weather.

What exactly is the source of the bleeding?

Usually, the source of the bleed is the front of the nose, closer to the nostrils, in the nasal septum, an area referred to as “Kiesselbach plexus”. This happens because this area is rich with blood vessels, it is located in the front of the nose and is prone to blows and often scratched or touched by the child, and also because the mucosa of this region is very thin and is easily injured.
In most cases, the bleeding happens suddenly and occurs in one nostril.
When the nosebleed occurs at night, the child will sometimes swallow the bleed and have either a bloody vomit or black stools the following morning (due to the blood having been digested in the gastrointestinal tract).

What are the immediate actions one should take if they see a child with a nosebleed?

First of all, keep in mind that most nosebleeds will stop on their own within minutes. Start by pressing on both sides of the nose, on the soft parts under the bone and tilt the child’s head forwards (remember forwards, and not backwards!).
Try to stay calm and please, do not ask the neighbour to pour a bucket of water on the child.
A cold compress applied to the nose (to restrict blood flow) may be helpful.
If the nosebleed stops within a few minutes, that’s great.
If not, go to the nearest urgent clinic for management with more aggressive therapy.

But the child just lost a ton of blood, isn’t that right?

Even though the nosebleed may seem severe, and the child’s bed may feel as though it is full of blood, in the majority of cases the amount of blood loss is not significant.
Children who have a history of coagulation disorders may lose a lot of blood as a result of a nosebleed, as you will see below.

What are the causes of epistaxis?

We tend to categorize epistaxis into two:
Primary epistaxis – this is epistaxis due to an unknown reason and may be a result of mild coagulation disorders. Other signs indicating a child may have a coagulation disorder include having a family history of nosebleeds or a personal history of long-lasting bleeds such as bleeding following injuries, circumcision, heavy menstruation, etc.

Secondary epistaxis – epistaxis could be secondary to trauma, a foreign object, inflammation, infections such as viral infections in the upper respiratory tract and chronic use of nose sprays.

When is investigation advised?

If someone gets a nosebleed after a blow to the face, and it subsides on its own, then clearly, they do not need to be worked up. However, if a child presents with recurrent nosebleeds for an unknown reason, it is important to do the following:
1. Consider, along with your primary care physician, the need for a brief workup including a complete blood count (more about this here), coagulation function tests, bleeding time test and von Willebrand factor test. These are all taken with the help of a simple blood draw. Several little tubes will be needed.
2. See a pediatric ENT specialist so that he/she will consider nasal cauterization.

How can one prevent a nosebleed from occurring?

Try applying any jelly-based products or ointment to the front area of the nose. This is especially true for the winter months when the nose gets very dry. If it is red and inflamed, some may advise you to apply an antibiotic ointment, to help reduce the number of bacteria present in the region and by doing so reduce local inflammation.
If a child has a history of allergic rhinitis, make sure it is well controlled so that the number of times the child touches that area of the nose and triggers a bleed is brought to a minimum.

Additionally, try to stop the child from picking on their nose, and try to keep their bedroom humid, especially when it’s cold and dry.

Again, see an ENT specialist for severe and recurrent cases for assessment and considering local treatment.

In summary, this is a very common condition in pediatric medicine. I hope this post provides reassurance to most of you and at the same time helps those few cases that will need further workup and management by a healthcare professional.