Nosebleed  in children are worrying.Causes may be many and management of pediatric nose bleeds can be tricky .Read about nose bleed in adults here .

As a parent, it’s heartbreaking and you feel terribly upset.

It’s actually very common.

And not as worrying as it looks.

As an ENT surgeon nosebleed are some of the most frequent emergencies we attend.

The most important advice in cases involving children is rarely medicine.

I felt a little info about first aid home care for nosebleed would be useful.

Why does it happen?

Most  often it’s  due  to nose picking.

Nose picking is easily the most common reason   for nosebleed in children.

Luckily nosebleed in children are hardly ever life threatening.

But just knowing the why is not good enough .

Parents need to be aware of  danger signs.

The signs below  show when you need to visit the emergency.

#IMPORTANT TIP 1

THE DANGER SIGNS WHICH YOU SHOULD KNOW

• Massive nosebleed which  cause  difficulty breathing
• Massive nosebleed , which doesn’t stop even after  the home-care described below.
• You find nosebleed has made your child pale, tired or disoriented.
• Nosebleed  occur repeatedly, often and in very large amount without any trauma
• Child has undergone a recent nasal surgery
• Child has some tumour in the nose

Doctors will focus more on the child’s breathing and  hemodynamic stability  ,than the nosebleed.

This means the child might need intravenous fluid support, blood transfusion, moist oxygen inhalation

Identification of the site and cause of nosebleed, is of importance only after making the child stable.

 WHAT CAUSES  NOSEBLEED

IN CHILDREN:

• Blowing the nose very hard
• Injury to your  child’s  nose during playing
• Broken bones
• Temperature and humidity changes make the  inside of your child’s nose become dry.
• Juvenile nasopharyngeal angiofibroma

WHAT COULD BE THE CAUSE OF FREQUENT NOSEBLEED IN CHILDREN?

Mostly systemic causes

• Bleeding  disorders,coagulopathies:Haemophilia A, B, Factor IX deficiency(Von Willebrand disease)
• Leukemia
• Hereditary Haemorrhagic telangiectasia(HHT)

A study   had found at least 1 episode of nosebleed occur

• In 30% children less than 5 years
• 56% children  aged 6 to 10 year
• Children  younger than two years rarely have nosebleed.

Child abuse is another worrying cause of recurrent nosebleed in children.

That’s a potential red flag for healthcare providers.

50% Adults with nose bleeding  has the history of nosebleed during childhood.

#IMPORTANT THING NO.2

WHAT IS THE BEST WAY TO STOP A NOSEBLEED AT HOME?

How to stop Nose bleed

Make your child sit down  and bend forward and pinch the soft part of their nose.

• Make your child breathe gently through the mouth 
• Do this for at least 5 minutes.Most nosebleed stop by a maximum of 10 minutes of pinching the nose this way
• Bending in front, helps to drain blood down the nose and prevents trickling to the back of the throat .Trickle to the back of throat can cause vomiting and more bleeding.
• You should pinch just above the nostrils
• Place an ice pack on the bridge of your child’s nose
• Avoid nose blowing
• You can apply antibiotic ointment, petroleum jelly,nasal drop.

ANTERIOR EPISTAXIS

Nosebleed in children most commonly occurs from the front part of the nose.

This is known as anterior epistaxis.If its not  controlled at home you might need to visit, the emergency of your nearest hospital.

WHAT OTHER WAYS WILL THE DOCTOR STOP THE NASAL BLEEDING

CAUTERY

• Chemical cautery – silver nitrate, TCA
• Electric cautery
• Laser photocoagulation
• Indication – if bleeding site is identified by noting
  • Active bleeding
  • An eschar
  • Prominent vessel

CHEMICAL CAUTERY

• Agent – silver nitrate commonly used

Anaesthesia – LA

• 4% lidocaine within adrenaline or 4% lidocaine with 0.5 phenylephrine or by 10% cocaine

TECHNIQUE

• Circumferentially around the bleeding site and then the real offending bleeding vessel

Disadvantage –

• Repeated cauterization required
• Ulceration or septal perforation

ELECTRIC CAUTERY

• Indication active arterial bleed not controlled by silver nitrate
• Bipolar cautery preferred over unipolar cautery
• If aggressively performed  a hole may be formed in the septum
• For posterior  bleeding , it has to be stopped  using a 30° endoscope and cautery
• In children – cautery should be used under GA.

CARE AFTER CAUTERY

• Local antibiotic ointment x 10 days
• Avoid nose blowing/ picking
• To keep the mouth open while sneezing

ANTERIOR PACKING

INDICATION

• If cautery is not possible
• If obvious site can not be identified
• If bleeding not controlled by cautery.
• Mechanism
  • Adequate pressure to the bleeding site
  • Thrombosis of bleeding
• Anaesthesia LA/GA

MATERIAL USED

• Absorbable substance
  • Oxidized cellulose
  • Gelatin sponge
  • Surgicel

INDICATION

• In bleeding disorders
• Hereditary telangiectasia

Mechanism of action:All the absorbable packs  help the blood to clot .They give a matrix for the platelets and fibrin particles interlinks. This way the bleeding from the nasal cavity can be stopped

ADVANTAGE

• Dissolves spontaneously
• Trauma of pack removal eliminated

MEROCEL PACK: This is in between an Absorbable nasal pack and ribbon gauze.This is made of biocompatible , polyvinyl alcohol sponge material  which helps to stop bleeding .It has a very high-capacity for absorption .

Provides a mild pressure and tamponade effect after insertion in the nasal cavity .This tamponade effect helps to stop the bleeding.

It may be kept for upto 5 days , but under antibiotic cover.

Advantage:

• Highly hydrophilic and can absorb blood upto 21 times its volume
• Soft , compressible, easy to insert
• Very little trauma during insertion and removal
• Easy to cut and shape according to size of nasal cavity

Disadvantage:

It’s expensive.

Nasal bleeding which needs high tamponade effect to stop , may not be controlled

RIBBON GAUGE PACK

• Impregnated with antibiotic and vaseline.

– Layered placement of the pack  filling

COMPLICATION OF ANP

DURING PACKING

• Vasovagal attack
• Blind packing aggravates bleeding ,as the friable mucosa is traumatized. 
• Pushed into throat

WHILE PACK IS PREVENTION IN THE NASAL CAVITY

• Epiphora, or watering of eye
• Secondary sinusitis.Infection of the sinuses.
• Anosmia, sleep apnea
• Toxic shock syndrome

DURING REMOVAL OF PACK

• Vasovagal attack
• Further bleeding

Posterior nosebleeds:

Originate toward the back of the nasal passage, near the throat.Occurs mostly in elderly as hypertensive epistaxis. 

Posterior nosebleeds are less common than an anterior nosebleed. But they can be serious and can cause a lot of blood loss. Children do not usually get posterior nosebleeds.

But  if it does occur, they can be serious .Posterior epistaxis can cause significant blood loss and collapse.

In children  it   can occur following trauma  to nose.

This causes the nasal bone to  break and injury to the sphenopalatine artery .This sphenopalatine artery at the back of the nose can cause profuse bleeding.Thus is a serious emergency and needs urgent medical intervention.

 

HOW CAN FREQUENT NOSEBLEED IN CHILDREN  BE MANAGED?

Consultation with your doctor is important in case of frequent nosebleed.

Careful history: Generally there is the history  of  prolonged bleeding after minor trauma, teeth extraction etc.

The child may be having other signs of frequent bleeding:

• Pinpoint bleeding spots under the skin (purpura)
• Repeated  bruising
• Swollen painful  joints
• Bleeding from other places, blood in urine, blood in stool

Investigation:

• Complete haemogram
• BT, CT,  platelet count
• Prothrombin time/Activated Partial Thrombosis tin Time
• Hess’s test, factor VIII and IX assay

Treatment:

• Treat the cause
•  Stop bleeding
• Cautery is contraindicated

#IMPORTANT THING NO.3

NOSEBLEED PREVENTION

If your child  gets nosebleeds frequently.After a full checkup if you find its due to nasal crusts and nosepicking.

There are a few things which you can do to help stop nasal crusting.

The less the crust, less will be the childs tendency to pick his/her nose.

Te following measures will help reduce  drying and crusting.This in turn will significantly decrease the nose picking and the chances of getting a nosebleed:

• Use a humidifier in your bedroom while sleeping, especially when the air is very dry.
• Keep your child’s  nose moist using a saline nasal spray.
• Teach your  child to stop picking his/her  nose, clip their  fingernails to avoid injury.
• Explaining to your child about the possibility of a doctors visit ,with nose bleed may help  them not to pick their nose.

I hope you found this post helpful.

Please share and help another parent.They will thank you for this.

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