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How to manage a nosebleed

October 24, 2012

One of the more common reasons to visit a pediatric ENT is for nosebleeds, also known as epistaxis.  Nosebleeds are extremely common.  These can range in severity from a small amount of blood in the nasal mucus to bleeding like from a faucet.  In any case, particularly when it happens in your child, it can be very scary.

Nosebleeds can happen at any time.  One of the most common times is during sleep, where a child will wake up either in the morning, with blood on their pillow, or from sleep in the middle of the night with active bleeding from the nose.

The nose can bleed for many reasons.  The anatomy of the nose explains the ease with which the nose seems to bleed.  There is an extensive blood supply to the nose coming from all different directions.  The middle part of the nose, or nasal septum, which divides the left and right side of the nose, has blood supply coming from the back of the nose, bottom of the nose and top of the nose.  These all meet on the front part of the nasal septum in an area called Kisselbach’s plexus or Little’s area.  This network of vessels is under a very thin lining of mucosa.  A small disruption of that mucosa, from a sneeze, nose picking, or a simple bump of the nose, can result in an injury to those vessels and a nosebleed.

While children are notorious for picking their noses, there are many other reasons for this problem.  A simple cold, nasal trauma, allergies, or anything that causes congestion can result in engorgement of the vessels increasing their prominence and making them higher risk for injury.  While most nosebleeds come from the front part of the septum, there are other more serious causes of nosebleeds which need to be evaluated by your pediatric ear, nose and throat doctor.  Anytime a nosebleed is associated with headaches, changes in vision, double vision, weight loss, loss of smell, or pain, it raises a concern of something more significant occurring.  These symptoms should be brought to the attention of your doctor right away.

In general, nosebleeds from the front of the nose are controllable.  If the nose is actively bleeding, it is important to encourage your child, and for you, to remain calm.  This will help keep blood pressure low and help facilitate the bleeding vessel to clot.  Firmly apply pressure to the soft part of the nose with your thumb and index finger and hold that pressure for 1 minute, watching the clock, without letting go.  You should not apply pressure to the hard part of the nose or bridge of the nose as this wont give pressure to the area most likely bleeding.  Be sure to have your child’s head tilted slightly forward so that blood is not running down the back of the throat.

After 1 minute, you should let go, again, trying not to have your child get upset and see if the bleeding has stopped.  If it has, success, but if you have not, then it is safe to use oxymetazoline (brand name Afrin) 1-2 sprays on each side, then hold pressure for 2 minutes without letting go.  These maneuvers should stop the great majority of nosebleeds.  If this is unsuccessful, you should go to the emergency room or call your pediatric ear, nose and throat doctor.

Now that we have stopped the nosebleed, we should focus on prevention.  Encourage your child not to aggressively rub or pick their nose.  Sometimes this is not enough.  I like to have my children use a small amount of bacitracin ointment in each nostril each night before bed.  After applying a small amount to each nostril, gently squeeze the soft part of the nose together and wipe away the excess.  Body heat will melt the ointment, then, the natural function of the nose will transport that ointment back through the nose.  This provides both a low grade antibiotic effect as well as a moisturizing barrier effect to the mucosa of the nose.  This should be done only if your child does not have an allergy to bacitracin.  You should stop this after 2 weeks and be reevaluated.

Further workup should be done if this does not solve your problems.  Your child may require cauterization of the bleeding area in the nose, which can be done in the office.  Also, an in office endoscopy to look at the inside of the nose can provide additional information.  Sometimes, blood tests and imaging may need to be ordered.

If you are concerned about your child's nosebleed, contact your child's pediatrician or and ear, nose, and throat specialist for more information.