Nosebleed in Children

I have always known that nosebleed is a common medical issue that needed some general education, yet for years I kept procrastinating about a discussion on the subject. Parents worry so much and are frightened when their children bleed from the nose. They come to my medical office with pillowcases and bedsheets stained from a nosebleed that occurred at night when the child was sleeping. Some bring their children from school to my office, with blood dripping down their nostril from an injury which began unprovoked while the child was in the classroom with other children.

My decision to finally talk about nosebleeds came when I learned that, two months ago, a relative suffered a nosebleed, and just a couple of weeks ago a friend of my wife and her child both suffered the same thing. I hope that this brief general discussion on such a common condition will allay parental fears, as well as give them critical information on how to proceed when their children suffer a nosebleed.

Where does the blood come from in nosebleed?

An understanding of where the blood comes from is the first step to help ease parental anxiety when their children have a nosebleed. A wound inside the nose is what causes the majority of nosebleed in children. This wound frequently occurs in a part of the nose called the septum, which one can touch by inserting a finger in the nostril, below the tip of the nose. There could be other reasons a child might bleed from the nose, but those other reasons are less common; I will mention a few of them later in this discussion. Meanwhile, as you read on, it will be clear how the wound in the nose occurs and leads to a nosebleed. A photograph of the nose may help you understand what I mean.

The Nasal Septum

This junction needs extra attention. People have one nose, but two nostrils (referring to the two openings of the nose). The bridge of the nose is the top part that goes from the tip of the nose up to the level of the eyes. If you run your finger up and down the bridge of your nose, you will notice that the tip of the nose feels rubbery, while the rest feels bony. The bony bridge, with some modifications along the way, continues down like a curtain (septum of the nose) and divides the nose into the two nostrils we talked about earlier. If there were no curtain (septum) separating the two nostrils, you would be able to reach the right nostril by putting your finger through the left nostril and vice versa.

What Causes Nosebleed?

The reason why I spent time making sure you know the location of the septum is that most of the bleeding from the nose happens at this location. One of the first things doctors do when they attend to people who bleed from their nose is to inspect that area of the nose, easily seen with the naked eye. I like to show parents where their children’s nosebleed occurs. "Apply a little Vaseline or antibiotic ointment over it until the wound heals," I tell them.

Nosebleed occurs from this location because it contains numerous tiny blood vessels, so that when the overlying thin skin or membrane breaks down (that is, there is a wound), those tiny blood vessels break down as well, leading to blood dripping from the nostril. Children who pick their nose often trigger nosebleed by disturbing those numerous tiny blood vessels. Dry weather or Harmattan, which dries the nose, can crack open like cracked cement the thin protective skin covering the blood vessels located in the wall of the septum. Catarrh, nose allergies, sneezing, and runny nose are some seasonal illnesses that can disrupt those thin skin membranes that protect these tiny blood vessels and expose them to breakdown and resultant nosebleed. Fortunately, this type of nosebleed from the part of the nostril most easily seen (anterior septum) is the most common nosebleed, and the one easiest to treat.

Treating Nosebleed

A pinch of the nose with the thumb and index finger can put enough pressure on those tiny blood vessels in the septum to stop bleeding. Three to five minutes of nose pinching may be required to stop the nosebleed. Healing of the wound over the tiny vessels may take days. As mentioned earlier, antibiotic ointment or Vaseline ointment applied directly with the fingers or a cotton bud, twice daily over the area of the nostril where the skin broke down, will help heal the wound. A saline nasal spray is useful to moisten nasal mucosa and ameliorate cracks.

In certain circumstances where an anterior septum nosebleed is stubborn and recurrent, I prescribe Afrin (oxymetazoline) or neo-synephrine (0.25-1%) containing vasoconstrictor agents, to help stop further bleeding. Removal (cauterization) of those tiny rich blood vessels may be necessary for children who have daily or frequent nosebleeds. Silver nitrate sticks in the hand of a skillful practitioner are useful in getting rid of bleeding blood vessels in the septum. Experienced practitioners perform these last two interventions.

A Nosebleed that Does Not Stop

There are times when nosebleed arises from areas located deep at the back of the nostrils. A torrential nosebleed that does not stop after minutes of nose pinching is likely from the posterior or the deep part of the nose and requires immediate medical attention because it may lead to significant blood loss. Mid-level hospitals may have ready-to-use nasal packs and specialized instruments, devices with which to stop a nosebleed that does not stop by the standard measures mentioned earlier.

What Else You Need to Know about Nosebleed

Up until now, I have discussed nosebleed in a typical child with no underlying medical illness - a child whose only problem is an on-and-off nosebleed. In taking notes concerning nosebleed, pediatricians also inquire whether the child bleeds from any other parts of the body, such as the gums while brushing teeth, the rectum while passing stool, in the urine and so forth. Bleeding from other parts of the body is a warning to look for other general reasons why a child is bleeding from the nose.

Bruises, black and blue, on the arms and legs in a child who suffers from repeated nosebleeds is another reason to do a thorough investigation into the cause. Rash, fever, and weight loss occurring in a child with recurrent nosebleed may suggest other sinister causes of nosebleed outside the scope of this article. High blood pressure may predispose to nosebleed in certain individuals. So do medications such as nasal steroid sprays, Aspirin, Ibuprofen, and Naprosyn. Children who inherit certain bleeding-causing disorders (for example, hemophilia and von Willibrand disease) from their families may, in addition to having nosebleed, also have bleeding into their joints and under the skin and in girls a heavy and prolonged menstrual period.

A Visit to the Doctor: What to Expect

In examining a child who has suffered a nosebleed, I look in the nostril to locate the wound from where the bleeding occurred. I check for objects, like beads, that if present might explain the cause of the nasal wound and the nosebleed. Many of the nosebleeds I encounter have stopped before the mothers bring the children to my office. When I encounter an active ongoing nosebleed, I allay parental fears and instruct the child, if he is of age, on how to pinch the nostril and breathe from the mouth to control the bleeding.

The location of the area on the septum from where the bleeding occurs is of interest to me. Usually, I find it on the nasal septum, a little distance behind the tip of the nose. Reassurance to parents and instructions to use Vaseline or antibiotic ointment to the nasal wound until it heals maybe all that is necessary. In recurrent nosebleed that is concerning, ordering blood tests may be necessary to ascertain whether there is anemia, or to check patients’ platelets status (blood-clotting factors). This year, I have not needed to use blood tests in managing children who presented in my office with nosebleed.

Summary

Though frightening, most nosebleeds in children do come from the nose, and not from inside the brain or internal organs as parents often imagine. However, repeated nosebleed in children deserves a definite diagnosis, especially if the episodes of bleeding last for 5-10 minutes or more. As already discussed, probable causes of such nosebleed could range from minor ailments, like a breakdown of tiny blood vessels in the septum, to concerning issues such as diseases in which there is a failure of blood to clot properly, to major issues such as blood vessel tumors deep in the nostrils. The good news is that most nosebleeds in children will fall into the first category and are easy to treat. Your child’s physician can provide guidance. When in doubt, seek expert medical opinion, including a referral to a hematologist or otolaryngologist (ear, nose and throat specialist).

Disclaimer: This discussion does not diagnose or treat any condition. Information presented here is an overview of a topic based on the author’s experience and understanding of the subject. Every child is different, and every nosebleed is different. Parents must consult with their children’s medical practitioner at all times for specific advice concerning nosebleed.

Reference

Schechter M, Stevens DM. Epistaxis. In: McInerny TK, Adam HM, Campbell DE, DeWitt TG, Foy GM, Kamat DM, eds. American Academy of Pediatrics, Textbook of Pediatric Care (2nd Edition). Elk Grove Village, IL: American Academy of Pediatrics; 2017:1312-1318