Introduction
Epistaxis in children is common and mainly due to enlarged vessels in Little’s area at the anterior septum.
Most bleeds are short lasting and controlled by first aid measures. These consist of pressure to the anterior nose (not the bony part) with the head leaning forward to avoid swallowing of blood followed by emesis.
Management has to be tailored to the urgency of the situation.
Most childhood epistaxis is readily controlled and merits outpatient referral only, very occasionally ongoing severe epistaxis will have to be referred to Emergency Department urgently.
First Aid
1. Pinch soft anterior part of nose for up to 20 minutes
2. Lean forward
3. If actively bleeding in GP practice apply vasoconstrictor (co-phenylcaine or otrivine)
Assessment
Is the bleeding acute and does not stop despite correct first aid measures
- Resuscitate if necessary
- Refer urgently to Emergency Department
Chronic epistaxis assessment
1. Duration, predisposing factors, history of injury
2. Determine whether bleeding is unilateral or bilateral
3. How often does bleeding occur
4. How long does it last
5. Any signs of anaemia
6. Medications – NSAIDS, Aspirin, Warfarin, other anticoagulants, others (rare in children)
7. Family history of bleeding disorder
8. Past medical history – coagulopathy, platelet disorder or hypertension.
If suspecting blood dyscrasia
o Thorough history (including bruising, bleeding)
o Family history
Examination
- BP, pulse if active bleeding
- Anterior rhinoscopy –? bleeding point, visible vessels in Little’s area, crusting, septal perforation, mass present.
Investigation
- If significant blood loss or recurrent episodes check FBC
- If on anticoagulants or suspect coagulopathy check clotting, renal and liver function
Treatment chronic epistaxis
- Prolonged course of Naseptin cream for 6 weeks settles most paediatric epistaxis
o Naseptin contains peanut oil, so check for allergy
o Bactroban or Vaseline can be used in case of peanut allergy, but are not as effective
ED
If episode of epistaxis not controlled with first aid and still bleeding after 20 minutes of compression
ENT
If recurrent epistaxis not improved with above management refer to RHCYP for routine review in clinic.
Significant pain/obstruction refer as urgent
Paediatric Haematology
Known bleeding disorder – refer direct to paediatric haematology
Medical paediatrics or haematology
If child under 2 refer to medical paediatrics/haematology as in this age group there is more likely to be an underlying bleeding problem or child protection issue.
Prolonged course of Naseptin cream for 6 weeks settles most paediatric epistaxis
Naseptin contains peanut oil, so check for allergy
Bactroban or Vaseline can be used in case of peanut allergy, but are not as effective
Cautery using 75% silver nitrate sticks if able to provide in community (avoid simultaneous bilateral cautery performing treatment to each side at an interval of 4-6 weeks in children with bilateral epistaxis to avoid septal perforation.
NICE guidance on epistaxis When considering cauterization please be aware that this is essentially a chemical burn and so it can be painful. Local anaesthetic is very important.
