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 (if persistent problems): very occasionally ongoing severe epistaxis will have to be referred to A&E urgently. See Primary Care Management for full details of assessment and initial treatment.
G.T & C.M – 6-10-26
URGENT
A&E
- If episode of epistaxis not controlled with first aid and still bleeding after 20 mins of compression
ENT
- If recurrent epistaxis not improved with initial approaches (see Primary Care Management for details) refer to RHCYP for routine review in clinic.
- Significant pain / obstruction – please refer as urgent
- If complex history (known bleeding disorder/haematological problem) discuss with on call team.
Medical paediatrics or haematology
- If child is aged 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.
First Aid
- Pinch soft anterior part of nose for 20 minutes
- Lean forward
- If actively bleeding in GP practice apply vasoconstrictor if available (Lidocaine with phenylephrine or Xylometazoline).
Assessment
If bleeding is acute and does not stop despite correct first aid measures?
- Resuscitate if necessary
- Refer urgently to A&E.
Chronic epistaxis assessment
- Duration, predisposing factors, history of injury
- Determine whether bleeding is unilateral or bilateral
- How often does bleeding occur
- How long does it last
- Any signs of anaemia?
- Medications – NSAIDS, Aspirin, Warfarin, other anticoagulants (rare in children)
- Family history of bleeding disorder
- Past medical history – coagulopathy, platelet disorder or hypertension.
If suspecting blood dyscrasia
∙ Thorough history (including bruising, bleeding)
∙ 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 of chronic epistaxis:
- Prolonged course of Chlorhexidine with Neomycin cream for 6 weeks settles most paediatric epistaxis
- Chlorhexidine with Neomycin cream contains peanut oil, so check for allergy
- Mupirocin ointment or petroleum jelly can be used in case of peanut allergy, but are not as effective.
- Cautery using silver nitrate sticks if able to provide in community (avoid cautery bilaterally at same time, stage cautery one side and then the other 4-6 weeks later)
