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   Spontaneous Epistaxis (Nosebleeds) in Children

By Mark B. Levin, M.D., Timothy J. Patrick-Miller, M.D. and Louis J. Tesoro, M.D.
The Pediatric Group, P.A., Princeton

This is the 39th article written in a series for Princeton Online Click here for an archive of other articles.

Nosebleeds, though common and often alarming to witness, are, thankfully, not usually serious. Many of us have suffered a nosebleed as a consequence of an injury to the nose. We do not view these nosebleeds as particularly surprising. However, spontaneous nosebleeds can startle the observer because of the apparent volume of the bleeding and the absence of evident cause. Moreover, they are sloppy - getting all over clothing and bed linens. Awareness of the mechanism, causes and treatment of epistaxis in children can lessen anxiety about the process and, hopefully, prevent some of the sloppiness!

Just inside the nostril is a collection of capillaries (called Hasselbach's plexus) on the middle wall of the nose. This is the most common site of spontaneous nosebleeds in children. Simple inspection of this area after a nosebleed can often identify the offending vessels - a pleasant job most often left to the pediatrician. These blood vessels, which are simply tubes constructed of cells that are adherent to one another, become dilated when inflamed. This dilatation creates gaps between the cells, which can no longer withstand increasing pressure of the blood that fills the vessels. This pressure is less when a person is quietly standing so that gravity pulls blood away from the face. However, as a result of increases in local pressure when reclining or bending over, when sneezing or coughing, or when experiencing a minor injury not normally forceful enough to cause a nosebleed, the dam bursts and the blood gushes out. Actually, although the volume of blood often seems to be greater than that of the Mediterranean Sea, it is usually only a couple of teaspoon's worth. Signs that the bleeding is excessive include light-headedness, pallor, rapid pulse, rapid respirations or low blood pressure. Should any of these rare occurrences supervene, you should either call the Rescue Squad or transport your child to a medical facility as soon as you can.

Among the common reasons for the lining of the nose to be inflamed are colds, allergies (even in the absence of other allergy symptoms) and overuse of decongestant nose drops. Other topical or oral medications may also trigger nosebleeds. Less common conditions that can cause recurrences of nosebleeds or bleeding from other sites usually involve abnormal platelet function or number, or inability to clot. An examination by your pediatrician, sometimes supplemented by simple laboratory tests, can usually determine the cause.

We have all learned from our elementary first aid training that the preferred method to stop bleeding is by direct pressure on the bleeding site. That is fine for a cut on the forearm, but most folks would be reluctant to use their fingers for direct pressure on Hasselbach's plexus! As luck would have it, by squeezing the nose on the soft part just under the juncture of the nasal bones and the nasal cartilage from the outside of the nose, pressure is conveniently applied directly to the offending vessels. We recommend having the child tip his or her head forward slightly during this process to avoid swallowing any blood that is dripping down the back of the nose into the throat. Our main goal with this position is to prevent the child from vomiting the blood (blood in the stomach is notorious for this distasteful complication) all over the child's caretaker (you). The nose must be pinched in this fashion for at least eight to ten minutes continuously (no peeking!). Shorter periods often necessitate recommencing the entire process. A girl might find that 40 to 60 minutes of pressure is necessary if a nosebleed occurs during her menstrual period. This is due to natural anticoagulants that are found normally in the blood at this time. Pressure or application of cold packs under the upper lip, on the bridge of the nose or on the nape of the neck are not helpful, despite the fact that these alternate methods seem to be steeped in tradition.

Most nosebleeds are re-bleeds. Once the epistaxis is stopped, the clot that forms on the breach in the vessel is loosely attached and can easily be dislodged by a wanton sneeze or a careless nose rub. After a nosebleed stops, gently spraying a saline solution (a number of different brands are available over the counter) a few time per day for a day or two to rinse out any dried blood and carefully applying petroleum jelly inside the nostrils to keep the skin lubricated may be of benefit in preventing recurrences. If a child has repeated of epistaxis, or displays a seasonal pattern to the bleeding, your child's physician can suggest a regimen, usually comprised of allergen avoidance - particularly dust (see our article on Allergies), anti-allergy nasal sprays, and sometimes brief use of topical decongestant nasal preparations. Maintaining your home environment at a cool 65-70 degrees F with the relative humidity between 40 and 60% will often make nosebleeds less frequent. If your child prefers, as many children do, to sleep with stuffed animals, putting the toys in your drier on high heat for 30 minutes twice weekly may kill the dust mites so you can let your child continue to derive comfort and security from the stuffed animals. Likewise, during your child's allergy season, you may wish to get in the habit of having him or her bathe at night. This removes any available pollen from striking distance of those nostrils and the all-important Hasselbach's Plexus.

With the measures described in this article, you should be able to minimize the number of nosebleeds your child suffers and make his/her life that much more pleasant (your's, too!). As always, call your child's doctor with any concerns or questions you might have regarding his/her individual health.

Dr. Mark B. Levin 

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Timothy Patrick-Miller Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

Dr. Louis J. Tesoro

Dr. Tesoro has been a member of the staff at The Pediatric Group since 1988. Dr. Tesoro is Attending Pediatrician, Medical Center at Princeton, 1988 to present. He has served on several Departmental and hospital committees and was Chairman, Department of Pediatrics, Medical Center at Princeton from 1996 - 2000. He has lectured at the Universiy of Pennsylvania and has published original articles both while at The Children's Hospital of Philadelphia and at The Pediatric Group.

Pediatric Group 

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