Nosebleeds

Ellen Lamel, MD

One minute your child is sleeping, playing, or quietly reading; the next minute there's a bloody shirt or sheet, and - especially - nose. They're scary looking, both for children and parents, but fortunately nosebleeds are much less dangerous than the flood of red would appear.

Nosebleeds are common; 60 percent of all people will experience a nosebleed at some time in their lives. In children, they are most likely to occur between the ages if two and ten.

Why Does It Bleed?
The skin inside the nose is different from ordinary skin; technically, it's not considered skin at all, but "mucosa," which is far more fragile than the skin covering the nose or cheek. The gums are a good example of mucosa, delicate enough to bleed with simple tooth brushing, especially when inflamed.

Similarly, inflammation inside of the nose increases the chance of bleeding with any minor irritation. Some common causes of inflammation:
•    Recent or current upper respiratory infections
•    Sinus infections
•    Allergic rhinitis
•    Nose-picking
•    Drying conditions

Just as dry air causes chapped and cracking lips, it has the same effect inside the nose, especially in dry climates and cold weather.

Most nosebleeds come from the partition between the two nostrils, called the septum. The lower, front part of the septum has a large number of blood vessels (Little's area), so when it cracks, it bleeds. This means a child with a deviated septum is particularly susceptible, since air continually hits the deviated portion instead of gliding by, which promotes drying and cracking.

Trauma from accidents, fights, sports injury, or from young children inserting objects in their nose can also cause nosebleeds.

Parents should also know that some medications interfere with blood clotting: anti-inflammatory drugs like ibuprofen (Motrin, Advil, etc.), aspirin and naproxen (Aleve) are common over-the-counter medications in that category. Such medications don't cause nosebleeds by themselves but can make the difference between a few streaks of blood on a tissue after nose blowing, and a difficult-to-stop torrent.

What Treatment?

Home Treatment
Since most nosebleeds start from the septum, the first remedy is to compress that area, which is responsible for more than 90 percent of nosebleeds in children. Pinch the nose firmly on the lower half and hold pressure without stopping for at least 10 minutes. The upper part of the nose is bone, so pinching there won't help.

The pressure can be uncomfortable. If so, encourage your child to breathe through his or her mouth while providing reassurance. Additionally, the head should be upright or tilted slightly forward so that blood drips from the nose. Tilting the head back encourages blood to drip back into the throat, which tastes bad and makes some children feel they are choking.

If the bleeding doesn't stop after 10 to 20 uninterrupted minutes of pressure, see a doctor.

Medical Treatment
Often the first step at the doctor's office or emergency room is also pressure - usually with a plastic clip made especially for this purpose. Persistent bleeding calls for examination to determine the source. Examination of very young children can be difficult but sometimes made easier if you hold your child in your lap during the exam.

If the bleeding is coming from the front of the nose, as is usual, bleeding points can be clotted with heat or chemicals. To cauterize the bleeding, the doctor commonly uses a silver nitrate stick, which looks like a long cotton swab with a dark tip. Some emergency rooms have electrocautery, another route to the same result. In either case, the area to cauterize must be fairly dry, with the bleeding slowed or stopped.

Depending on how forceful the bleeding, the doctor may add topical medication to constrict the blood vessels and slow the flow. Afrin or Neo-synephrine-type sprays are frequently used as constrictors.

Cauterizing is more comfortable after an anesthetic, which can be applied by a soaked cotton wad placed in the nostril for five minutes, or - more rapidly - by spray. Be warned, however: the anesthetic spray stings a bit, and most children won't enjoy the taste. ***

In the rare cases when these measures aren't sufficient, packing the nose effectively compresses the bleeding points. Most emergency physicians are experienced at packing; office pediatricians may or may not be comfortable with the procedure. The older method of packing involved layering gauze in the nose, but most emergency rooms now use pre-formed nasal balloons or nasal tampons.

Obviously, this procedure can be distressing to children, as nasal packing in any form is uncomfortable. It may be directly painful, or extremely annoying like the worst stuffy nose ten times over. You should have pain relief available for your child, ranging from acetaminophen (such as Tylenol or Datril) to a prescription pain reliever. Do not give ibuprofen, naproxen, or aspirin in this situation: such medications inhibit clotting. Your doctor may prescribe antibiotics as well, since sinuses can't drain with the packing in place. Children with nasal packing should be checked again within two to three days; oftentimes the packing can be removed at that visit.

If packing doesn't stop the bleeding, or if the bleeding is coming from the back of the nose, your child needs a specialist - otolaryngologist, head and neck surgeon, or ear, nose and throat specialist are alternate terms for the type of physician needed.

Other Remedies - Are They Effective?
New Treatments
New, non-prescription products have recently become available to stop bleeding and promote clotting. Since products such as NosebleedQR and Nasalcease are considered wound dressings rather than drugs, they have not had the rigorous testing the FDA demands for medications.

The manufacturer of NosebleedQR has posted a limited number of testimonials, but little research exists on whether either of these is effective enough to be worthwhile. Both are advertised for minor nosebleeds only, and it is unclear how they measure up against simple pressure.

Old Treatments
One familiar folk remedy has been proven ineffective; research has shown that icepacks on the back of the neck, or the forehead, don't slow or stop bleeding.

Are Nosebleeds Significant?
While they are rarely dangerous, nosebleeds are irritating and uncomfortable. Some children will have recurrent nosebleeds, upsetting to both parents and child.

Despite the horror movie appearance of a bloody nose, healthy children rarely bleed enough to lower their blood count or blood pressure, so blood tests aren't routinely recommended for a nosebleed. There are exceptions: when your child appears to have lost a large amount of blood, or has decreased blood pressure, or an increased heart rate that persists after the bleeding stops. Also, if a child repeatedly bleeds for no reason, your doctor should check whether your child's blood clots normally. Children with diseases that interfere with blood clotting may have repeated nosebleeds that are particularly difficult to stop.

Prevention
•    When your child wipes his or her nose, encourage wiping straight across the nostrils. Discourage attempts to stuff a tissue inside nostrils, even "a little bit."
•    Discourage nose-picking
•    Humidify the air in your house if possible, especially when using a heater
•    Moisturize the inside of the nose with saline nasal sprays

You may buy commercial products such as Ocean, NaSal, and Ayr. Or make your own: one-quarter teaspoon of salt mixed with one cup of water. Use a bulb syringe to squirt the homemade version into the nose from one to three times a day.

Doctors frequently recommend applying petroleum jelly (Vaseline) or an antibacterial ointment (such as Bacitracin, or Neosporin) to the inside the nose to prevent drying and cracking. Recent studies have not proved this is effective, but the studies aren't considered conclusive. Since the main possible side effect is an unhappy child who doesn't want ointment in his or her nose, the possible benefit may be worthwhile - it depends on your child's reaction. The application is usually quick using a cotton swab, and older children can easily do this for themselves.

Nosebleeds can be annoying, messy, and frustrating. But for many, they are a common, and even normal, occurrence that almost always looks far worse than they are. Fortunately.

Ellen Lamel, MD, [is] a graduate of University of Colorado School of Medicine and the Los Angeles County/University of Southern Californnia Medical Center Emergency Medicine Residency program. She has practiced emergency medicine for over 20 years.
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