Nosebleeds in children: what are the causes and is it normal?

What is epistaxis?

Bleeding from the nose is called epistaxis. It is bleeding from tissues inside the nose (nasal mucus membranes) caused by a broken blood vessel. Most nosebleeds in children occur in the front part of the nose. This part of the nose has many tiny blood vessels. These can be damaged easily. A nosebleed can look scary but is usually not a serious problem.

Nosebleeds happen more often in dry climates. They also happen more during the winter. That is because dry heat in homes and buildings can cause drying, cracking, and crusting inside the nose. Many children outgrow nosebleeds during their teen years.

Most nose bleeds in children are from the front part of the nose (anterior epistaxis). Nosebleeds from the back of the nose (posterior epistaxis) are uncommon in children and do not stop with pinching. It can indicate some tumours in the nose like angiofibroma typically presenting as one-sided nosebleeds in teenagers.

How common is a nosebleed?

Epistaxis is the commonest ENT emergency affecting up to 60 per cent of the population in their lifetime, with six per cent requiring medical attention. Peaks in incidence occur in children younger than 10 years of age.

What are the causes?

More than 90 per cent of nose bleeds in children occur from the front part of the nasal septum (cartilage that divides the nose into two halves). This area is called the ‘Little's area’. There are numerous small bold vessels in this area. Nosebleeds can be caused by many things.

Some common causes include:

  • Dry air
  • Picking the nose
  • Blowing the nose too hard
  • Injury to the nose
  • Colds and allergies
  • Bleeding from other parts of the body - such as in the stool, urine, or gums, or bruises easily
  • An object in the nose (foreign body)
  • Incorrect use of steroid nasal sprays.

In many cases, no specific cause for a nosebleed is found.

When should I take my child to see an ENT Specialist?

Referral to or a consultation with an ENT surgeon is indicated for patients with severe epistaxis (e.g. uncontrollable bleeding lasting for more than 15 to 20 minutes), troublesome recurrent epistaxis, bleeding from only one side of the nose and parental concern etc.

The need for referral should also be considered if, for example, epistaxis occurs in a child younger than two years of age as epistaxis is rare in this age group, or if there is a likely underlying cause for the bleeding with conditions that are predisposed to bleeding, such as haemophilia or leukaemia.

Above children should be considered for referral to ENT for evaluation with rhinoscopy and nasal endoscopy to search for the source of bleeding and to rule out any other lesions causing the bleeding.

This is particularly important when epistaxis is combined with nasal airway obstruction, especially when a one-sided nasal obstruction is present. Most children older than six years can tolerate a flexible fibre-optic examination of the nasal cavity without discomfort or mental trauma if the nose is anaesthetised and decongested.

Children suffering from recurrent uncontrolled nose bleeds could be considered for silver nitrate cautery, which can be performed after the application of local anaesthetic spray. Alternatively, younger or less compliant children may require a general anaesthetic for cautery although this is uncommon.

Bleeding uncontrolled by direct pressure for more than 20 minutes should warrant urgent referral to hospital. These children may require resuscitation, nasal pack insertion and other measures to stop bleeding. In most other cases, referral to outpatients would be sufficient.