Recent recurrent nosebleeds in a child.

Nosebleeds are common. Up to 60 per cent of people will experience a nosebleed at least once, although they affect children and the elderly more frequently. Most people do not seek medical help. Usually they are spontaneous (primary bleeds) with no obvious cause but can be secondary bleeds, attributed to local or systemic aetiology
as well as drug-induced bleeding. 

Local and likely diagnosis 

• Complication of local infections
• Environmental – temperature and humidity changes
• Epistaxis digitorum (nose picking)
• Foreign body
• Medicines
• Rhinitis
• Trauma. 

Local and possible diagnosis  

• Deviated nasal septum
• Polyps.

Nosebleeds in an otherwise healthy child are caused or aggravated by minor trauma (e.g. nose picking, crusting from nasal inflammation, or nasal foreign bodies), and should form your initial hypotheses to test. 

Further information needs to be sought from the child’s mother and should include, but not be limited to, onset, duration, frequency and severity of nosebleed; other sites of bleeding or bruising; current medical conditions, family history of bleeding including nosebleeds; and history of nasal trauma. 

Questioning reveals that the nosebleeds tend to occur randomly, last for a few minutes each time with the bleeding usually bilateral. Sarah reports no obvious bleeding or bruising elsewhere nor any family history of nosebleeds. Ryan takes no medicines from the doctor.

From this description it appears that most, if not all, local likely causes can be excluded from your thinking. No nose picking has been described and the random nature of events suggests it is not trauma. Foreign bodies present with unilateral and not bilateral symptoms. The child is fit and healthy, medicines can be eliminated as a cause and Ryan has had no symptoms of recent URTI.

Rhinitis seems unlikely given Ryan does not have nasal congestion or other symptoms associated with rhinitis. Nasal inflammation, possibly precipitated via environmental factors, can not be fully excluded.

At this stage idiopathic nose bleeding seems likely but other less common causes should be ruled out, although many of these conditions would be very unlikely in a five-year-old child. 

Those which should be considered are nasal polyps and a deviated nasal septum – but both would present with nasal congestion/obstruction often accompanied with facial pain.

Inherited causes, while rare, would present with nosebleed but these would be more frequent and severe than in this case. In addition, the absence of a history of bruising also does not support these as the cause. Idiopathic factors therefore seem to be the cause of the nosebleeds.

It appears that Ryan has no symptoms that warrant concern at the present time.

Nosebleeds are usually benign, self-limiting and spontaneous, with many children ‘growing out’ of the problem. 

As Ryan does not have an active nosebleed, then advice on how to manage further episodes would be appropriate. Nose pinching is likely to resolve the bleeding. Sustained nasal compression applied to the lower third of the nose (direct pressure at the tip) for five minutes or longer should be performed. If this fails to resolve the bleeding, Sarah should be told to seek medical attention.

Once the nosebleed has been controlled, Ryan should be advised to avoid activities that could traumatise the nose further (e.g. some sports).

If nasal compression fails to control the bleeding, either nasal cautery or nasal packing by a specialist could be considered. In most cases, on examination, the source of bleeding is clearly visible, and the bleeding point cauterised with a silver nitrate stick. If the bleeding point cannot be seen, nasal packing is recommended. 

In this case no actions need to be taken.