Nosebleeds

What is it?

Nosebleeds are very common in childhood. They can be very frightening to the child and parents, but they rarely have a serious cause or pose any real danger. The most common causes of nosebleeds in children are minor trauma, dry mucous membranes, and nose-picking. Some children have one or more nosebleeds for no apparent reason. Doctors think that these "spontaneous" nosebleeds may come from changes in the child’s face during normal growth and development.

Nosebleeds are most common in children during cold or dry weather. These conditions tend to dry the mucous membranes lining the nose. The membranes may crack and bleed on their own, or the dryness may cause itching and irritation, which leads to the child picking or digging at his or her nose. Please remember that all children pick their noses during the toddler and early preschool years.

Almost all nosebleeds happen on only one side of the nose at a time. If a child has bleeding from both sides of the nose without any known injury, s/he may have a serious blood problem. Please check with your doctor right away if this happens.

Children with nosebleeds, and their parents, are usually very upset about the bleeding itself. Blood spreads rapidly on skin and clothing, so it always looks like a larger amount than it really is. In truth, most children lose only a very small amount of blood from a typical nosebleed. In most cases the major concern then is to get the bleeding stopped, and to try to find out what caused the nosebleed. Usually, the cause will turn out to be a small scratch or disruption of the membrane in the nose. Very often, the doctor will not be able to see any cause at all.

In unusual cases, children who have frequent or severe nosebleeds may have a problem with their blood clotting system. Doctors do not usually recommend doing a lot of testing for children who have one or two nosebleeds that stop easily. If your child has many nosebleeds, or bleeding that does not stop easily after a short period, your doctor may decide to do some tests.

The immediate first aid for a nosebleed is to pinch the nostrils together gently. This applies pressure to the bleeding tissue in most cases, and will get the bleeding to stop within about 10 minutes. The blood supply to the lower front part of the nose, where most bleeding occurs, comes from the upper lip blood vessels. For this reason, it will not help to pinch the bridge or upper part of the nose, as people sometimes recommend. Ice packs do not usually help much either, and they just contribute to the general mess. It is best not to try to pack any material such as cotton or gauze into the child’s nose yourself. This is likely to cause renewed bleeding when you remove it.

Hold the pressure for 10 minutes by the clock. It’s important to resist the temptation to check every minute or so – this just disturbs the forming clot and makes the bleeding last longer. Try to avoid checking for at least a full ten minutes. Please avoid wiping, cleaning, washing, or blowing the nose for a few hours after you got the bleeding to stop. It is important for the blood clot to get well set up in the nose, and wiping or blowing will disturb it. After a few hours, you can gently wash the outer part of your child’s nose and face to make him or her look a little better.

If you or your doctor think that dry air contributed to the problem, it will be good to use a humidifier or vaporizer in the house, especially in your child’s bedroom. Please don’t put any medication in the water, and be sure to change the water daily to keep mold from growing. A little dab of petroleum jelly (Vaseline® and others) or some antibiotic ointment like polysporin or neomycin can help to keep the mucous membranes moist. Apply it with the tip of your finger or a cotton swab. Older children may prefer to do this themselves.

If the doctor finds one specific area of bleeding in your child’s nose, s/he may apply a chemical called silver nitrate. This causes a small chemical burn at the site, and "cauterizes," or congeals the injury. Silver nitrate application is painful, and many doctors believe that it does not help in the long run. You may want to discuss other options with your doctor if your child has many nosebleeds.

In severe nosebleeds, doctors may pack the nose with gauze or apply a gel-like material to increase clotting. Your doctor will give you very specific instructions about what to do in this case. When the packing is in the back of the nose ("posterior packing"), only the doctor should remove it. With any nasal packing, your doctor will start your child on an antibiotic, because there is a risk of toxic shock syndrome, caused by bacteria in the nose.

Nosebleeds are almost always more of an annoyance or irritation than a serious problem. In unusual cases, though, a nosebleed can represent a more serious problem that should get some attention. Here are a few things to look out for:

• Bleeding that does not stop after 15 – 20 minutes
• Bleeding that continues to ooze or re-starts after it has stopped once
• Bleeding from both sides of the nose at the same time
• Pain in the nose before or during bleeding
• Bruises or tiny red dots on the child’s body without any local injury
• Blood in stool or urine
• A persistently "stuffy" nose on one side only
• If the doctor put in a packing to control the bleeding, any fever, redness, or swelling

Most children with nosebleeds can’t help swallowing some of the blood. This is normal, but it can irritate the child’s stomach and cause vomiting. You may see traces of blood in the vomit, either as red streaks or as dark, coffee-grounds material. If your child continues to vomit more than a few times after the bleeding stops, or if you see evidence of blood in the vomit more than a few hours after the bleeding stops, please let your doctor know.

Nose-picking is unfortunately a normal part of early childhood. You will not likely have much success in getting your child under 3 or 4 years old to stop picking his or her nose. You can try, but please use only gentle encouragement and not punishment. Children at this age simply can’t control this behavior. Humidity or ointment in the nose can help reduce the urge to pick. In an older child, gentle encouragement to avoid picking, and gentle reprimands for picking, are likely to work. Picking is often a sign that a child is anxious or bored. You can often get it to stop by distracting the child with a toy, a game, or a project. As with most irritating behaviors, the less of a big deal you make of it, the better. You might want to read our Aftercare Instruction on Concerning Habits and Behaviors.

Although it is unusual, nosebleeds can be signs of other more serious conditions. Anything that causes the child’s blood to clot poorly can cause nosebleeds. These things include forms of hemophilia and leukemia. A condition called ITP lowers the number of clot-forming platelets. Children with ITP usually have tiny red spots and/or bruises first and only develop nosebleeds after a few days. Your doctor will decide to do blood tests if s/he is concerned about any of these rare conditions.

Rat poison contains a chemical that interferes with blood clotting. Please let your doctor know if there is rat or mouse poison or bait in your house.