This guideline provides clinical practice guidelines to guide clinicians involved in the emergency management
of children with epistaxis.
Epistaxis is a common condition in children encountered in the community and in the Emergency Department
(ED)
. Bleeding from the anterior portion of the nasal cavity known as Kiesselbach’s plexus accounts for 90-
95% of all epistaxis,1,3 and most episodes will resolve with direct compression of this area ie gentle pressure
on the nasal alae for 5-10 minutes4
. Whilst childhood epistaxis is common – up to 60% of children will have
had at least one nose bleed by age 10 years – it is usually venous in origin and rarely severe.
 Most episodes can be effectively treated in the ED and will not require nasal packing or hospital admission.
Aetiology
In the majority of cases bleeding arises from a normal vein without any obvious abnormality to account for it,
although there may be contributing factors.9 Most cases are due to a normal vessel in the nasal vestibule
aggravated by digital manipulation. However allergic rhinitis, trauma and vestibulitis are all commonly
associated with recurrent epistasis and thus successful management may be enhanced by addressing these
conditions.
Other common causes include incorrect use of topical steroid sprays resulting in trauma and post operative
bleeding associated particularly with turbinate surgery. Bloody rhinorrhoea is also a common presentation
post adenoidectomy and if associated with fever may benefit from oral antibiotics.
It is important to consider any potential contributing factors and red flags for underlying aetiologies.Red flags for Paediatric Epistaxis
Young age (under
2 years old)
Epistaxis is a rare cause of emergency department presentation in children under the
age of 2 years17,18
Potential aetiologies include acute rhinitis/ coryza, NAI (deliberate suffocation –
consider if BRUE or SIDS and epistaxis), hereditary haemorrhagic telangiectasia,
coagulation disorder, fall or minor trauma and idiopathic17
Adolescent male Consider risk of Juvenile Nasopharyngeal Angiofibroma (JNA) – a benign very vascular
tumour that can be locally invasive and can cause severe or recurrent epistaxis25,26
‘Classic triad’ = unilateral nasal obstruction, epistaxis, nasal discharge15 (in an
adolescent male)27
New onset epistaxis in adolescent male with no obvious bleeding source on anterior
rhinoscopy or absence of other obvious cause should be referred to ENT for follow up
Suggestion of
underlying
bleeding disorder
Prolonged epistaxis (> 30 min) despite adequate first aid
Easy bruising
Evidence of other bleeding - petechiae, purpura, ecchymoses, menorrhagia, GI
bleeding, past history of prolonged bleeding after surgical challenges eg dental
extractions, tonsillectomy, circumcision, minor trauma
Evidence or presence of liver disease
Family history of known bleeding disorder, history of recurrent epistaxis, menorrhagia,
bleeding after surgical challenges
Suspicion of
malignancy –
local or systemic
Easy or abnormal bruising, petechiae, purpura
Bleeding gums, pallor, lethargy, generalised lymphadenopathy, hepatosplenomegaly
Severe bleed Need for resuscitation is rare in children with epistaxis and indicates unusual / more
complex case
Bleed recalcitrant
to treatment
Consider systemic underlying cause (<10% of presentations)
Consider mechanical /anatomic causes (foreign body, mass)
Recurrent ED
presentations
Failed medical management may be associated with higher risk of underlying bleeding
diathesis.