Saturday, January 18, 2014

Nosebleeds

Many of us remember having a lot of nosebleeds as children, yet they bring fear to parents when their kids have them.

Why won't it stop?
Why are they getting so many?
Is there a bleeding disorder?
Does it need to be cauterized or packed?

Most of the time a nosebleed is just that. A nosebleed. 



Unfortunately, they are common in kids -- especially when they are sick or suffering from allergies (due to swollen nose tissues) or the air is dry. They often happen at night, when the head is at the level of the heart. They also start with a forceful blow of the nose, sneezing, or other things that cause sudden pressure in the nose.

The part of the nose that commonly bleeds is the center part separating the nostrils. If you look carefully up the nose toward the center on both sides, you can often see blood vessels close to the surface. After a bleed you can often see the scab. Trauma to the nose can cause bleeding higher up, but the most common bleed in kids is very close to the tip of the nose.

Once it bleeds, it is likely to bleed again and again until the skin completely heals. Sometimes it is just a few specks of blood when the nose is blown, other times it is full-on bleeding that seems to keep going and going.

When the nose is bleeding:

  • Sit or stand. Don't lay down-- that increases the pressure in the head, which increases the bleeding.
  • Don't tilt the head back -- that causes blood to go down the back of the throat. You can tilt it forward slightly.
  • Pinch the nostrils at the highest part the nose is soft (just below the hard part) with a tissue or cloth. 
  • HOLD IT FOR 10 MINUTES. Do not peek. Do not check. Do not let go.
  • Seriously, don't let go for 10 minutes. This is the step kids have a hard time with. One minute seems long. Ten is forever. Hold it for 10 minutes anyway.
  • Some people like to put an ice pack over the nose, but if you do this, still try to hold pressure on the nostrils. Put the ice pack on top of the nose, above your fingers that are holding pressure.
  • AFTER 10 minutes, gently remove the tissue or cloth. If it is still bleeding, hold for ANOTHER 10 minutes. Still don't peek during this time. 
  • If after the two 10 minute holds (20 minutes of pressure total) it is still bleeding, it is time to go to the doctor. If you haven't tried a real 10 minutes of consistent pressure, that is what they will do first, so save yourself the trip and the money and HOLD IT FOR 10 minutes!

After the bleeding stops:

  • Do not blow the nose for 24 hours if possible to allow the skin to heal under the clot.
  • Do not pick the nose. 
  • Add humidity to the air with a humidifier or vaporizer.
  • Add petrolatum jelly to the nostrils. Use a cotton tipped applicator or a tissue. My kids loved the "Vaseline sword" -- we put vaseline on the tip of a tissue and pulled it into a sword shape. We put the sword in the nose, plugged it from the outside, and pulled the sword down, coating the inside of the nose with the petrolatum jelly.
  • Treat allergies if needed to decrease the swelling in the nose tissues.
Remember that as long as there is a scab in the nose, it will re-bleed if the scab falls off before the skin completely heals underneath. Keep moisture in the air, the nostrils lubricated, and remind kids to not pick!

Most nosebleeds are simple nosebleeds, despite how scary they look!  

Red flags (or things to see a doctor about):

  • Frequent nosebleeds that take 20 minutes of pressure to stop.
  • Bruises that are not explained by injury. (In general, any child with bruises all over the shins is normal. Think of areas that don't often get bumped or hit -- if they are bruising for no reason, that is more of a concern.)
  • Gums bleeding. This is commonly due to poor oral hygiene and gingivitis, but can be due to a clotting problem.
  • Red or purple spots on your skin that don't blanch with pressure. These are petechia and can be seen when there is a clotting problem. 
  • Blood in the stool. While the most common cause of this is constipation, if you have multiple sites of bleeding, you should be evaluated by a doctor.
  • If you think your child stuck something up the nose that might have contributed to the bleed.
  • If there was trauma to the nose or face that otherwise needs to be checked out.
  • If your child seems pale, unusually tired or dizzy, or has unexplained weight loss or fevers.
  • If your child takes any medications that thin the blood. (This is unusual in kids, more common in adults, but high doses of fish oil might increase bleeding risks.)

What do doctors do about nosebleeds?

  • Usually all that is needed is home treatment and I simply reassure the parent and child with the above information.
  • If there are frequent bleeds, I will sometimes recommend cauterization of the nose. This sounds scary, but it is a relatively easy procedure. One common method is using silver nitrate. It is applied to the areas where the blood vessels are close to the surface of the nose. In many people a single treatment is all that is needed. Some people require repeat treatments.
  • Treat any underlying allergy to control the nasal swelling.
  • If there is a family history of a bleeding disorder or signs of other bleeding (bruises or petechiae, rectal bleeding, gum bleeding, heavy menstrual bleeding) blood work can be done to see if there is a bleeding disorder.
  • If the bleeding is from trauma, we make sure there is no hematoma or broken bones.

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