Bloody Noses Bleed Like Stink

In the spirit of the holidays, and in a quest to provide a technicolor topic with a red and green theme, let’s talk about nosebleeds. For a phenomenon that most often resolves relatively quickly and innocently, fewer things will get the blood running (so to speak) than a good ol’ bleeding nose. We get scads of calls from them after hours and on weekends, and they comprise a significant number of visits to clinics or emergency rooms. Hey, a little bit of blood goes a long way, and a 3 minute nostril gusher can make a kid’s bedding look like an abbatoir. Ick. In my house, my kids have a special yawp that my wife and I know another dripper is coming. Nosebleeds can be scary, disruptive, and annoying. All in all, it is a rather fascinating topic that lends itself to horrible puns. Let’s dig in, shall we?

Anatomy plays a big role here. Most bleeding occurs at the front of the nose. Thanks to how our noses are plumbed, a rich network of blood vessels comes together just past the openings of the nostrils. As any observer at a playground knows or traffic lights knows, that is primo nosepicking territory. And, correspondingly, nosepicking (aka rhinotillexomania) is a leading cause of nosebleeds (known in the trade as epistaxis). More on that in a bit. These blood vessels have a terrific tendency to ooze or gout when they get bonked, or when something conspires to irritate or inflame the fragile lining of the nose. Whatever the proper insult, kids will feel the impending onset of stuff coming out their nose, or will have that trademark freaked look when they wipe their nose and see a stripe of blood.

“Mom! I’M BLEEDING!”

Nosebleeds rarely happen in kids under two. Babies and toddlers apparently lack the cleverness or the dexterity to excavate in those gooey chambers. Anyway, after the second birthday, nosebleeds become incredibly common ’til about the tenth birthday. After the minor traumas of picking or falls, the causes can vary, or even conspire to make bleeds recur. Irritation of the lining of the nose can arise from seasonal allergies, colds, or sinus infections—or from nasal sprays applied to treat same.

Dry autumnal or winter air that chaps the lips can dry out the lining of the nose, causing fissures and cracks. Foreign bodies are a culprit in younger kids. Beads, bits of food, old tissues, and a host of other items (I could go on on this one….) can get introduced by curious toddlers, and can be forgotten about until the passages become inflamed and bleed. Much more seldom, nosebleeds herald an underlying condition, such as a bleeding problem, unrecognized reflux of stomach contents into the nose, chronic cough, or other problems. That’s where the clinician comes in, to try to help figure out the cause, and to separate the routine from the worrisome.

Getting the history of the problem is key. While we tend to a patient or if we discuss this with a family ‘between bleeds,’ a few questions help us narrow down this list, or our need to worry, considerably. Was there a trigger for a bleed, like a sneeze, picking, or a fall? (Just about no one admits to nosedigging, but we ask anyway). Is the bleeding out of one or both nostrils when it happens? (Most benign situations have-one sided bleeding). How long does your nose bleed when it gets going? (Most go for about 5 minutes, and just about all less then 15 minutes). How often do these bleeds occur and when did they start? (This gives us a sense of how chronic, disruptive or difficult the situation is for a particular child or family).

As much as we all tend to focus on the nosebleeds in the moment, we all must consider ‘the rest of the picture’ for each child. Doctors should remember to ask and/or parents should volunteer if their kids have complex or chronic illnesses (eg leukemia, bleeding or respiratory problems, etc). That’s a whole other ball of wax that might require more extensive evaluation.

So, when the blood is flowing, and the call for help goes out, what to do?  For the first grownup on the scene, the first thing to do is take a yogic breath of calm, offer reassurance, and go to work. Basic first aid works well. Have the child sit upright, and gently squeeze the nostrils shut. Clinical wisdom dictates to apply this pressure for five minutes (no peeking!), and if blood is still seen coming, for 5-10 minutes more. Apparently, my school nurse did it all wrong during my nosebleeding days of kindergarten through third grade: she applied ice to the back of my neck (ineffective), tilted my head back (risk for making me choke or gag on blood), and plugged twisted wads of paper towel up my schnoz and sent me back to class (gross, and more importantly, at risk of getting irretrievably lost up there and requiring an MD visit to remove them). I have since made a full recovery, thank you very much, but it has left me entirely sympathetic to the distress and discomfort that nosebleeds can cause. Most nosebleeds can be managed at home, or in a cleverer school nurse’s office.

A few kids may need urgent evaluation. After taking a history and assessing in person or by phone, we may send to the ER children with nosebleeds lasting more than 20-30 minutes, kids in obvious discomfort or distress, or if there is a concern that something more complicated is going on. For recurring but nondangerous rebleeders, a consultation with a specialist may be in order if the first lines of prevention seem not to work. This is where primary care can help; working with clinicians who are familiar with your child’s health helps establish the right level of response at the right time.

Happily, low tech interventions can help prevent nosebleeds in susceptible children. While no one has identified a cure for nosepicking (that I am aware of), trimming a child’s nails will lower the likelihood they’ll retraumatize a healing area inside the nose.Reducing nasal irritation by eschewing offending medications, like nasal sprays, or humidifying dry rooms with vaporizers or even bowls of water on the heater can help the drying out effect. I also recommend that some children try applying small smears of hydrolated petrolatum (eg Vaseline) to the inside of the nose much like a chapstick a few times a week. And in the hours and days after bleeding has been stopped, I urge kids to avoid setups for trouble: avoid picking, rubbing, or putting anything inside their nose if they can help it.

My best wishes then, for a safe and happy holiday for all. And, that if kids playing under the tree happen to bonk their siblings with a new light saber, and provoke a gusher, may these interventions keep the muss and fuss to a minimum. And, may all your Christmases (and bedlinens) be white.

(photo above by nominadubia; cartoon below by me)

Comments