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BMJ Clin Evid. 2008; 2008: 0311.
Published online 2008 May 19.
PMCID: PMC2908001

Nosebleeds in children

Mr Gerald W McGarry, MD, MB ChB, FRCSRCPSGLAS, FRCSED, FRCS(ORLHNS), Consultant Otorhinolaryngologist, Honorary Clinical Senior Lecturer

Abstract

Introduction

Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for recurrent idiopathic epistaxis in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2008 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found six systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiseptic cream, cautery, petroleum jelly.

Key Points

Up to 9% of children may have recurrent nosebleeds, usually originating from the anterior septum, but many grow out of the problem.

  • Nosebleeds may be associated with local inflammation and trauma, including nose picking.

Antiseptic cream may reduce nosebleeds compared with no treatment, and may be as effective as silver nitrate cautery.

  • Antiseptic creams may smell and taste unpleasant.
  • Silver nitrate cautery is usually painful even if local anaesthesia is used.
  • Simultaneous bilateral cautery is not recommended owing to the possible increased risk of perforation of the septum.
  • We don't know whether petroleum jelly speeds up resolution of recurrent bleeding compared with no treatment.

About this condition

Definition

Recurrent idiopathic epistaxis is recurrent, self-limiting nasal bleeding for which no specific cause is identified. There is no consensus on the frequency or severity of recurrences.

Incidence/ Prevalence

A cross-sectional study of 1218 children (aged 11-14 years) found that 9% had frequent episodes of epistaxis. It is likely that only the most severe episodes are considered for treatment.

Aetiology/ Risk factors

In children, most epistaxis occurs from the anterior part of the septum in the region of Little's area. Initiating factors include local inflammation, mucosal drying, and local trauma (including nose picking). Epistaxis caused by other specific local (e.g. tumours) or systemic (e.g. clotting disorders) factors is not considered here.

Prognosis

Recurrent epistaxis is less common in people aged over 14 years, and many children "grow out" of this problem.

Aims of intervention

To reduce the number and severity of epistaxis episodes; to minimise adverse effects of treatment.

Outcomes

Number and severity of epistaxis episodes, adverse effects of treatment.

Methods

BMJ Clinical Evidence search and appraisal April 2008. The following databases were used to identify studies for this systematic review: Medline 1966 to April 2008, Embase 1980 to April 2008, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2008, Issue 1. Additional searches were carried out using: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We included open studies. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table
GRADE evaluation of interventions for nosebleeds in children

Glossary

Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

References

1. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of the prevalence of von Willebrand's disease. Blood 1987;69:454–459. [PubMed]
2. Watkinson JC. Epistaxis. In: Kerr AG, Mackay IS, Bull TR, eds. Scott-Brown's Otolaryngology, Volume 4 Rhinology. Oxford: Butterworth-Heinemann, 1997;18:1–19.
3. Kubba H, MacAndie C, Botma M, et al. A prospective, single blind, randomized controlled trial of antiseptic cream for recurrent epistaxis in childhood. Clin Otolaryngol 2001;26:465–468. [PubMed]
4. Ruddy J, Proops DW, Pearman K, et al. Management of epistaxis in children. Int J Paediatr Otorhinolaryngol 1991;21:139–142. [PubMed]
5. Loughran S, Spinou E, Clement E, et al. A prospective, single blind, randomised controlled trial of petroleum jelly/Vaseline for recurrent paediatric epistaxis. Clin Otolaryngol 2004;29:266–269. [PubMed]
6. Murthy P, Nilssen ELK, Rao S, et al. A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Otolaryngol 1999;24:228–231. [PubMed]
2008; 2008: 0311.
Published online 2008 May 19.

Antiseptic creams

Summary

NOSEBLEEDS Compared with no treatment: Antiseptic cream (chlorhexidine/neomycin) may be more effective at 8 weeks at reducing the number of nosebleeds in children with recurrent epistaxis ( low-quality evidence ). Compared with cautery: Antiseptic cream (chlorhexidine/neomycin) is as effective at 8 weeks as silver nitrate cautery at reducing the number of nosebleeds in children with recurrent epistaxis ( moderate-quality evidence ). Compared with antiseptic cream plus cautery: We don’t know how effective antiseptic creams alone are compared with antiseptic cream plus silver nitrate cautery in children with recurrent epistaxis (low-quality evidence).

Benefits

We found no systematic review.

Antiseptic creams versus no treatment:

We found one RCT (103 children aged 3–13 years with recurrent epistaxis for a mean of 20 months, unblinded design), which compared antiseptic cream (chlorhexidine hydrochloride 0.1%, neomycin sulphate 3250 U/g) applied to both nostrils twice daily for 4 weeks versus no treatment. It found that antiseptic cream significantly increased the proportion of children who had complete resolution of bleeding at 8 weeks compared with no treatment (no bleeding in past 4 weeks: 26/47 [55%] with antiseptic cream v 12/41 [29%] with no treatment; RR 0.53, 95% CI 0.31 to 0.91; NNT 4, 95% CI 3 to 9).

Antiseptic creams versus cautery:

We found one small RCT (48 children aged 3–14 years with at least 1 episode of epistaxis during the previous 4 weeks and a "history of repeated epistaxis"), which compared antiseptic cream (chlorhexidine hydrochloride 0.1%, neomycin sulphate 3250 U/g) applied to both nostrils twice daily for 4 weeks versus silver nitrate cautery. Cautery was undertaken in secondary care using silver nitrate applied on a stick to prominent vessels or bleeding points. The RCT found no significant difference in the proportion of children with complete resolution of bleeding at 8 weeks (no bleeding during the past 4 weeks: 12/24 [50%] with antiseptic cream v 13/24 [54%] with cautery; RR 0.92, 95% CI 0.54 to 1.59). It also found similar rates of partial success with antiseptic cream compared with cautery at 8 weeks (proportion of children with 50% reduction in number of bleeds during the past 4 weeks: 4/24 [17%] with antiseptic cream v 3/24 [13%] with cautery) and of failure at 8 weeks (proportion of children with less than 50% reduction in number of bleeds in past 4 weeks: 7/24 [29%] with antiseptic cream v 6/24 [25%] with cautery).

Antiseptic creams plus cautery:

See benefits of silver nitrate cautery.

Harms

Antiseptic creams versus no treatment:

The RCT comparing antiseptic cream with no treatment gave no information about adverse effects. Some commercial antiseptic creams contain arachis (peanut) oil, and the RCT excluded all children with peanut allergies.

Antiseptic creams versus cautery:

The RCT comparing antiseptic cream versus cautery found no adverse reactions with antiseptic cream, but some children found the smell and taste unpleasant (no further data reported). Chlorhexidine/neomycin cream may cause occasional skin reactions. All children undergoing cautery experienced pain, even with 5% cocaine as a local anaesthetic.

Comment

Antiseptic creams versus cautery:

See comment on silver nitrate cautery.

Substantive changes

No new evidence

2008; 2008: 0311.
Published online 2008 May 19.

Petroleum jelly

Summary

NOSEBLEEDS Compared with no treatment: Petroleum jelly seems to be no more effective at reducing nosebleeds at 4 weeks in children with recurrent epistaxis ( moderate-quality evidence ).

Benefits

We found one RCT (105 children aged 1–14 years), which compared petroleum jelly applied to both nostrils twice daily for 4 weeks versus no treatment. It found no significant difference in the proportion of children with complete resolution of bleeding at 8 weeks (no bleeding during the past 4 weeks: 14/51 [27%] with petroleum jelly v 18/53 [34%] with no treatment; P = 0.472).

Harms

The RCT gave no information about adverse effects.

Comment

None.

Substantive changes

No new evidence

2008; 2008: 0311.
Published online 2008 May 19.

Silver nitrate cautery

Summary

NOSEBLEEDS Compared with antiseptic cream: Silver nitrate cautery is as effective at reducing the number of nosebleeds at 8 weeks in children with recurrent epistaxis ( moderate-quality evidence ). Compared with antiseptic cream plus cautery: We don’t know how effective silver nitrate cautery is compared with antiseptic cream plus cautery in children with recurrent epistaxis ( low-quality evidence ). NOTE We found no direct information about whether silver nitrate cautery is better than no active treatment in children with recurrent epistaxis.

Benefits

We found no systematic review.

Silver nitrate cautery versus no treatment:

We found no RCTs.

Silver nitrate cautery plus antiseptic cream:

See benefits of antiseptic creams.

Silver nitrate cautery plus antiseptic cream:

One RCT (40 adults, 24 children) compared once-only silver nitrate cautery plus chlorhexidine hydrochloride 0.1%/neomycin sulphate 3250 U/g cream twice daily for 2 weeks versus antiseptic cream alone. The RCT did not provide discrete results in children and included too few children to draw conclusions.

Harms

Silver nitrate cautery versus no treatment:

We found no RCTs.

Silver nitrate cautery versus antiseptic cream:

See harms of antiseptic creams.

Silver nitrate cautery plus antiseptic cream:

The RCT did not report harms. Recognised complications of cautery include pain and septal perforation, although the incidence of septal perforation following unilateral cautery in children is not known.

Comment

Both RCTs involving silver nitrate cautery were undertaken in the context of secondary care. Silver nitrate cautery is also used in primary care. It is unknown whether complication rates differ.

Clinical guide:

Simultaneous bilateral cautery in children is not recommended because of an expected increased risk of perforation.

Substantive changes

No new evidence


Articles from BMJ Clinical Evidence are provided here courtesy of BMJ Publishing Group