When your child has frequent nosebleeds

For the past two years my son has been having nosebleeds. He is now anemic, which one doctor put him on 325mg of ferrous sulfate three times per day. We have gone to several doctors who have done the usual questioning, when, where, under what circumstances, nosepicking, etc to find an quick easy answer for the cause of the nosebleeds. We have gone through several medications, nose sprays all to no avail.

My questions are these:

What else should they be looking for and what kind of testing should be done to try to find the cause of the nosebleeds? Is there any possibility of a hemophilia related condition? Is there any definitive test for them?

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ABOUT THE EXPERT

Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

Nosebleeds are a common occurrence in childhood. They may occur from trauma to the nose, dry nasal passages on non-humid days, from inflammation due to allergies, and, of course, from nose picking. They may also occur for no particular reason that can be identified. These episodes of nosebleeding can be quite distressful for parents because just a few drops of blood can have a deceptive appearance of being a large amount, so a nosebleed that lasts for five minutes may appear like the child is hemorrhaging.

The most common reason for a nosebleed to not stop bleeding is improper technique in getting it to stop. When a nose bleed occurs:

  1. Tilt the head slightly back and preferably keep the child upright either standing or in a chair. Keeping the head higher than the heart will decrease the amount of blood pooling that can occur in tissues that have a lot of blood vessels in it such as the nose.
  2. You want to stop the bleeding by applying pressure to the site of bleeding. Pinch about halfway up the nose where the bone and cartilage meet. If pressure is applied only at the opening of the nose, you catch a lot of blood, but do not apply pressure in the correct spot.
  3. Keep pressure on the nose for at least 10 minutes, and NO peeking. This is where most adults fail because 10 minutes can be a long time to hold pressure to the nose. It is difficult to resist the urge to "peek" just to see if the bleeding has stopped. Each time this "peeking" is done, the clot that was forming inside the nose gets ripped away, and bleeding may start all over giving the appearance of abnormal bleeding.

Rarely, a child who has an underlying bleeding disorder may have frequent and severe nosebleeds without any other symptoms. There are clues that may support the idea of a problem causing these nosebleeds:

  • Is the child taking any medications?
    Aspirin and aspirin-containing products can cause bleeding problems. Most medications for children do not contain aspirin, but it is always a good idea to check the labels to see if this could be factor. Other common medications that can cause excessive bleeding include ibuprofen (Motrin, Advil, etc), guaifenesin (a common expectorant found in over-the-counter cough medications), and several of the anti-histamine preparations. While most of these last medications probably do not cause bleeding problems themselves, the use of them by people who are mildly predisposed to bleeding will make this bleeding tendency apparent.
  • Have there been any other excessive bleeding episodes in the past?
    Bleeding problems from the circumcision, from where the umbilical cord fell off, after having dental work, tonsillectomy, or from otherwise minor cuts may be a clue to a bleeding problem. In addition, children with bleeding disorders may bruise rather easily or extensively.
  • Is there anyone in the family that has a bleeding disorder?
    Most bleeding disorders such as hemophilia are hereditary, therefore, knowing of anyone in the family who had a diagnosed bleeding disorder or problems with bleeding such as those mentioned above may be a clue as well.
  • Is the nosebleeding always from both sides of the nose?
    In children with no bleeding tendency or family history of bleeding tendency, nosebleeds that usually occur on just one side are unlikely to be caused by a bleeding disorder. This absolutely does not mean that a nose bleed that occurs on both sides of the nose means there is a bleeding disorder. It just means that if it usually occurs on only one side, the likelihood of the nosebleed being from a bleeding disorder is rather remote.

The most common cause of nosebleeds is picking the nose which is why you have probably been asked those questions about a thousand times. A very thorough examination of the nasal passages may be all that is needed to define the cause. If he has an area of fragile blood vessels somewhere up in the nose, they may be eliminated with cauterization. This is usually done by an ENT specialist. If examination does not seem to elucidate an answer, there are a few simple blood tests that can rule out hemophilia or a decrease in platelets (cells that help blood clot). The most common bleeding tendency problem is called von Willebrand's Disease which keeps the platelets from working correctly. Diagnosing this takes a special type of blood test. In the end, an answer may not be found other than just to improve the technique of stopping a nose bleed when it starts. Continue to work through your HMO woes because if his anemia is caused by these nosebleeds, it certainly signals that there could be a more significant problem. I suggest you set up an appointment and see if additional time can be allotted for the visit. In addition, see if you can arrange to make sure you see the same physician each time. The answer may take a while to reach, so having the same person seeing your son will be helpful.

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