Nosebleeds are one of the most frequent reasons for referral to a hematology clinic for evaluation of a possible bleeding disorder, and yet, nosebleeds are one of the poorest indicators of an underlying bleeding problem. More often, nosebleeds are related to a variety of other issues. It is estimated that over 25 percent of children will have a significant problem with nosebleeds sometime during their childhood. Nosebleeds are much more common in children than in adults.

The nose is the part of the body where air first enters on its way to the lungs. Its job is to clean, warm and humidify the air before it reaches the lungs. To accomplish this, the nose has a complicated system of baffles and small hair, as well as arteries and veins that carry blood to the nose to help warm the incoming air. A thin membrane covers these blood vessels. In children this membrane tends to be very fragile. It is, therefore, not surprising that children are more prone to nosebleeds. More than 80 percent of nosebleeds in children occur in the front part of the nose where the largest number of blood vessels are located. This is fortunate because this is one area that is accessible and will respond to pinching to stop the bleeding.

The majority of nosebleeds are mild, infrequent and easily remedied at home. Occasionally, nosebleeds become more troublesome and that often results in a call to the doctor’s office. Often, the blood drips out of the nose but sometimes the bleeding is in the back part of the nose and drips down the throat. This can make a person feel sick, and they may throw up. Once in the stomach, this blood is mixed with a large amount of stomach fluid. When this is thrown up, it appears there is more blood being lost than there actually is. In these situations it can be difficult to estimate the blood that is being lost. These types of episodes can be very frightening. There are a few simple things that can be done to help avoid such a situation.

Causes of nosebleeds

• Trauma - This can include a blow or bump to the nose but, more frequently, it involves picking or rubbing the nose, particularly in younger children. Frequent nose blowing or sneezing can also be traumatic. Many times the trauma occurs at night when the child is sleeping and is unaware of what he or she is doing.
• Respiratory infections
• Nasal or sinus infections
• Allergies
• Repeated use of medicated nasal sprays
• High altitude
• Dry air and forced-air heating (a particular problem in Minnesota winters)
• Surgeries to the nasal area
• Foreign objects in the nose

There are also several medical diseases that may contribute to nosebleeds, though they are rare in children, including increased blood pressure, liver disease, kidney disease, tumors, hemangiomas and inherited bleeding disorders. Bleeding disorders are the cause of nosebleeds in less than 5 percent of cases, but it is important that they be considered, especially if there is a history in the patient or the family of other bleeding problems. Very often the cause of nosebleeds is a variety of factors.

Acute nosebleed

What to do:

• Stay calm.
• Sit up and lean forward. Try to have the person not swallow the blood but rather spit it out if it is going down the back of the throat. Remember, if blood is swallowed, it can make a person sick and vomit. Very often, the amount of blood loss is hard to assess and can seem much greater than it actually is.
• Pinch the nose for 10-15 minutes continuously while breathing through the mouth.
• Apply ice or a cold compress to the bridge of the nose or the area over the sinus.

Follow-up
For 24 hours following the nosebleed, try not to blow the nose, pick or rub it. Try to keep quiet, and do not lift heavy objects, exercise or participate in strenuous activities such as running. It takes seven to 10 days for the nasal mucous to heal after a nosebleed stops. During this time, be careful about rubbing and blowing the nose. Discourage strenuous activities or sports. Keep the nose moist using saline spray and/or a vaporizer at the bedside. Saline nose spray is particularly helpful if there is crusting blood in the nose. Put a small amount of Vaseline or antibiotic ointment in the very front part of the nose using a Q-tip.

When to consider seeing an ear, nose and throat specialist or hematology physician:

• If the nosebleeds are frequent, last longer than 30 minutes and involve both sides of the nose
• If the above measures have been tried and failed
• If there is a family history or personal history for bleeding problems
• If there is any suspicion of a nasal fracture or if the patient may have put a foreign object in their nose

Other treatments that may be helpful to prevent nosebleeds:

• When the humidity in the air begins to drop, place a vaporizer in the bedroom near the head of the bed where the patient is sleeping.
• Use saline nose spray if there is any crusting in the nose; this may also be used to supplement the vaporizer to keep the nasal mucous moist.
• Discourage any rubbing or picking of the nose.
• Use a small amount of Vaseline or antibiotic ointment such as Bacitracin, Bactroban or Neosporin, one to three times per day. Use a Q-tip or your finger to put a small amount in the very front part of the nose. Do not put the Q-tip or finger high up in the nose.
• Use olive oil or other vegetable oil in the very front of the nostril at night to improve pliability of the nasal membrane. Once again be careful not to put the oil beyond the very anterior part of the nose.
• If allergies are suspected, you may use a decongestant such as Sudafed or Claritin to help decrease nasal drainage, sneezing and nose blowing. If allergies are particularly problematic, then a referral to an allergist may be helpful.
• A person with chronic nosebleeds should consider a multivitamin with iron. If there has been evidence of iron deficiency, then more formal iron replacement should be given.
• Be careful about over-the-counter medications such as aspirin, non-steroidals such as ibuprofen and certain decongestants and expectorant. Any of these may increase the likelihood of nosebleeds. It is important to read the labels of medications since some medications may contain aspirin without you realizing it.

Salt pork treatment of nosebleeds
Salt port has been used since the 1800s to treat nosebleeds. It is believed the cold and salt work to constrict the blood vessels and the fat stimulates the clotting system.

You can buy salt pork at most butcher shops and sometimes at grocery stores. It is very inexpensive. Before using, place the slab in the freezer. When a bleed develops, apply pressure until the bleeding is stopped or slowed down. Pull the slab of salt pork out of the freezer and cut off a cone shaped piece that equals the length of your/your child’s nose from top to bottom. Add a little at the bottom so it will stick out of your/their nose slightly in case you need to remove it. The salt pork slice will be slightly thawed by the time you are ready to put it into your/your child’s nose. Some nurses tape the salt pork in place. We suggest you leave the strip in place until it falls out.

Some people are uncomfortable putting salt pork up their or their child’s nose. This is just a suggestion that has been successfully used by many patients.

Additional information about nosebleeds