Child health

..................................................

Nosebleeds in children
Search date April 2008
Gerald McGarry

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 obser-
vational 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.

QUESTIONS
What are the effects of treatments for recurrent idiopathic epistaxis in children?. . . . . . . . . . . . . . . . . . . . . . . . 2

INTERVENTIONS
TREATING RECURRENT EPISTAXIS Unknown effectiveness
Likely to be beneficial Cautery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Antiseptic cream . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Petroleum jelly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

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.

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/ A cross-sectional study of 1218 children (aged 1114 years) found that 9% had frequent episodes
[1]
PREVALENCE of epistaxis. It is likely that only the most severe episodes are considered for treatment.

AETIOLOGY/ In children, most epistaxis occurs from the anterior part of the septum in the region of Little's area.
[2]
RISK FACTORS Initiating factors include local inflammation, mucosal drying, and local trauma (including nose
[2]
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 To reduce the number and severity of epistaxis episodes; to minimise adverse effects of treatment.
INTERVENTION
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
BMJ Publishing Group Ltd 2008. All rights reserved. . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . Clinical Evidence 2008;05:311
 Child health
Nosebleeds in children
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, p
5 ).

QUESTION What are the effects of treatments for recurrent idiopathic epistaxis in children?

OPTION ANTISEPTIC CREAMS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 dont know how effective antiseptic creams alone are compared
with antiseptic cream plus silver nitrate cautery in children with recurrent epistaxis (low-quality evidence).

For GRADE evaluation of interventions for nosebleeds in children, see table, p 5 .

Benefits: We found no systematic review.

Antiseptic creams versus no treatment:

We found one RCT (103 children aged 313 years with recurrent epistaxis for a mean of 20 months,
unblinded design), which compared antiseptic cream (chlorhexidine hydrochloride 0.1%, neomycin
[3]
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 314 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
[4]
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, p 3 .

Harms: Antiseptic creams versus no treatment:

The RCT comparing antiseptic cream with no treatment gave no information about adverse effects.
[3]
Some commercial antiseptic creams contain arachis (peanut) oil, and the RCT excluded all
[3]
children with peanut allergies.

Antiseptic creams versus cautery:

The RCT comparing antiseptic cream versus cautery found no adverse reactions with antiseptic
[4]
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
[4]
cautery experienced pain, even with 5% cocaine as a local anaesthetic.

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 Child health
Nosebleeds in children
Comment: Antiseptic creams versus cautery:
See comment on silver nitrate cautery, p 3 .

OPTION PETROLEUM JELLY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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).

For GRADE evaluation of interventions for nosebleeds in children, see table, p 5 .

Benefits: We found one RCT (105 children aged 114 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
[5]
4 weeks: 14/51 [27%] with petroleum jelly v 18/53 [34%] with no treatment; P = 0.472).
[5]
Harms: The RCT gave no information about adverse effects.

Comment: None.

OPTION SILVER NITRATE CAUTERY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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 dont 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.

For GRADE evaluation of interventions for nosebleeds in children, see table, p 5 .

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, p 2 .

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
[6]
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, p 2 .

Silver nitrate cautery plus antiseptic cream:

[6]
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.
[4]
Comment: Both RCTs involving silver nitrate cautery were undertaken in the context of secondary care.
[6]
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.

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 Child health
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.

REFERENCES
1. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of the preva-
lence of von Willebrand's disease. Blood 1987;69:454459.[PubMed]
2. Watkinson JC. Epistaxis. In: Kerr AG, Mackay IS, Bull TR, eds. Scott-Brown's
Otolaryngology, Volume 4 Rhinology. Oxford: Butterworth-Heinemann,
1997;18:119.
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 Oto-
laryngol 2001;26:465468.[PubMed]
4. Ruddy J, Proops DW, Pearman K, et al. Management of epistaxis in children.
Int J Paediatr Otorhinolaryngol 1991;21:139142.
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;29:266269.
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;24:228231.[PubMed]

Gerald W McGarry
Consultant Otorhinolaryngologist, Honorary Clinical Senior Lecturer
Glasgow Royal Infirmary
Glasgow
UK

Competing interests: GWM declares that he has no competing interests.

We would like to acknowledge the previous contributors of this review, including Martin Burton and Robert Walton.

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
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 Child health
Nosebleeds in children
TABLE GRADE evaluation of interventions for nosebleeds in children

Important outcomes Nosebleeds, adverse effects

Number of studies Type of evi-
(participants) Outcome Comparison dence Quality Consistency Directness Effect size GRADE Comment
What are the effects of treatments for recurrent idiopathic epistaxis in children?
[3]
1 (103) Nosebleeds Antiseptic cream v no treat- 4 2 0 0 0 Low Quality points deducted for sparse
ment data and no blinding
[4]
1 (48) Nosebleeds Antiseptic cream v silver ni- 4 1 0 0 0 Moderate Quality point deducted for sparse
trate cautery data
[6]
1 (24) Nosebleeds Antiseptic cream plus silver 4 1 0 1 0 Low Quality point deducted for sparse
nitrate cautery v antiseptic data. Directness point deducted
cream alone for inclusion of adults and children
[5]
1 (105) Nosebleeds Petroleum jelly v no treatment 4 1 0 0 0 Moderate Quality point deducted for sparse
data
Type of evidence: 4 = RCT; 2 = Observational; 1 = Non-analytical/expert opinion. Consistency: similarity of results across studies.
Directness: generalisability of population or outcomes.
Effect size: based on relative risk or odds ratio.

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