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Epistaxis in Children: IAP Guidelines
Epistaxis is defined as bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that affects a patient's quality of life.
The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Epistaxis in Children. The lead author for these guidelines on Epistaxis in Children is Dr. Shalu Gupta along with co-author Dr. Arpita Gogoi Borgohain and Dr. Swathy Rao. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.
Following are the major recommendations of guidelines:
Epistaxis is a common, usually benign condition of childhood and accounts for about 0.5% of all emergency department visits. Children with epistaxis mainly present between 2 and 10 years of age. About 30% of children aged 2–5 years, 56% of children aged 6–10 years, and 64% of children aged 11–15 years developing epistaxis during their lifetime.
Since epistaxis is so common, how extensive would be the workup and treatment of a child with nasal bleeding can be a difficult decision. While there is no consensus on the duration or frequency of episodes constituting recurrent epistaxis, some studies have defined recurrent epistaxis as five or more episodes per year.
Pathophysiology:
There are diverse causes and risk factors, which can lead to epistaxis. Sometimes the etiology is not clear and thus primary (i.e., idiopathic) epistaxis is the main cause.
Dry atmospheric conditions lacking humidification leads to dried nasal mucosa and associated fissuring of nasal mucosa, subsequently leading to desiccation and exposure of blood vessels.
Mostly, the site of the bleeding is on the anterior nasal septum due to network of small blood vessels known as Kiesselbach's plexus
These vessels are located in a superficial portion of the septal mucosa, which makes them prone to injury from the slightest mechanical or chemical insult. Other sites of bleeding include the lateral nasal wall, particularly the branches of the sphenopalatine artery. Posteriorly, bleeding can arise from posterior branches of the sphenopalatine artery, Woodruff plexus, and venous sources.
Risk Factors and Etiology:
Local inflammation
Prior upper respiratory tract infections
Mucosal drying
Local trauma (including nose picking)
Other specific local (e.g., tumors) or systemic (e.g., clotting disorders) factors.
Primary epistaxis is defined as idiopathic bleeds without identifiable and precipitating factors, whereas bleeds known to be associated with a clear and definitive cause are classified as secondary epistaxis.
The etiology varies in different age groups:
>2 years: Mainly due to local factors
<2 years: Epistaxis is rare (1 per 10,000), must be worked up for:
- Burton MJ, Dorée CJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2004;1:CD004461.
- ElAlfy MS, Tantawy A, Eldin BEMB, Mekawy MA, elAziz Mohammad YA, Ebeid FSE. Epistaxis in a pediatric outpatient clinic: could it be an alarming sign? Int Arch Otorhinolaryngol. 2022;26(02): e183-90.
- Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005;71(2):305.
- Send T, Bertlich M, Eichhorn KW, Ganschow R, Schafigh D, Horlbeck F, et al. Etiology, management, and outcome of pediatric epistaxis. Pediatr Emer Care. 2019;37:466-70.
- Svider P, Arianpour K, Mutchnick S. Management of Epistaxis in children and adolescents avoiding a chaotic approach. Pediatr Clin N Am. 2018;65:607-21.
- Tunkel DE, Anne S, Payne SC, Ishman SL, Rosenfeld RM, Abramson PJ, et al. Clinical practice guideline: nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020;162(1S):S1-S38.
The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/
I have done my Bachelor of pharmacy from United Institute of Pharmacy and currently pursuing pharmaceutical MBA from Jamia hamdard. I worked as an intern at the position of content creator in Medical Dialogue and am highly obliged to the company for giving me this wonderful opportunity.
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751