Nosebleeds in Children: First Aid & When to Worry

Why children’s noses bleed, how to stop a nosebleed the right way, and when frequent bleeds need a closer look

Few things alarm a parent like a blood-covered pillowcase at 2 a.m. Fortunately, most nosebleeds in children look far worse than they are, stop with simple pressure, and come from a spot at the front of the nose that is easy to protect. Some children have nosebleeds that keep coming back, and a few have a bleeding problem or a growth that needs attention. As a fellowship-trained pediatric ENT in Frisco, I see children with frequent nosebleeds every week, especially once dry winter air and indoor heating arrive. This guide covers why children’s noses bleed, first aid that works, prevention, and the signs that a nosebleed is more than a nuisance.

Key takeaways

• Most children’s nosebleeds start at the front of the nasal septum, the wall between the nostrils, where many small blood vessels sit just under a thin lining.
• To stop a nosebleed, sit up, lean forward, and pinch the soft part of the nose firmly and without letting go. National guidelines call for 5 minutes or more of continuous pressure, timed by the clock and without peeking. Do not tilt the head back.
• Dry air, nose picking, colds, and allergies cause most repeat nosebleeds, and keeping the inside of the nose moist prevents many of them.
• For frequent nosebleeds, an antiseptic cream and in-office cautery have performed similarly in children’s trials, and neither has been proven clearly better.
• A family history of bleeding problems is the strongest clue to a bleeding disorder such as von Willebrand disease.
• One-sided bleeding with one-sided blockage in a teenage boy deserves an ENT exam, to rule out a rare but important growth.
• Go to the emergency department if bleeding does not stop after 20 minutes of proper pressure, is very heavy, or follows a significant injury.

Why children’s noses bleed so easily

Just inside each nostril, on the septum, several small arteries join to form a network of vessels called Kiesselbach’s plexus (also called Little’s area). The lining over it is thin, and it is the first surface that dry air hits with every breath. The AAO-HNS (American Academy of Otolaryngology–Head and Neck Surgery) epistaxis guideline notes that most nosebleeds come from this front part of the nose, which is why pressure on the soft part of the nose works so well.

In children, that delicate area is exposed to a predictable set of triggers:

North Texas winters bring dry cold fronts and long hours of forced-air heating, and our long pollen seasons keep many children rubbing itchy noses. If allergies are part of the picture, our Frisco pollen and allergen forecast and allergy testing can help.

First aid: how to stop a nosebleed

The AAO-HNS guideline recommends firm, sustained compression of the lower third of the nose for 5 minutes or longer. Here is how I teach it to parents and children:

1. Stay calm and sit your child upright. A calm child bleeds less and cooperates better.
2. Lean forward slightly, chin toward the chest, so blood drains out the front instead of down the throat.
3. Pinch the soft part of the nose, just below the hard bony bridge, squeezing both nostrils closed between your thumb and index finger. Pressing on the bony bridge does not help, because the bleeding vessels are lower down.
4. Hold firmly and continuously for at least 5 minutes by the clock. Do not let go to check. Peeking releases the pressure and lets the clot break apart. If the nose is still bleeding when you release, pinch again for another 5 minutes or more.
5. Breathe through the mouth and spit out any blood rather than swallowing it. Swallowed blood often causes vomiting.
6. After the bleeding stops, have your child avoid blowing or picking the nose, and avoid rough play, for the rest of the day.

Common mistakes to avoid:

• Do not tilt the head back or lie your child down. Blood runs down the throat, which can cause coughing, choking, or vomiting, and hides how much bleeding is happening.
• Do not stuff tissue deep into the nostril. It can stick to the clot and restart the bleeding when it is pulled out.
• Do not use a decongestant nasal spray in a young child unless your child’s doctor has told you to. These sprays are not intended for young children and cause rebound congestion with repeated use.

Prevention: protecting the front of the nose

The guideline recommends that clinicians teach families preventive measures, and most of them come down to moisture:

• Humidify the bedroom during dry months. Clean the humidifier as the manufacturer directs.
• Use saline spray or saline gel once or twice a day during dry seasons or colds.
• Apply a thin layer of petroleum jelly or a moisturizing ointment just inside the front of the nostril, on the septum, at bedtime. Use a fingertip; do not push anything deep into the nose.
• Keep nails short and help younger children break the picking habit. Moist lining crusts and itches less, which makes picking less tempting.
• Check nasal steroid spray technique. An expert panel review recommended a standard technique that directs the spray toward the outer wall of the nose. A simple way to do this: use the right hand for the left nostril and the left hand for the right nostril, pointing the tip toward the ear on the same side. If bleeding continues, check with the prescriber before stopping or changing the spray.
• Treat allergies so the nose is less itchy and inflamed.

An honest note: in a small trial included in a Cochrane review, petroleum jelly alone did not significantly reduce nosebleeds compared with no treatment. Moisturizing is still low-risk and guideline-endorsed, but it does not stop every child’s bleeding.

Recurrent nosebleeds: what a pediatric ENT can do

The examination

For a child with repeat nosebleeds, I start with a history (how often, which side, how long, bleeding elsewhere, family history, medicines) and a look inside the front of the nose, an exam the guideline recommends for every nosebleed patient. Often I can see a prominent vessel or a crusted, raw spot on the septum. When bleeding is recurrent on one side, or the cause is not obvious, the guideline recommends nasal endoscopy, a look with a thin camera after a numbing spray, to check the back of the nose.

Treatment options

The Cochrane review, which included five trials and 468 children, concluded that the best treatment for recurrent nosebleeds in children without an identified cause is still unknown. It found no serious side effects from any of the treatments studied, though children did find silver nitrate cautery uncomfortable despite numbing. The antiseptic cream used in several of those trials, a neomycin and chlorhexidine product, is a UK preparation that is not sold in the United States, so your child’s doctor will recommend a local alternative.

When I do use cautery, the guideline recommends numbing the area first and treating only the bleeding site. I avoid cauterizing both sides of the septum at the same visit, to protect the septum while it heals. When a procedure under anesthesia is needed, I perform it at Stonebridge Surgery Center, and at Children’s Medical Center Plano or Texas Health Hospital Frisco when hospital care is the safer choice.

A note on scope: the AAO-HNS epistaxis guideline applies to patients 3 years and older, but much of its evidence comes from adults, and sections such as managing blood thinners rarely apply to children. The pediatric-specific evidence comes mainly from the Cochrane review.

When a nosebleed points to something else

A bleeding disorder

Most children with frequent nosebleeds have nothing wrong with their blood clotting, but some do. In one study of 178 children referred to a pediatric hematology clinic for recurrent nosebleeds, one-third had a diagnosable bleeding disorder, most commonly von Willebrand disease, followed by platelet function problems. A family history of bleeding was the only part of the history that predicted a diagnosis; how long or how severe the nosebleeds were did not. Because that study looked only at children already referred to specialists, the rate is higher than in children in general, but it shows why I always ask about relatives with easy bruising, heavy periods, or excessive bleeding after surgery or dental work. Your pediatrician or a hematologist can order screening blood tests when the history raises concern. This matters before surgery too, including tonsillectomy.

Hereditary hemorrhagic telangiectasia (HHT)

HHT is an inherited condition that causes fragile, dilated blood vessels. Its hallmarks are recurrent spontaneous nosebleeds, small red spots (telangiectasias) on the lips, tongue, face, or fingers, and a close relative with HHT. The guideline recommends checking for telangiectasias in patients with recurrent nosebleeds on both sides or a family history of recurrent nosebleeds. HHT needs a specific evaluation, because it can affect blood vessels in the lungs, brain, and liver.

An object in the nose

A young child with one-sided, foul-smelling, sometimes blood-streaked drainage has a foreign body in that nostril until proven otherwise. Beads, foam, food, and toy parts are common. A button battery in the nose is an emergency, because it can burn through the septum within hours. My post on nasal obstruction in children covers one-sided blockage in more detail.

A growth in the back of the nose

Juvenile nasopharyngeal angiofibroma is an uncommon, benign but locally aggressive tumor made of blood vessels. It occurs almost exclusively in adolescent and young adult males, and its most common symptoms are nasal blockage and nosebleeds, often on one side. It is diagnosed with an endoscopic exam and imaging; it should not be biopsied in the office because of the risk of heavy bleeding. Treatment is surgical, usually endoscopic, often after the blood supply is blocked beforehand. This is rare, and most teenagers with nosebleeds do not have it, but a teenage boy with repeated one-sided bleeding and one-sided blockage should have the back of the nose examined.

Injury

A nosebleed after a hit to the nose usually stops with first aid. Afterward, watch for a crooked nose, new blockage on both sides, or a soft swelling inside the nose (a septal hematoma), which needs a same-day exam.

Babies

Nosebleeds are uncommon in the first two years of life. A study of hospital records in children under 2 found that nosebleeds in this age group were often associated with injury or a serious illness. Any nosebleed in a baby deserves a prompt medical evaluation.

Red flags: when a nosebleed is an emergency

Call 911 or go to the emergency department if:

• Bleeding does not stop after 20 minutes of firm, continuous pressure, done correctly
• Bleeding is very heavy, or your child becomes pale, dizzy, sweaty, or faint
• Blood is pouring down the throat, or your child is vomiting large amounts of blood or having trouble breathing
• The nosebleed followed a significant blow to the head or face, or there is clear fluid draining from the nose after an injury
• Your child may have put a button battery in the nose
• Your child has a known bleeding disorder and bleeding will not stop

Call your pediatrician promptly if your child has nosebleeds along with easy bruising, tiny red or purple spots on the skin, bleeding gums, unusual tiredness, or paleness.

When to see a pediatric ENT

• Nosebleeds keep coming back despite moisturizing and good first aid
• Bleeding is usually from the same side, especially with blockage on that side
• A teenage boy has repeated one-sided bleeding and nasal blockage
• There is one-sided, foul-smelling drainage that suggests a foreign body
• The nose looks crooked or stays blocked after an injury
• You are considering cautery or another treatment for recurrent bleeding
• A bleeding disorder or HHT is suspected, and the nose needs evaluation alongside blood testing
• Allergies or a nasal steroid spray seem to be contributing. See my pediatric ENT services.

From my research and practice

Foreign bodies in the nose, airway, and esophagus are an area I have written about. With Dr. Douglas Ruhl, I co-authored the chapter “Foreign Bodies and Caustic Ingestion of the Aerodigestive Tract” for Sataloff’s Comprehensive Textbook of Otolaryngology (2015). That work shapes how I listen when a parent describes one-sided drainage, a bad smell, or bleeding from just one nostril in a young child. The full list is on my publications and research page.

Frequently asked questions

Should my child tilt the head back during a nosebleed?

No. Tilting the head back sends blood down the throat, which can cause coughing, gagging, or vomiting, and it does not slow the bleeding. Have your child sit up, lean slightly forward, and pinch the soft part of the nose continuously for 5 minutes or more, without letting go to check.

How often is too often for nosebleeds?

There is no single number that applies to every child. Occasional nosebleeds, especially in dry months or with colds, are common and usually harmless. Bleeds that keep returning despite moisturizing, that are hard to stop, that come mostly from one side, or that happen along with easy bruising are good reasons to see your pediatrician or a pediatric ENT.

Is nasal cautery safe for children?

Yes, when it is used for the right reason. In the trials reviewed by Cochrane, no serious side effects were reported, although children found silver nitrate cautery uncomfortable even with numbing, and a 75 percent silver nitrate stick caused less pain than a 95 percent stick. Cautery is applied only to the bleeding spot, and an antiseptic cream has been about as effective in children’s trials.

Can frequent nosebleeds be a sign of a bleeding disorder?

Sometimes. In one study of children referred to a hematology clinic for recurrent nosebleeds, about one-third had a bleeding disorder, most often von Willebrand disease. A family history of bleeding problems was the most useful clue, so tell your child’s doctor about any relatives with easy bruising, heavy periods, or bleeding after surgery.

Does a humidifier really help prevent nosebleeds?

It can, particularly in dry winter months when indoor heating is running. Moist air keeps the lining at the front of the nose from drying and cracking. I usually suggest pairing it with saline spray or gel and a thin layer of moisturizing ointment just inside the nostril.

References

1. Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1 Suppl):S1–S38. doi:10.1177/0194599819890327
2. Qureishi A, Burton MJ. Interventions for recurrent idiopathic epistaxis (nosebleeds) in children. Cochrane Database Syst Rev. 2012;(9):CD004461. doi:10.1002/14651858.CD004461.pub3
3. Sandoval C, Dong S, Visintainer P, Ozkaynak MF, Jayabose S. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol. 2002;24(1):47–49. doi:10.1097/00043426-200201000-00013
4. Faughnan ME, Mager JJ, Hetts SW, et al. Second international guidelines for the diagnosis and management of hereditary hemorrhagic telangiectasia. Ann Intern Med. 2020;173(12):989–1001. doi:10.7326/M20-1443
5. López F, Triantafyllou A, Snyderman CH, et al. Nasal juvenile angiofibroma: current perspectives with emphasis on management. Head Neck. 2017;39(5):1033–1045. doi:10.1002/hed.24696
6. McIntosh N, Mok JY, Margerison A. Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection. Pediatrics. 2007;120(5):1074–1078. doi:10.1542/peds.2007-2097
7. Benninger MS, Hadley JA, Osguthorpe JD, et al. Techniques of intranasal steroid use. Otolaryngol Head Neck Surg. 2004;130(1):5–24. doi:10.1016/j.otohns.2003.10.007
8. Cable BB, Ruhl D. Foreign bodies and caustic ingestion of the aerodigestive tract. In: Sataloff’s Comprehensive Textbook of Otolaryngology. JP Brothers Medical Publishers; 2015.

If your child’s nosebleeds keep coming back or are hard to stop, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.