When a Child’s Nosebleeds

is a Blood disorders?
Bambang Sudarmanto
Kariadi Academic Medical Centre / Department of Child
Health Medical Faculty Diponegoro University Semarang
Introduction

Epistaxis or nosebleeds is a common pediatric complaint

Severe and recurrent forms of epistaxis  constitute a major trouble parent and
doctor

It results from an interaction of factors damaging nasal mucose lining, affect the
vessel walls, or alter the coagulability of the blood, and malignancy

According to the literature, causes of epistaxis look different between adults and
children.

Persistent / Recurrent epistaxis  Suspecion of Blood disorders or Neoplasm

Definition
Nosebleeds (epistaxis, nose bleeds) is defined as acute hemorrhage from the nostril, nasal
cavity, or nasopharynx.

Epidemiology
Epistaxis is
 A frequent ED complaint complaint; often causes significant anxiety in patients and cli
nicians
 Rarely seen in infant < 2 years old
 40% children will have presented with at least 1 episode of epistaxis by the age of 5
 In age group 6-10 years  56% incidence rate
NOSEBLEEDS- EPISTAXIS
Cause of epistaxis

ENT

Pediatric
Frequency distribution of hematological patients
according to cause
 EPISTAXIS : ADULT vs CHILDREN
ETIOLOGY NOSEBLEEDS

Adult Children
Most common cause: Most common cause:
Medication (NSAIDs, Warfarin,and Vascular fragylity
Aspirin) Alergic rhinitis, trauma
Hypertension Neoplasma (benigna, maligna)
Arteriosclerosis BLOOD DISORDERS
Cardiovascular disorder
Diagnosis
01 HISTORY

Duration, severity, the side of initial bleeding

Previous epistaxis, sistemic disease.

Family history of bleeding disorder, easy bruising, prolonged

bleeding after minor surgical procedure (circumsition)
Use of medications (aspirin, NSAID, warfarin, heparin and
dipyridamole)
Diagnosis
02 PHYSICAL EXAMINATION
Exam of nasal cavity; blowing the nose or applicatng
vasoconstrictor  better exam result
Insert nasal speculum gently, spread vertically. 90% nosebleeds
can be visualized in anterior portion of nasal cavity
Confused with hemoptysis/hematemesis? Dripping blood from
posterior nasopharynx  confirms nasal source
No visualized anterior bleeding, hemorrhage from both nares,
visualized blood draining from posterior  posterior bleeding
 Nosebleed
Nosebleeds are categorized base on they originate:
Anterior :
The bleeding usually originates from a blood vessel on the nasal
septum, where a network of vessels converge (Kiesselbach plex
us). Easy to control.

Posterior:
Posterior nosebleeds are much less common than anterior noseb
leeds. They tend to occur more often in elderly people.
Complicated, require admision to the hospital.
Nosebleeds in serious ?

Frequent nosebleeds
1. Accur more than once a week.

2. May be a sign of problem. Suspecion of BLEEDING Disorders or

neoplasma

Recurrent / Persistent nosebleed

(posterior nasal cavity)
NOSEBLEEDS IS A BLEEDING DISORDER,
WHAT CAUSES ?

Vessel wall disorders

Platelets disorders

Coagulation factor disorders

Combination of these
Blood coagulation is localized to surfaces
Primary hemostasis:
platelet adhesion and aggregation

• Secondary hemostasis:
clot formation
Primary hemostasis relies on platelets and von
Willebrand factor
Platelet functions:
– Adhesion (to sub endothelium)
– Release of platelet granules
– Aggregation (platelet-platelet)
Primer hemostasis
Vessel wall damage activation of primary hemostasis followed
by thrombus formation (secondary hemostasis)
VASSEL IN NASAL CAVITY
PLATELETS DISORDERS

Thrombocytopenia

Thrombopathy
THROMBOCYTOPENIA

DECREASE PRODUCTION EXCESSIVE PRODUCTION

Bone marrow failure
Leukemia ITP = Immune Thrombocytopenia
Megaloblastic anemia Alloimmune neonate
Myelofibrosis Drugs – Heparin
Myelo infiltration SLE

ANEMIA APLASTIK Squestration: Hypersplenism

Idiopathic Dilution : ec. Massive transfusion
Drugs
Platelet function disorders
Platelet count normal, Bleeding, Bruising, increase bleeding time

Inherited disorders Acquired disorders

Glanzman’s Thrombasthenia Uremia
Platelet membran 11b/111 absent Myelodisplasia syndrome
Defect platelet aggregation Drug induced
Benard Soulier Syndrome
Absent platelet membran
Defective adhesion
Storage pool defect
COAGULATION
• Activation of Blood Coagulation Tissue factor (TF)
exposed at sites of vascular injury
• FVIIa binds to Tissue Factor
• TF-FVIIa complex activates FIX and FX
• Activation and Propagation of Coagulation
• FVIIIa/IXa complex
• Explosion of thrombin formation
Abnormalities in primary hemostasis, secondary
hemostasis and fibrinolysis may cause a disturbance
of hemostatic balance and feed back mechanism:
– Bleeding
– Thrombosis
When to suspect nosebleeds is a blood
coagulation disorder?
Classification of coagulation disorders in children

Inherited Acquired
Hemophilia A Vitamin K deficiency

Hemophilia B Liver diseases

Von Willebrand disease Disseminated Coagulation disorder

Deficiency of factors II, V, VII, X, XI, XII or XIII

Dys-, Hypo-, Afibrinogenemia

Plasminogen activator inhibitor-1 deficiency

Approach of bleeding disorders in children

Comprehensive
Complete family
01 medical and
bleeding history
02 history

Detail physical Selected

03 examination 04 laboratory tests
Screening test for bleeding disorders

Platelet count
Bleeding Time (BT)
Protrhombin Time (PT)
Partial Thromnoplastin Time (PTT)
Thrombin Time (TT)
 Approach of bleeding disorders in children (1)
Initial Laboratory Evaluation to Screen for Bleeding Disorders: Analysis and Interpretation

Possible bleeding
PT aPTT Platelet count
disorder

Von Willebran diseases (vWD)

Normal Normal Normal Platelet functional disorders
Factor XIII deficiency

Hemophilia A, Hemophilia B
Normal Prolonged Normal Factor IX deficiency
vWD with F VIII disfunction
Early Vit K deficiency
Prolonged Normal Normal Factor VII deficiency
Warfarin excess
 Approach of bleeding disorders in children (2)
Initial Laboratory Evaluation to Screen for Bleeding Disorders: Analysis and Interpretation

PT aPTT Platelet count Possible bleeding disorder

Liver diseases
Vit K deficiency
Prolonged Prolonged Normal
Common pathways factors
Dysfibrinogenesis
DIC
Prolonged Prolonged Low
Liver diseases
Acute ITP
Normal Normal Low
Chronic ITP
 When we suspect malignancy?
Nosebleeds and Leukemia
01
Acute leukemia  most common
hematology malignancy in childhood
Acute Lymphoblastic Leukemia (ALL)
Acute Mieloblastic Leukemia (AML)
03 Nosebleeds and other malignancy
Nosebleeds and Liver cancer
02
Hepatoblastoma and hepatocellular
carcinoma  most common type of
liver cancer in childhood
No major symptoms until 3rd or 4th
stage:
• Weight loss
• Lack of appetite
• Abdominal pain
• Nausea and vomiting
• Weakness jaundice
Nosebleeds  in 3rd or 4th stage
When to referred to pediatric hematology

01 Bleeding does not to stop after 20 minutes

02 History of easy bruising

03 Repeated nosebleeds

04 Bleeds frequently

Nosebleed episodes are not associated with a

05 cold or other minor irritation
Summary
Nosebleeds is one of the clinician problem in emergency
01
unit and hospitalized patient

The evaluation of a children presenting with nosebleeds

02
should include a comprehensive medical and bleeding
history, a complete family history, a detail physical exa
mination and selected laboratory test
THANK YOU