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Nasal bleeding and non-accidental injury in an infant
  1. L J Walton1,
  2. F C Davies2
  1. 1
    Queen’s Medical Centre, Nottingham, UK
  2. 2
    Emergency Department, Leicester Royal Infirmary, Leicester, UK
  1. Correspondence to Dr Ffion Davies, Emergency Department, Leicester Royal Infirmary, Leicester LE1 5WW, UK; Ffion.davies{at}uhl-tr.nhs.uk

Abstract

Bleeding from the nose has been a point of controversy in the field of child protection in the UK in recent years. Epistaxis in childhood is common but is unusual in the first year of life. Oronasal blood in infancy has been proposed as a marker of child abuse in this age group, but despite this widely held belief, there is a lack of published evidence in this area. The case is reported of an infant who presented at one month of age with serious inflicted injuries, who had been seen in the emergency department only 13 days previously with a “spontaneous” self-limiting nose bleed.

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A 19-day-old baby presented to our emergency department (ED) with a history of spontaneous bleeding from the nose while lying in his cot following a feed. Bleeding was reported to have stopped within a few minutes. The baby was said to have been crying more than usual that day and sneezing. The baby was seen by a junior doctor within the ED. A limited history and examination was recorded, documenting that the infant appeared well, with dried blood in both nostrils and no blood in the mouth. The child protection register was checked and the baby was not found to be registered. The baby was discharged home following verbal advice, but not face-to-face review, by an ED senior doctor.

At one month of age, 13 days later, the baby returned to ED by ambulance. The parents gave a history of slipping from their hands the previous day, while being bathed, falling 30–40 cm. The parents reported that they were not concerned at the time of the injury, but presented the baby the next day when they became worried by the increasing size of a swelling on the right side of his head. Examination revealed a boggy swelling over the temporoparietal area and bruising to the forehead and face. Subsequent investigations revealed a linear fracture of the right parietal bone, with subdural and intraparenchymal haemorrhages, a right mid-shaft femoral fracture, metaphyseal fractures of both femurs and tibia, and healing fractures of the right clavicle and left seventh rib.

Discussion

Nasal bleeding has been a point of controversy in the field of child protection in the UK in recent years. In his Professional Conduct Committee hearing with the General Medical Council (GMC) in 2004,1 the view from Professor David Southall, a consultant paediatrician involved in the Sally Clark case, that a bilateral nosebleed in an infant in the absence of identifiable disease or accident was virtually always the consequence of life-threatening child abuse, was central to the proceedings.

Infants presenting with spontaneous bleeding from the nose are rare. A recent case series of children under 2 years of age who presented with facial blood to hospitals in Scotland identified 16 cases of nosebleed out of 77 173 ED attendances in this age group over a 10-year period.2 Of the 16 cases, eight were associated with visible trauma, and the explanation accepted as accidental at the time, and four with thrombocytopenia (three secondary to malignancy). Review of previous and subsequent history, however, suggested that seven of the cases of “accidental” injury might have been caused by abuse and would, by current standards, have raised child protection concerns in 44%.

Another recent population-based study in the UK of 36 children under one year attending hospital with a discharge diagnosis or epistaxis gave an incidence of less than one in 5000 and a differential diagnosis of coryzal illness, trauma, coagulopathy, craniofacial malformation and physical abuse, which represented one case, although there were social concerns in another four.3

No case reports of isolated nasal bleeding preceding re-presentation with severe inflicted injuries are present in the literature. Stricker and colleagues4 report two cases of child abuse in which the initial presentation was bleeding in the mouth, and the child subsequently had severe inflicted injuries.

Conclusion

Two recent studies2 3 have demonstrated that epistaxis in infants is rare, but when it occurs it is often associated with injury or serious illness, in contrast to “spontaneous” nosebleeds that are common in school-aged children. Oronasal bleeding in infancy has been proposed as a marker of child abuse, but there has been limited published evidence to support this view. This case adds to that literature, demonstrating the tragic consequences that can occur when early signs are missed. We recommend that isolated bleeding from the nose or mouth be taken seriously in the infant age group. We recommend that any infant presenting with isolated bleeding from the nose and/or mouth, in the absence of a clear cause, warrants admission to hospital for further investigation. If no blood abnormality or local source for the bleeding is found, a full social investigation should occur and such infants should be kept under close surveillance.

REFERENCES

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Footnotes

  • Funding None

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and Peer review Not commissioned; not externally peer reviewed.

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