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Recognizing Bleeds

Injuries manifest themselves in different ways, and some individuals (with or without hemophilia) are more likely to sustain bleeding injuries more than others. Bleeding episodes can be classified by the severity of the bleed, as well as where the bleed occurs. Sometimes, as with cuts, the blood is visible. Many times, the bleeding is internal. Usually, internal bleeds cause the most concern, especially head bleeds.

With young children, it can be difficult to know when your child is having a bleed. He or she cannot tell you if it hurts, where it hurts, or how badly it hurts. The more parents can learn about their child’s bleeding disorder, the better prepared a family will be able to cope with the everyday experiences they face. The types of bleeds your child experiences will change as he or she grows and becomes more active. For babies and toddlers, the most common bleeding sites are the head and the mouth.

Regardless of life stage, bleeds can happen in any area of the body including joints, muscles, the abdomen or the head. Sometimes you may notice an incident that may cause a bleed, such as falling and a head bump. Factor should be infused as soon as possible after a head bump/injury and the incident should be evaluated by a healthcare professional as soon as possible after it occurs. In these cases, for younger children that may not be able to express their feelings verbally, look for signs that a bleed is occurring:

  • Pain when using the affected body part
  • Noticeable bruising
  • Swelling might be present
  • Unexplained irritability
  • When old enough to speak, he or she may be able to start describing various ways bleeds feel

Types of Bleeds

Small cuts and scrapes can happen frequently. Most will stop bleeding on their own. Use basic first aid principles to help stop the bleeding, including holding direct pressure on the cut and using ice packs.
Nosebleeds are quite common. Ask your hematologist how long you should wait before notifying the office. In the case of a nosebleed, sit with the head tilted slightly forward. Pinch the bridge of the nose using firm, continuous pressure for 20 minutes. Apply an ice pack to the back of the neck. Large amounts of blood or prolonged bleeding should be reported to the hematologist.
Joint bleeds usually start in the lining of the joint, called the synovium. If not treated, bleeding can continue until the joint space is filled with blood. This can happen with or without trauma to the joint. A bleeding event with no obvious cause is called a spontaneous bleed.
Muscle bleeds can happen in a single muscle or a muscle group. They can happen spontaneously (with no obvious injury) or after receiving a blow or other trauma to the area. Prompt treatment is recommended, and you should consult your hematologist.

Head bleeds can happen on the inside or the outside of the skull and should always be considered serious bleeds. Head bleeds can occur spontaneously or as the result of an injury. Symptoms can progress slowly and may not be noticed for days after an injury. Prompt treatment is required as soon as possible after the injury occurs. A head bleed should be considered an emergency and your hematologist should be notified.

Early signs and symptoms of a head bleed:
  • Irritability
  • Nausea and vomiting
  • Sensitivity to bright light
  • Acting confused
  • Being inconsolable
Later signs and symptoms of a head bleed:
  • Inability to balance
  • Dilated or unequal pupils
  • Seizures
  • Confusion
  • Persistent headache
Neck bleeds are also very serious. Swelling can place pressure on the airway, making it difficult to breathe. Prompt factor infusion is required, and you should notify your hematologist immediately. A neck bleed should be considered an emergency situation.
Mouth bleeds can be frightening because the blood and saliva mixed together can make these bleeds look much worse than they might be. Most mouth bleeds are caused by falls or by sharp objects a baby may have placed in the mouth. We don’t usually consider things like potato chips or corn chips as sharp, but they can cause mouth bleeds. For those caring for an individual with hemophilia, it is important to inspect the mouth and find the source of the bleeding. Mouth bleeds will usually stop within a couple of hours. Direct pressure to the area or a cold pacifier for babies can help stop the bleeding. In some cases, mouth bleeds are not just uncomfortable; they can be dangerous. Ask your hematologist for more information on dealing with mouth bleeds.
For babies, teething can cause some discomfort and gums may appear swollen or discolored. Do not apply over-the-counter medications to the baby’s gums without first discussing this with your pediatrician and hematologist. If bleeding occurs, speak with your hematologist. A damp, soft baby washcloth kept in a clean plastic bag in the refrigerator or freezer can be helpful. Always remove the clean cold baby washcloth from the plastic bag before gently applying it to the gums. Do not rub the gums if there is bleeding or a clot. To avoid the possibility of choking, never leave the baby alone with the washcloth.
Bruises are usually considered mild and not a cause for alarm. They first appear dark blue or purple in color and may have a bump in the middle or feel like there are knots. Something as simple as lifting a child can often cause bruising. They will turn green and yellow over time as the body clears the blood that caused the bruise. They can take about two weeks to fade and are usually not painful. They do not need to be treated with factor unless your hematologist advises you to do so. You should call your physician immediately if bruises appear on or near the head, throat, joints, or groin.
Other bleeds such as eye, stomach, intestine, kidney, bladder and hip or thigh muscle bleeds should also be considered serious. Prompt factor infusion is required. You should consult your hematologist to arrange for evaluation.
Blood tests or immunizations are a potential cause of a bleed in infants in the first few months of life. If you know your child has hemophilia, it is best to consult with your hematologist before any treatment or testing is done. Even the simple drawing of blood from a vein for a routine test can cause a muscle bleed if a tourniquet placed on the arm is too tight. Some immunizations are usually given into the muscle (intramuscular or IM), and some are given under the skin (subcutaneous or Sub-Q). Most immunizations can be given Sub-Q rather than IM to avoid bleeding into the muscle4 . Consult your hematologist beforehand to determine the best method for you or your child.
 

1. National Heart, Lung and Blood Institute. What is hemophilia? https://www.nhlbi.nih.gov/health/health-topics/topics/hemophilia. Accessed Aug. 4, 2017.

2. White E, Christie B. "Common bleeding episodes." Nurses' Guide to Bleeding Disorders. National Hemophilia Foundation. 2013.

3. Banks D. "Introduction to Bleeding Disorders." Nurses' Guide to Bleeding Disorders. National Hemophilia Foundation. 2012.

4. Riske B. "Wellness in persons with bleeding disorders." Nurses' Guide to Bleeding Disorders. National Hemophilia Foundation. 2013.