Abstract
Background:
Epistaxis is a common symptom in children. The effect of air pollution on epistaxis is not yet clear.
Objectives:
To explore the characteristics of pediatric epistaxis in Beijing and its correlation with air pollutants.
Material and Methods:
Data were collected from 2014 to 2017 in Otolaryngology Department of Capital Institute of Pediatrics. Children diagnosed with epistaxis with relevant information with the same period of municipal air pollutants’ concentration were compared.
Results:
The annual visits of epistaxis showed a bimodal trend. The incidence of epistaxis in infants was low, increased with age, reached the peak between the ages of 4 to 5, and then gradually decreased with age. In different age groups, male patients were more than females. From 2014 to 2017 in Beijing, particulate matter less than 2.5 μm in diameter (PM2.5), particulate matter less than 10 μm in diameter (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide (CO) showed a downtrend, lower in summer than in the other 3 seasons. Ozone (O3) was significantly higher in 2016 and 2017, showed an increase trend in summer. The incidence of epistaxis was negatively correlated with PM2.5, PM10, SO2, NO2 and CO, which was positively correlated with O3 (P < .05).
Conclusions:
Pediatric epistaxis in Beijing changes with age and has obvious seasonal variation. There are some correlations between air pollutants and the incidence of epistaxis in children.
Keywords
Background
Epistaxis is a common symptom in children. It can be caused by nasal disease or by systemic disease. With the development of economy, air pollution is getting more and more attention. As the first gateway of respiratory defense, nose could be damaged by air pollutants first. The aim of the study was to investigate the characteristic of epistaxis in pediatric population in Beijing from 2014 to 2017, and the relationship between epistaxis and the outdoor ambient air pollutants of the same period, to better understand nasal hemorrhage, a very common symptom in children, and to assess the acute effect of air pollution on this symptom, in order to reduce and prevent epistaxis occurrence and reasonable arrangement of medical resources.
Material and Methods
Subjects
From the information center of Capital Institute of Pediatrics affiliated Children’s Hospital, we obtained patients’ medical information from January 1, 2014, to December 31, 2017, visited the otolaryngology department, with the diagnosis of epistaxis (it may not be the first diagnosis), including age, sex, treatment, and so on. Repeated visit within 2 weeks for the same child was calculated as one case.
Inclusive criteria: according to the International Classification for Diseases, 10th revision (R04.000 and R04.001).
Exclusion criteria: trauma, tumor, cardiovascular system disease, blood system disease, or other systemic diseases.
Exposure Assessment
Air pollution data in the same period was obtained from online platform of Chinese air quality monitoring analysis (https://www.aqistudy.cn/historydata/index.php), contained the air quality index, air quality grade, the major pollutant, as well as the concentration of pollutants in the 6: particulate matter less than 2.5 μm in diameter (PM2.5), particulate matter less than 10 μm in diameter (PM10), sulfur dioxide (SO2), carbon dioxide (CO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3). The concentrations of PM2.5, PM10, SO2, NO2 and CO were all 24-hour average, and the concentration of O3 was moving average of 8 hours. The concentration unit of CO is mg/m3, the concentration unit of other pollutants is μg/m3.
Statistical Analysis
Comparisons of air pollutants were performed by T tests and 1-way analysis of variance (ANOVA), comparison of rate was performed by χ2 test. Correlation analysis was performed by Pearson rank correlation analysis. A 2-tailed P < .05 was considered statistically significant. Statistical analyses were performed using SPSS for Windows, version 20.0.
Results
Medical Visits of Epistaxis in Children
From 2014 to 2017, there were 27 508 children who were diagnosed of epistaxis by otolaryngology department, Capital Institute of Pediatrics affiliated Children’s Hospital, among which 18 268 (66.41%) cases were males and 9240 (33.59%) cases were females. Annual visits of epistaxis were 4855, 6554, 6558, and 9541 respectively. Analyzed by 1-way ANOVA, the number of patients diagnosed as epistaxis was the lowest in 2014, no obvious difference in 2015-2016, significantly higher in 2017 (P < .05). From 2014 to 2017, the annual visits of epistaxis reached its 2 peaks in May to June, and August to September, as shown in Figure 1.
Medical visits of epistaxis in 2014 to 2017.
The age distribution of children with epistaxis in 2014 to 2017 showed that the incidence of epistaxis in infants under 1 year of age was very low, increased year by year, reached a peak between the ages of 4 and 5, and then gradually decreased with age. The average age was 5.5 years of age. In different age groups, male patients were more than female patients (P < .05), as shown in Figure 2.
Age and gender distribution of medical visits of children with epistaxis in 20l4 to 2017.
Air Pollution in Beijing From 2014 to 2017
Among the outdoor ambient air pollutants in Beijing from 2014 to 2017, the major pollutant is CO, with an annual average of 1.17 mg/m3, followed by PM10, with an annual average of 99.98 μg/m3, O3 74.79 μg/m3, PM2.5 73.22 μg/m3, NO2 48.63 μg/m3, SO2 12.41 μg/m3, as shown in Table 1.
Comparison of the Monthly Average of Air Pollutants in 2014 to 2017.
Abbreviations: CO, carbon monoxide; NO2, nitrogen dioxide; O3, ozone; PM2.5 particulate matter less than 2.5 μm in diameter; PM10, particulate matter less than 10 μm in diameter; SO2, sulfur dioxide.
Generally speaking, PM2.5, PM10, SO2, NO2, and CO showed an overall decline from 2014 to 2017, especially in 2017, and the pollutants’ concentrations were lower in summer than in the other 3 seasons. In contrast, O3 was significantly higher in 2016 and 2017 than in the previous 2 years, and showed an obvious trend of increase in summer, as shown in Figure 3.
Air pollutants in Beijing in 2014 to 2017.
Relationship Between Visits of Epistaxis and Outdoor Ambient Air Pollutants
We analyzed the number of cases of epistaxis daily and the outdoor ambient air pollutants from the day of consultation to the previous 14 days, as shown in Table 2. The results showed that the incidence of epistaxis in children was associated with the concentration of all the pollutants detected from the day of medical visit to the previous 14 days, P < .01, and the absolute maximum values of r except the column of O3 were all less than 0.5. That is to say, the incidence of epistaxis in children was correlated with the pollutants’ concentration, but there was only statistically significant correlated with O3. The incidence of epistaxis was negatively correlated with PM2.5, PM10, NO2, SO2, and CO concentration, and was positively correlated with O3 concentration. In PM2.5, NO2, SO2, CO, and O3, the absolute maximum value of r was in the day of consultation to the second day before the visit, and in PM10, the absolute maximum value of r was in the fourth day before the visit.
Correlation Analysis Between Visits of Epistaxis in Children and Air Pollutants.a
Abbreviations: CO, carbon monoxide; NO2, nitrogen dioxide; O3, ozone; PM2.5 particulate matter less than 2.5 μm in diameter; PM10, particulate matter less than 10 μm in diameter; SO2, sulfur dioxide.
a All values listed are r values. The values marked in bold are absolute maximum.
Values with superscript b are P < .01.
In other words, there are some correlations between air pollutants and the incidence of epistaxis in children. The onset of epistaxis due to air pollution has not obvious delayed effect.
Discussion
Epistaxis in the pediatric population is a common problem faced by both pediatricians and otolaryngologists. Most childhood epistaxis is spontaneous, anterior and self-limiting, unlikely to require nasal packing or hospital admission. Gently pressing the nasal ala for 5 to 10 minutes is usually all that is required. Up to 60% of children will have had at least one nosebleed by age of 10. 1
Most cases occur due to vascular fragility aggravated by local inflammation of Little’s area on the anterior nasal septum. 2 Other causes include allergic rhinitis, infections, trauma, and bleeding disorders. Some studies suggested that there were other causes of recurrent nosebleed in children in addition to idiopathic Little’s bleeding. Iranian scholar Rahmanzadeh-Shahi S. reported that interleukin-6 and tumor growth factor-β were risk factors for idiopathic epistaxis. 3 Korean scholar Kim J. pointed out that F11 gene mutation leaded to congenital factor XI deficiency (hemophilia C), which could cause recurrent nose bleeding. 4 Since recurrent epistaxis can be troublesome and alarming for parents and children, it is important to understand the pathogenesis and regularity of epistaxis.
In our study, we found that the incidence of nosebleed in infants under 1 year of age was very low, gradually increased with age, reached the peak at the age of 4 to 5, and then gradually decreased with age. The average age was 5.5 years of age. The average age in our results was closely to the 4.99 years of Yu et al, 5 but slightly lower than the 7.3 years of Damrose et al, 6 7.8 years of Brown et al. 7 This condition has a universal predilection for males in our study and a similar predominance of male patients reported in other studies. 1,6 -9
In our study, it was found that the incidence of nasal hemorrhage in children in Beijing had obvious seasonal variation, the annual medical visits showed a double-peak trend in May-June and August-September, and this trend was particularly significant in 2017. This result is inconsistent with many previous studies. Some studies proved that the incidence of nasal hemorrhage was the highest in winter due to cold weather, repeated respiratory infection and dry air created by indoor heating, 10,11 while other studies presented that there was equal frequency of nasal hemorrhage throughout the seasons. 1,6,7 In this regard, we believe that it is related to regional climate and environmental factors.
In May-June and August-September of 2014 to 2017, the number of visits of nasal hemorrhage in children in Beijing was significantly higher than that in other months. Meanwhile, the 4 months are exactly the months with the highest pollen concentration in Beijing, 12,13 the onset of allergic rhinitis increases correspondingly, 14 suggesting that allergic rhinitis may be correlated with nasal bleeding to some extent. This is consistent with a recent American study 15 about epistaxis in pediatric population. Clinically, we also found that children with allergic rhinitis often blow their nose due to lots of clear watery secretion or rub and dig their noses fiercely due to severe nasal itching. These behaviors tend to cause damage to the mucous membrane of Little’s area, and lead to nasal bleeding. After antiallergic treatment, the nosebleed symptoms were significantly decreased. It is suggested that allergic rhinitis should be considered a risk factor for pediatric nasal hemorrhage, especially in allergic seasons. Early antiallergic treatment may reduce the occurrence of nasal bleeding.
In July, however, the number of visits for nosebleed in children was significantly lower than in the 4 months adjacent to. The possible reasons were as follows: the rainy season in Beijing occurs in July every year, with high humidity and relative low pollen concentration. 12,13 Therefore, the number of visits for nosebleed in this month is slightly lower, form a bimodal distribution for the calendar year.
In this study, we found that annual visits of epistaxis in children in recent 4 years increased year by year, especially in 2017. At the same time, PM2.5, PM10, SO2, NO2, and CO showed an overall decline from 2014 to 2017, slightly lower in summer, while O3 was significantly higher in 2016 and 2017 than in the previous 2 years, and significant increase in summer. The incidence of epistaxis in children was negatively correlated with PM2.5, PM10, NO2, SO2, and CO concentration, and was positively correlated with O3 concentration. With the strong oxidation and corrosive characteristics, the increased concentration of O3 near the ground can stimulate nasal mucosa and cause acute injury. 16 Szyszkowicz et al pointed out that exposure to O3 and PM10 would increase the risk of emergency department visits for epistaxis. 9 It would increase by 1.05 times or each 14 ppb increase in O3, and 1.02 times for each 15 μg/m3 increase in PM10. Therefore, combined with the above, it is considered that the increase of O3 concentration in summer in recent years is an important risk factor for the visits of children’s nosebleed.
Limitations in this study that should be noted as following: As a retrospective study, there are no detailed clinical records to show us how many epistaxis children with definite cause, such as allergic rhinitis, acute respiratory infection, and coagulation disorders. As we all know, air pollution has harmful impact on rhinitis and respiratory tract infection. Therefore, this problem largely affected our judgment of risk factors influencing epistaxis. In the future studies, this limitation should to be addressed.
Conclusions and Significance
Pediatric epistaxis in Beijing changes with age, and has obvious seasonal variation. There are some correlations between air pollutants and the incidence of epistaxis in children.
Footnotes
Acknowledgment
The authors thank Prof. Ling-Hui Meng in the Department of Epidemiology, Capital Institute of Pediatrics, for assisting in the statistical analysis of our data.
Author Contribution
Ying-Xia Lu and Jie-Qiong Liang are contributed equally to this work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Received special fund of the Pediatric Medical Coordinated Development Center of Beijing Municipal Administration of Hospitals, No. XTZD20180102.
