Paeds · respiratory-sleep-and-airway
Pulmonary haemorrhage and haemoptysis
Also known as Haemoptysis in children · Diffuse alveolar haemorrhage · Idiopathic pulmonary haemosiderosis · Heiner syndrome · Pulmonary capillaritis
Fellowship guide to pulmonary haemorrhage and haemoptysis in children — why young children rarely cough up their blood, how to separate focal bleeding from diffuse alveolar haemorrhage, the haemosiderin-laden macrophage that confirms it, the immune-versus-bland split that drives treatment, and the resuscitation-and-corticosteroid management of idiopathic pulmonary haemosiderosis, Heiner syndrome, and capillaritis.
On this page
Related topics
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A young child does not need to cough up blood to be bleeding into the lungs — unexplained iron-deficiency anaemia with diffuse chest infiltrates and breathlessness is diffuse alveolar haemorrhage until proven otherwise
- Massive haemoptysis in a child is a rare but immediately life-threatening emergency in which the danger is asphyxiation from blood flooding the airway, not exsanguination, so airway protection comes before everything
- Haemoptysis with haematuria, an active urinary sediment, or rising creatinine is a pulmonary-renal syndrome such as anti-GBM disease or ANCA vasculitis and demands urgent serology and nephrology input
- Recurrent pulmonary haemorrhage in an infant, especially with faltering growth or gastrointestinal bleeding, should prompt a search for Heiner syndrome and a trial of cow milk elimination
- Blood coughed from the lungs is bright red and frothy and must be distinguished from swallowed blood vomited back (haematemesis) or blood from the nose, because chasing the wrong source wastes the crucial early window
- Idiopathic pulmonary haemosiderosis is a diagnosis of exclusion — labelling a child idiopathic before excluding capillaritis, vasculitis, cow milk hypersensitivity, and cardiac disease misses treatable causes
Life stages
Care settings
Clinical exam formats
Board mappings
- Respiratory Medicine
- General and Community Paediatrics
- Pulmonary haemorrhage and haemoptysis
- Paediatric respiratory and sleep medicine competencies
- Diagnosis and management of diffuse alveolar haemorrhage and haemoptysis
- Current PREP curriculum — pulmonary haemorrhage syndromes and pulmonary-renal disease
- Clinical Applications
- Systematic evaluation of the child with haemoptysis or alveolar haemorrhage
- Long and Short Cases
- Respiratory long case: recurrent pulmonary haemorrhage and idiopathic pulmonary haemosiderosis
- 1. Good clinical care: Managing acute and life-threatening illness
- Respiratory: Recognises and manages the child with haemoptysis and pulmonary haemorrhage
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Respiratory medicine
- Clinical
- Respiratory assessment and acute management
- History taking and management planning
- General Pediatrics Content Outline — Respiratory system
- Pulmonary haemorrhage and diffuse alveolar haemorrhage
- General Pediatrics EPA: Evaluate the child with haemoptysis
- Patient Care: Recognition and management of pulmonary haemorrhage
- Medical Knowledge: Diffuse alveolar haemorrhage syndromes in children
- Systems-Based Practice: rational use of bronchoscopy, imaging, and multidisciplinary care
- Medical Expert
- Paediatric respiratory assessment and pulmonary haemorrhage management
- Pediatrics Core EPA — Assessing and managing haemoptysis and alveolar haemorrhage
Overview & Definition
A pale, tired six-year-old is referred with three months of breathlessness and a microcytic anaemia that will not respond to iron, and a chest film shows patchy shadowing that keeps changing. No one has seen her cough up blood, so lung bleeding is never considered. The task of the paediatrician is to recognise that a child can bleed steadily into the lungs and never produce a drop of visible haemoptysis, because young children swallow their airway secretions rather than spit them out. [3] [4]
Pulmonary haemorrhage means bleeding into the airways or the alveolar spaces of the lung. Haemoptysis is the coughing up of blood from below the vocal cords, and it is the dramatic, unmistakable end of the spectrum. The crucial teaching point is that the two are not the same: substantial alveolar bleeding in a small child commonly shows itself as anaemia, breathlessness, and shifting infiltrates rather than as frank haemoptysis. [1] [3]
The reason young children so often hide their lung bleeding is mechanical and developmental. They lack an effective adult cough and tend to swallow blood-stained secretions, so the blood reappears, if at all, as a coffee-ground vomit or simply as a falling haemoglobin. Recognising this is what stops a clinician from excluding pulmonary haemorrhage merely because the child has never coughed up blood. [4] [3]
Framed this way, the topic stops being about one alarming symptom and becomes a structured search. Ask first whether the child is bleeding from a single focal lesion or diffusely across the alveoli, then whether diffuse bleeding is immune or bland, because those two answers decide both the urgency and the treatment. Holding that map in mind turns a frightening presentation into an orderly plan. [3] [2]
References12ShowHide
- [1]Gaude GS Hemoptysis in children. Indian Pediatr, 2010.PMID 20371892
- [2]Gipsman AI, Grant LMC, Piccione JC, et al Management of severe acute pulmonary haemorrhage in children. Lancet Child Adolesc Health, 2025.PMID 40246361
- [3]Susarla SC, Fan LL Diffuse alveolar hemorrhage syndromes in children. Curr Opin Pediatr, 2007.PMID 17505192
- [4]Saha BK Idiopathic pulmonary hemosiderosis: A state of the art review. Respir Med, 2021.PMID 33246295
- [5]Saha BK, Aiman A, Chong WH, et al Updates in idiopathic pulmonary hemosiderosis in 2022: A state of the art review. Pediatr Pulmonol, 2023.PMID 36324124
- [6]Arasi S, Mastrorilli C, Pecoraro L, et al Heiner Syndrome and Milk Hypersensitivity: An Updated Overview on the Current Evidence. Nutrients, 2021.PMID 34070007
- [7]Moissidis I, Chaidaroon D, Vichyanond P, et al Milk-induced pulmonary disease in infants (Heiner syndrome). Pediatr Allergy Immunol, 2005.PMID 16176405
- [8]Fullmer JJ, Langston C, Dishop MK, et al Pulmonary capillaritis in children: a review of eight cases with comparison to other alveolar hemorrhage syndromes. J Pediatr, 2005.PMID 15756223
- [9]Roebuck DJ, Barnacle AM Haemoptysis and bronchial artery embolization in children. Paediatr Respir Rev, 2008.PMID 18513669
- [10]Batra PS, Holinger LD Etiology and management of pediatric hemoptysis. Arch Otolaryngol Head Neck Surg, 2001.PMID 11296044
- [11]Yang CT, Chiang BL, Wang LC Aggressive corticosteroid treatment in childhood idiopathic pulmonary hemosiderosis with better outcome. J Formos Med Assoc, 2021.PMID 32505591
- [12]Bannister M Paediatric haemoptysis and the otorhinolaryngologist: Systematic review. Int J Pediatr Otorhinolaryngol, 2017.PMID 28012543