Hemoptysis is defined as coughing up blood or having blood tinged sputum.  Compared to adults, it is an unusual symptom in pediatrics.  It is important to establish whether the blood is from the respiratory tract as opposed to the gastrointestinal tract.  GI blood is darker and brownish in color, it may contain food, and is often associated with nausea.  Blood from the respiratory tract is brighter, more frothy, and there is an absence of nausea.  The evaluation of the patient with hemoptysis is dependent on the extent and the etiology of the bleeding.  The majority of cases resolve spontaneously. 

1. History
   a. Was the onset acute? 
   b. Has there been any trauma? 
   c.  Does the child have a chronic pulmonary or cardiac disease? 
   d. Does the patient take any medications?  Aspirin, cocaine? 
   e. Is there a history of TB or exposure? 
   f. Has the child had a recent nose bleed? 
   g. Is there a family history of coagulopathies? 
   h. Has there been hematuria? 
   i. Has there been any chest pain? 

2. Physical Examination
   a. Complete examination of the oral and nasopharynx. 
   b. Lung and chest examination 
   c. Check for bruising and signs of trauma. 
   d. Skin examination for hemangiomas, telangiectasias, clubbing( chronic lung disease, AV malformations, cardiac disease) 

3. Common Etiologies
   a. Trauma.  Chest contusions, oral trauma, injuries to the face and neck 
   b. Pneumonia and tracheobronchitis account for about 40% of cases of hemoptysis
   c. Bronchiectasis and Cystic Fibrosis- may have massive hemorrhage 
   d. Foreign body in the airway leading to mucosal damage. This is common in young children 
   e. Epistaxis 
   f. Following airway or lung procedures, the child may cough up blood. 
   g. Idiopathic- accounts for approxiamtely 15% of cases and is established after no caus is found after appropriate evaluation is performed.

4. Other Etiologies
   a. TB 
   b. AV malformations 
   c. Inflammatory diseases- Lupus, HSP, Goodpasture's syndrome, Wegener's granulomatosis 
   d. Pulmonary hemosiderosis 
   e. Lung tumors, hemangiomas 

5. Evaluation
   a. CBC and platelets 
   b. UA 
   c. ? PT and PTT 
   d. PPD 
   e  Chest radiograph 
   f. Bronchoscopy 

6. Management
   a. Management of the patient is dependent upon the etiology of the bleeding.  Most cases resolve without any therapy, but severe cases may require oxygen, IV fluids, and transfusions.  Bronchoscopy may be both diagnostic as well as therapeutic.  It can help identify and remove a foreign body, identify an area of infection or endobronchial lesion,  clear blood from the airway, and be used for performing tamponade and embolization procedures. 

References
1. Coss-Bu JA et.al.  Hemoptysis: A 10 Year Retrospective Study. Pediatrics. 1997; 100(3):e7.
2. Pianosi, Paul and Al-sadoon, Hammad. Hemoptysis in Children. Pediatrics in Review. October 1996.