Newborn and Infant Health Assessment | Pediatric Development | PDF

WEEK 1 Developmental Care Throughout Childhood Developmental Patterns of Newborns and Infants Infant: Newborn through 12 months of age (NICU age- newborn, fresh out, OB) Cephalocaudal pattern: Attainment of skills from head to toe – holding head up, head control (head lag should be up by...

WEEK 1 Developmental Care Throughout Childhood Developmental Patterns of Newborns and Infants Infant: Newborn through 12 months of age (NICU age- newborn, fresh out, OB) Cephalocaudal pattern: Attainment of skills from head to toe – holding head up, head control (head lag should be up by 4-6 months) Proximodistal pattern: Attainment of skills from trunk out to extremities Gains gross motor before fine motor skills -moving arms before knowing finger control -middle teeth first and then around -gross motor before fine motor Health Assessment of Newborns and Infants Frequent appointments- every other week for 2 months -looking for failure to thrive -obvious issues Involve the family Least invasive --> most invasive Explain each step! Appointments conducted at: newborn, 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months. Involve parents and caregivers. Assess infants on the caregivers lap. Auscultate first, while the child is quiet and/or sleeping. Perform the most invasive procedures last. Assess for hip dysplasia until 3 months of age. Explain everything to caregivers during the assessment Physical Variants in Newborns and Infants #1 Fontanelles: Posterior: smaller, closes between 2 and 3 months Anterior: larger, closes between 12 and 18 months- hydration status -pinna Strabismus is common until 6 months of age. To inspect the pinna of the ear, pull it back and down.- until 3 years old Diaphragmatic breathing.- belly breathing Irregular respirations with occasional pauses. Acrocyanosis may be present in newborns. Heart rate is often irregular. Asymptomatic murmurs are often present and normal.  Fontanelles: Posterior: smaller, closes between 2 and 3 months Anterior: larger, closes between 12 and 18 months Strabismus is common until 6 months of age. To inspect the pinna of the ear, pull it back and down. Normally appears barrel chested (1:1 anteroposterior transverse diameter). Diaphragmatic breathing. Irregular respirations with occasional pauses. Acrocyanosis may be present in newborns. Heart rate is often irregular. Presence of S3 may be audible. Asymptomatic murmurs are often present and normal Physical Variants in Newborns and Infants #2 Born with high levels of fetal hemoglobin (HgbF) and physiological anemia. Skin variants include: - salmon patches -hyperpigmented areas (Mongolian spots, rule out child abuse), etc. Passive immunity until 6 months of age ( from placenta) Reflexes Primitive reflexes: Includes: sucking, rooting, Babinski, Moro (startle)- hearing stepping, palmar grasp, plantar grasp, tonic neck (fencer). Are reflexes the child is born with. Typically disappear over the first year of life. Babinski reflex normally lasts until 24 months. Protective reflexes: Develop after the disappearance of primitive reflexes. Not present until after 12 months of age. Assessed in toddlers and older children. Pain Assessment of Newborns and Infants Assess pain through observations of behaviors and consolability. Incorporate caregiver in the pain assessment. FLACC scale:!!! -, can be used in disability, high levels of pain Face, legs, activity, cry, consolability Each domain scored 0 to 2 Scores 0 to 10; higher score indicates more pain Neonatal Infant Pain Scale (NIPS): Facial expression, cry, breathing pattern, arms, legs, and state of arousal are scored. Scale of 0 to 1 for all except cry, which is scored 0 to 2. Maximum score of 7; higher score indicates more pain. Physical Growth of Newborns and Infants - Very rapid growth Length: Grow 1.5 to 2.5 cm per month for first 6 months. Grow 1 cm per month for months 6 to 12. -do not memorize numbners Weight: Lose 10% body weight the first week of life, but regained by end of the 2nd week. Weight doubles by 4 to 6 months and triples by 12 months. -7 lbs birth- 4 months 15 lbs- DOUBLES Head circumference: Increases rapidly the first 6 months, then slows until 12 months. Document all physical growth data points on growth charts to assess trends and averages. -LARGE- risk for hydrocephalus, tumor Communication and Speech of Newborns and Infants Communicate through crying. Different pitches of cries based on needs. Begin cooing at 2 months of age. Babbles by 6 months of age. Copies sounds at 9 months of age. Says a few words by 12 months of age. By 12 months of age, can use simple gestures and follow simple directions. Sensory Development of Newborns and Infants -no color vision until 7 m.o- poor vision -prefer high pitch -prefer soft touch, sweet taste Social Determinants of Health Risks: Tobacco exposure Food and housing insecurity Parental substance abuse Protective factors: Support networks Positive family relationships Adequate childcare Infant behavior: Parent–infant relationships and daily routines Safety: Home environment and parental knowledge Immunizations Protect against communicable diseases. Provide vaccine information sheets and vaccine administration record. Types of vaccines: Live attenuated Inactivated Toxoid Conjugate Barriers: Lack of transportation Financial concerns Safety concerns Nutrition for Newborns and Infants: -formula v breast feeding -Hunger cues- - rooting and sucking -crying (late sign) and opening mouth -moving hand to mouth -Solid Foods- -start at 6 months -disappearance of tongue extrusion reflex and ability to sit in chair -start w iron fortified cereal and add pureed foods slowly bc of allergies Colic -mad baby, starts at 6 weeks and resolves at 3-6 months Self-limiting condition of increased fussiness and inconsolable crying. Peaks at 6 weeks of age and resolves by 3 to 6 months of age. Is often worse in the evening time. No treatment, but caregivers require psychological and emotional support. Encourage caregivers to lay the infant in the crib when frustrated. -no pharm tx Brief Resolved Unexplained Events (BRUE) -rare! -cyanotic for less than 60 sec and stops breathing -need evaluation asap -no actual seizure BRUE Includes the following symptoms: Cyanosis or pallor Irregular, slowed, or absent breathing Hypertonia or hypotonia Altered level of responsiveness Episodes last less than 60 seconds. Needs to be evaluated by healthcare provider. High risk for additional episodes when: Less than 2 months of age History of prematurity History of more than one BRUE Diaper Dermatitis Any skin breakdown in the diaper region. Painful for infants. Treat by leaving diapers off and allowing skin to dry. Commercial barriers can be used. Notify healthcare provider if odor, fever, or purulent drainage is present. Fever -TEMP OVER 38 C, 100.4 F -late sx of infection HR- 110-160 BP-70/40ish Care of the Toddler Health Assessment of Toddlers -1-3 y.o, playing Office visits become less frequent than infant Flexibility and play Allow toddler to touch safe medical equipment- stethoscope Do not ask permission- give choices Use positive reinforcement and praise Least to most invasive- not head to toe - First- RR, observe, WOB, - Last- looking in ears Visits conducted at: 15 months, 18 months, 2 years, 2.5 years, and 3 years. Be flexible during the assessment. Gather information through play. Provide distractions (singing, toys, pictures, etc.). Allow toddler to touch safe medical equipment. Do not ask permission. Use positive reinforcement and praise. Perform invasive procedures last. To inspect the pinna of the ear, pull it back and down. Explain procedures in simple, concrete, and positive terms. Physical Variants in Toddlers #1 Toddler stage: 12 to 36 months of age.- 2-3 y.o Hand preference at 2 to 3 years of age. Diaphragmatic breathing. Blood pressure increases and heart rate decreases as toddler grows and develops.- MORE PUMP, MORE EFFICIENT HR Decreased stool frequency (usually once daily). Protruding abdomen. -12-14 VS are like adults Pain Assessment of Toddlers Assess pain through valid and reliable pain scales. Incorporate caregiver input in pain assessment. FLACC scale: Face, legs, activity, cry, consolability Each domain scored 0 to 2 Scores 0 to 10; higher score indicates more pain -like pain scale Physical Growth of Toddlers Height: Measure standing height at 3 years of age. Weight: Perform sitting weight until 3 years of age. Gain 5 pounds (2.3 kg) per year. Head circumference: Increases by 2 cm from 12 to 24 months. Document all physical growth data points on growth charts to assess trends and averages. Gross Motor Development of Toddlers Communication and Speech of Toddlers Receptive language develops quicker than expressive language (Understand directions before getting it) Can understand directions before giving directions Encourage caregivers to read to their children. Read one book per day- development Safety Considerations for Toddlers - HIGH RISK of injury - Burns: - -HOT OBJECTS awat - -lower hot water heater to 120 - Falls: - - no climbing - -supervise stairs - -gates bottom of stairs - Vehicles: - -ride forward facing in 5 point harness from 2-4 years of age Play Considerations for Toddlers Parallel play: Playing alongside one another but not with each other. PLAYING NEXT TO EACH OTHER Toddlers have short attention spans. They do not understand the concept of sharing. Use toys to develop gross motor, fine motor, and social skills such as: Push or pull toys Tunnels Stackable blocks and puzzles with large pieces Larger crayons or chalk Household objects that can be used to make noise Musical instruments and active play outside are popular. Sleep Considerations for Toddlers Required for growth, development, and cognitive functioning. Negative consequences of lack of sleep: Mood disturbances and irritability. Poor behavior and hyperactivity. 11 to 13 hours of sleep in a 24-hour period: 9 hours at night and 2 naps until 18 months. 9 hours at night and 1 longer nap after 18 months. Incorporate consistent bedtime routines. Toilet Training Usually begins around 2 years of age. Signs of readiness include: Remaining dry for 2 hours at a time. Having words for urine and stool. Bringing a clean diaper to a parent to be changed. Voicing discontent with soiled diapers. Positive reinforcement is the most effective way. Provide stickers and “big kid” underwear. Do not punish for accidents. Temper Tantrums Result of receptive language development versus expressive language development. May begin at 12 months of age. Typically occur from 2 to 3 years of age. Frustrating for caregivers. Reward good behavior and ignore unwanted behavior. Biting and hitting should be addressed with time-outs. Disruption in routine and inconsistent expectations increases temper tantrums. Atopic Dermatitis Also known as eczema. Most common chronic skin condition in children. More likely to have allergies and asthma. Symptoms: Severely dry skin Erythematous patches Extreme pruritus Thickening of the skin Treat by identifying and avoiding triggers. Keep skin hydrated. Use topical corticosteroids if environmental changes are not effective. Acute Otitis Media (AOM) Also known as ear infections. Is the inflammation of the middle ear and middle ear effusion. Toddler is at risk for speech delay if frequent or untreated. Risk factors: Exposure to tobacco smoke Exposure to other children Congenital anomalies Protective factors: Breastfeeding Pneumococcal vaccination Treat with antibiotics and comfort measures. Myringotomy- put a slit in ear canal- if recurrent AOM. Care of the Preschooler, School-Aged Child, and Adolescent Preschool Stage From 3 to 6 years of age. Gross motor skills become more coordinated. Fine motor skills develop exponentially. Preschoolers take initiative and try new things. Imagination and creativity are key. Health Assessment of Preschoolers Begin to involve child in health history. Give choices throughout examination. Allow the preschooler to play with safe medical equipment. Perform most invasive parts last. To inspect the pinna of the ear at age 3, pull it up and back. Can incorporate more formal assessments and screenings. Play games to illicit cooperation. Begin to involve child in health history. Allow the choice of sitting on the examination table or in the parent’s lap. Give choices throughout examination. Allow the preschooler to play with safe medical equipment. Perform most invasive parts last. Implement visual acuity testing at age 4. Assess hearing with optoacoustic emissions test. To inspect the pinna of the ear at age 3, pull it up and back. Can incorporate more formal assessments and screenings. Play games to illicit cooperation. Can use radial pulses for heart rate assessments. Physical Variants in Preschoolers Visual acuity reaches 20/20 at 4 to 5 years of age. Thoracic breathing begins at age 5.- chest instead of belly May experience stool holding during toilet training. Full daytime bladder control around 3 years of age. Nighttime bladder control around 4 to 5 years of age. Genu valgum (knock-knees) in early preschool period. Body is more slender and abdominal muscles are stronger. Pain Assessment of Preschoolers -shy, refusal to talk Able to point to location of pain. Not able to describe the quality of pain. Able to use developmentally-appropriate self-report tools. FACES scale: or FLAC Six cartoon faces with different expressions. Scale of 0 to 10, with higher number indicating more pain. Also use observation and caregiver report to assess pain. -Use the parents Physical Growth of Preschoolers Height: Grow 2.5 to 3 in (6.1 to 7.6 cm) per year. Average 4 year old height is 40 in (3.3 ft). Weight: Gain 5 lb (2.3 kg) per year from ages 3 to 6. Average 4 year old weighs 40 lb (18.1 kg). Head circumference: Brain growth slows. Only 1.9 to 2.4 in (5 to 6 cm) increase from 3 to 18 years of age. Document all physical growth data points on growth charts to assess trends and averages. Gross Motor Development of Preschoolers Communication and Speech of Preschoolers #1 Rapid language acquisition. Uses concrete language. Children living in poverty are at increased risk of language delay. Language is learned through exposure to words. Screen for language delays at each well-child visit. Underlying causes of language delay include: Autism Cognitive impairment Emotional delays Low socioeconomic status or neglect Underlying neurological disorders Social and Emotional Development #1 Learn to cope with emotions. Use imaginary play and imaginary friends to explore communication and emotions. Interested in basic sexuality by the age of 5 to 6. Develop their own identity and independence. Cooperation is more common. Learn to share and take turns. Safety Considerations for Preschoolers Like new experiences. Role model safe behaviors. Stranger safety and street safety are most important. Teach home address and phone number. Natural curiosity can create harmful situations such as: Improper handling of firearms Poisoning Choking Play Considerations for Preschoolers Engage in imaginary and creative play. Allow to work through frustration and anxiety. Use arts and crafts for fine motor skills such as: Modeling clay Crayons Learn to share and take turns: Simple board games Outdoor activities: Playgrounds, bicycles, tricycles Unstructured physical activity Toys to avoid: Toys with small parts, small magnets, or lead paint. Excessive electronics. Sleep Considerations for Preschoolers -usually stop napping Hours of sleep are consolidated into one long block. Require 10 to 13 hours per day of sleep. Naps typically end around 4 years of age. Establish bedtime routines and remain consistent. Nightmares: Child wakes up scared and wants comfort from parents. Talk about nightmare and assist the child back to sleep. Night terrors: Child is not awake when they occur and does not remember episodes. May scream, kick, thrash, or push parents away. Do not try to wake the child. Nutrition for Preschoolers Focus on a healthy, well-rounded diet. Avoid foods high in fat and sugar. Three meals and one to two snacks per day. Involve child in meal preparation and offer choices when possible. Do not fix separate meals; this encourages picky eating. Do not force intake if child is not hungry. - Try to open new foods Fifths Disease- slapped cheek disease Also known as erythema infectiosum. Caused by parvovirus B19.- viral Peaks in late winter and spring. Bright red cheeks with “slapped” appearance. Lacy rash on trunk and upper extremities. Benign and self-limiting. Offer supportive treatment if prodromal symptoms. Avoid pregnant women because virus can harm fetus. Hand-Foot-and-Mouth Disease Caused by coxsackie virus. Spread through fecal-oral route. Prevented with proper hand washing. Vesicular and/or pustular lesions occur on the oropharynx, palms of hands, and soles of feet. May have mild fever and moderate pain. Self-limiting condition; usually resolves after 1 week. Supportive care for symptomatic management. Monitor for dehydration. Conjunctivitis Inflammation of conjunctiva. Also known as “pink-eye.” Can be bacterial, viral, or allergic. Typically associated with thick drainage, pruritus, and/or vision changes. Very contagious. Treat based on cause (antibiotics, symptomatic management, antihistamines). Viral is self-limiting. Care of the School-Age Child School-Age Period Ages 6 to 12 years old. Maturity increases. Coordination, balance, and strength improve. Logical thinking develops. Friends and peers become more important. Development of self-confidence. Participation in organized clubs and sports are important. Health Assessment of School-Age Children Annual health promotion visits between ages 6 and 12. Direct questions to child but verify answers with caregiver. Assess development through questions about life. Make child sit on examination table during assessment. Perform examination in a head-to-toe manner. Explain in concrete terms what will happen. Parents should remain in the examination room during assessment. Use the Snellen eye chart to assess vision. Begin hyperlipidemia screening at 11 years old. -head to toe for check up and least invasive first in hospitals Physical Variants in School-Age Children Oriented to person, place, and time. Fully developed respiratory system at 10 years old. Bowel movements affected by diet and physical activity. Acne may begin to develop. Legs and arms grow faster than the rest of the body. Puberty Monitor for precocious puberty. Males: Secondary sex characteristics develop in boys between 9 and 14 years of age. First sign of development is testicular enlargement. Growth spurts occur in males later in puberty. Females: Secondary sex characteristics develop in girls between 8 and 13 years of age. First sign of puberty is breast bud development (thelarche). Earlier growth spurts in girls. Menarche occurs 2 years after breast bud development. Tanner Sexual Maturity Rating Pain Assessment of School-Age Children Use the Numerical Rating Scale for children older than 7: Straight line with number spaced evenly. 0 to 10 scale, higher number indicates more pain. Ask questions to determine pain quality. Nonpharmacological pain methods work well. Use distraction for school-age children with chronic pain. Include cultural considerations in pain assessment. (cognitive impairment- still FLAC scale) -cultural approaches (amish) Physical Growth of School-Age Children Height: Grow 2.5 to 3 in (6.3 to 7.3 cm) per year. Intermittent growth spurts. Girls are taller than boys at 12 years old. Weight: Gains 6.5 to 7.5 lb (2.9 to 3.4 kg) per year. Weight varies based on diet, physical activity levels, and home environment. Begin plotting body mass index to determine risk for obesity. Motor Development of School-Age Children Gross motor: Muscle coordination, rhythm, and balance improve. Can ride bike by age 7 to 8. Growth spurts may decrease coordination. Organized sports, dance, and gymnastics are popular activities. Fine motor: Improved hand-eye coordination and finger dexterity. Playing an instrument, braiding string for bracelets, and building models are popular activities. May become frustrated as skills develop. Communication and Speech of School-Age Children Ability to think about language and how it is used (metalinguistic awareness). Increase use of jokes and humor in this stage. Reading skills increase. Ability to think about and talk through thoughts and feelings. Social and Emotional Development Separate from parents and develop peer relationships. Develop positive or negative self-esteem through interactions with others. Children identify a best friend by 7 years old. Want to be accepted by peers and are subject to peer pressure. Children with negative self-esteem are more likely to give in to peer pressure. Peer groups tend to be same-sex. Gender Dysphoria Identifying with a gender different from biological sex. First seen in children ages 9 to 10 years old. May be short-term or long-term. Encourage caregivers to support their children. Assist families in adjusting. Remain nonjudgmental. Watch for signs of bullying, depression, anxiety, and low self-esteem. Safety Considerations for School-Age Children Sports: Wear protective gear. Prevent dehydration. Water: Never allow children to swim alone. Teach children to swim. Bicycle: Always wear a helmet that fits securely. Pedestrian: Look both ways before crossing the street. Home: Store firearms in locked cabinets. Develop fire safety plan. Sleep Considerations for School-Age Children Require 9 to 12 hours of sleep per night. Adequate sleep is associated with: Healthy immune system Improved academic performance Overall better mood Improved behavior Encourage healthy bedtime routines such as: Consistent bedtime Only use bed for sleep No electronic devices Daily physical activity improves quality of sleep. School Refusal Unwillingness to attend school.- usually has a cause (bullying, test taking anxiety)- start a journal with the family Multiple short absences or one prolonged absence. Associated with severe emotional distress from school. Common in children ages 5 to 7 and 12 to 14. Refuse to board the bus, remain in bed, and/or throw temper tantrums. Vague somatic symptoms.- something hurts May be associated with recent life stressors. Multidisciplinary approach to treatment. -involve psychologists, nutritionists Bullying Common experience for children. The types most common in school are verbal and social. Bullying is associated with many negative consequences such as: Depression Anxiety Academic struggles Rates of cyberbullying are increasing. Report bullying behavior to the school and collaboratively develop an action plan. Pharyngitis and Tonsillitis Can be viral or bacterial. Sore throat is most common symptom. Streptococcal pharyngitis may also present with sandpaper-like rash. Treat streptococcal pharyngitis and tonsillitis with antibiotics. Tonsillitis likely to be viral. Tonsillar hypertrophy may lead to partial airway obstruction and/or sleep apnea. -tonsilectomy -sore throat, rash Care of the Adolescent Adolescent Period Ages 10 to 21 years old Divided into three stages defined by age: Early: 10 to 13 years Middle: 14 to 17 years Late: 18 to 21 years Children transition to adults Ongoing identity formation Increase in risk-taking behaviors -IDENTITY V ROLE CONFUSION -good v bad, Health Assessment of Adolescents Annual health promotion visits Privacy is important. Perform health history and assessment without caregiver present. Allow caregiver opportunity to ask questions. Sequential, head-to-toe manner Keep body covered as much as possible during examination. -drugs, alcohol, marijuana Physical Variants in Adolescents Wisdom teeth develop. Prefrontal cortex is undeveloped until late adolescence. Onset of puberty. Growth plates close in middle to late adolescence. Muscle development is greater in males. Active sebaceous glands lead to acne. Apocrine sweat glands increase. Skeletal growth occurs before muscle growth. Pain Assessment of Adolescents Use the Numerical Rating Scale: Straight line with evenly numbered spaces 0 to 10 scale, higher number indicates more pain. Nonpharmacological pain methods work well. Use cognitive interventions and deep breathing. Include cultural considerations in pain assessment. Assess developmental level as well. -non pharmacological- distract from pain Physical Growth of Adolescents Height: Growth spurts vary based on age and gender. Females grow 3 to 3.5 in per year during growth spurt. Males grow 3.5 to 4 in per year during growth spurt. Weight: Healthy body mass index between 5th and 85th percentile. Body fat increases in females. Muscle mass increases in males. Communication and Speech of Adolescents Vocabulary and language increase in complexity. Abstract thought improves. Use of slang and “text speak.” Language use is at the adult level by the end of adolescence. Social and Emotional Development of Adolescents Peers become most important. Separation from parents occurs. Body image and self-esteem affected by relationships. Strive for independence. Caregivers should maintain open and positive relationships. Peers can foster positive social behaviors. Opposite-sex relationships emerge. Self-concept and body image are closely related. Body image influenced by development of secondary sex characteristics. Gender identity and sexual orientation develops. Safety Considerations for Adolescents Motor vehicle safety: Always wear a seatbelt. Avoid distracted driving. Follow the speed limit and state driving laws. Fire safety: Learn how to be safe around campfires. Use matches safely. Have a fire escape plan for the home. Practice fire escape routes at home. Sun safety: Use sunscreen when outdoors. Wear a wide-brimmed hat outdoors. Do not use tanning beds. Risk Reduction Pregnancy and sexually transmitted infections (STIs): Maintain open and honest conversations and remain nonjudgmental. Encourage human papillomavirus vaccination. Offer resources on obtaining protection and provide education. Teach about the dangers of STIs. Substance use: Cognitive task deficits. Discuss dangers of substance use and abuse. Educate about dangers of vaping and tobacco use. Determine the risk for substance use disorder with validated screenings and tools. Sleep Considerations for Adolescents Require 7 to 8 hours of sleep per night. Change to circadian rhythm: Go to bed at 11 p.m. and wake around 9 a.m. School starts before 9 a.m. Sleep deficits common in adolescence. Sleep extra on weekends to compensate. Effects of sleep deficits: Negative mood and increased emotional reactivity Mood disorders Substance use Obesity Violence Can be victims of, or the ones eliciting, violence. Violence can be physical, verbal, sexual, bullying, or cyber. Exposure to violence leads to increased risk to perpetrate acts of violence. Risk factors that increase violent behavior include: Exposure to firearms Single-parent home Low socioeconomic status Poor family functioning Educate caregivers about violence in media and online. Depression Daily disruption of mood and loss of pleasure in activities. Lasts 2 weeks or longer. Incidence rates increase after the onset of puberty. Risk doubles if the parent has depression. Could also manifest as anger, aggression, and substance use. Treat with psychotherapy and antidepressants if no signs of improvement. Selective serotonin reuptake inhibitors are used most often for treatment. Increased risk for suicide. Infectious Mononucleosis Viral infection caused by Epstein–Barr virus. Spreads through oral secretions. Clinical manifestations: fever, pharyngitis, enlarged tonsils, hepatomegaly, and splenomegaly. Treat with supportive therapy (fluids, antipyretics, analgesics, and rest). Avoid contact sports for 2 to 3 weeks to avoid splenic rupture. Acute symptoms last 2 to 4 weeks. Full recovery may take 6 months. Dysmenorrhea Painful uterine cramps before the onset of menses. Can be primary or secondary: Primary: no underlying cause and is most common. Secondary: underlying cause. Symptoms last 1 to 3 days. Decrease prostaglandin production with nonsteroidal anti-inflammatory medications.- do not give w renal, GI, allergy bleeding issues If ineffective, start hormonal therapy with oral contraceptives. Implement alternative pain relief forms also. -distraction, heat packs