May 7, 2007 — An evidence-based review published in the May issue of Pediatrics provides recommendations to help reduce the pain children experience during immunizations.
The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them.
The current Centers for Disease Control and Prevention schedule recommends immunizations against 14 diseases, which translates into 14 to 20 separate injections before the age of 2 years, depending on the number of combination vaccines available. Therefore, immunizations are the most frequently occurring painful procedures performed in pediatric settings.
The recommendations divide the injection process into 2 periods: before the injection and during the injection. Before the injection, important aspects of the immunization include preparing the child and family, selecting the site for the injection, selecting the needle length and gauge, and specific properties of the injectate.
During the injection itself, key elements include parental demeanor, use of sucrose, use of topical anesthetic agents, nonpharmacologic and physical strategies, and specific aspects of administration technique. Before the injection, preparation of a child older than 2 years reduces anxiety and subsequent pain. For children younger than 4 years, the preparation should be done in close chronological proximity to the injection itself. Based on limited data available, intramuscular immunizations should be given in the vastus lateralis (anterolateral thigh) for infants and toddlers younger than 18 months and in the deltoid (upper arm) for children older than 36 months. Although site selection for 18- to 36-month-old children is still controversial, some studies suggest that the ventrogluteal area is the most appropriate for all age groups. Using longer needles usually causes less pain and less local reaction. During the injection, parental attitudes clearly affect the child’s pain behaviors. Excessive parental reassurance, criticism, or apology appears to increase distress, whereas humor and distraction may reduce distress. The age, temperament, and interests of the child, as well as personal style of the parents, will determine which distraction techniques will be most effective. These techniques may include storytelling, reading to the child, deep breathing, and blowing. Although it seems counterintuitive, children often are more distressed when parents are more rather than less involved, the authors write.
Therefore, a matter-of-fact, supportive, nonapologetic approach is endorsed. In children younger than 6 months, sucrose solution given directly into the mouth or on a pacifier reliably reduces evidence of distress and should be used routinely, in part because it is relatively inexpensive. Given the high cost and time needed for administration, routine local anesthetic administration is not necessarily appropriate. Despite the absence of a perfect topical anesthetic available at this time, selective use is recommended for children who are particularly fearful, who have had previous negative experiences, or who will require multiple procedures in the future.
Pressure at the immunization site decreases pain, whether applied with a mechanical device or manually with a finger. Furthermore, it is noninvasive, inexpensive, and without adverse effects.
Although properties of the injectate itself can exacerbate pain, there has been almost no sophisticated research in this area, and this issue should be pursued further. In the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available, the authors write. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.
However, they also note that dread evoked by painful immunization procedures may create feelings of persistent tension in future clinical encounters, thereby interfering with optimal delivery of healthcare. Pediatrics. 2007;119:e1184-e1198.