Reducing Pain during Childhood Immunization

April 15, 2010 at 7:12 pm 12 comments

I was invited to participate in a workshop yesterday in Toronto.  I was sitting beside a woman who I will call Anna.  She was there to tell the group her story:

When Anna was a child, she had a rare condition which took years to diagnose.  Through the process of diagnosis, she had many needles.  She remembers being physically restrained for the shots and tests.  Eventually her condition was diagnosed and she was able to go on with her life.  Around the age of 16, when she could refuse, she stopped having any sort of medical intervention which required a needle, no immunizations, no blood tests, no IVs.  Even if she was sick, she would suffer through it.

At the age of 31, in an ironic twist of fate, Anna discovered that to have children she would have to undergo in vitro fertilization which would need daily injections, as well as a battery of blood tests.  Anna wanted to have children more than she feared needles.  At the first blood test, she fell on the floor in a panic and the hospital’s crisis team was called in.  She was restrained and they took her blood (with her consent).

There is a happy ending.  Anna has two fully immunized children, ages 8 and 6, and now she goes first at influenza shot time.

So, here are a few questions for you to ponder:

Did you know that there are about 1 billion injections given to children annually worldwide (CDC, 2001)?

Did you know that the most commonly asked question by children in a doctor’s office is “Am I getting a needle today?”

Did you know that health professionals and parents, to this point, have done very little to manage the pain of children getting immunized? (Taddio et al., Pediatrics 2007)

We’ve always considered pain a necessary evil in childhood immunization.  We say “it will just hurt for a minute”.

But what if it doesn’t have to hurt, or at least not as much?

Research has shown that rubbing the arm or leg before injection, holding a child, injecting really quickly (without aspirating),  using the less painful brand of a vaccine, and doing the shot that hurts least first, work  to reduce pain(Taddio et al, 2009).

Research has shown that topical anesthetics (Emla patches), feeding sweetened water a couple of minutes beforehand, and breastfeeding during the immunization, work (Shah et al, 2009).

Research has shown that breathing exercises (in kids that could be blowing a windmill or blowing bubbles), distraction by the nurse or parent(same methods as previous suggestion), child-led distraction (video on an iPod or video game) work (Chambers et al. 2009).

At the workshop, we got to see videos of infants and children who had their shots with and without using these techniques.  The results were striking (and hard to watch for a parent).

So why do all immunizers not use these techniques? There could be less pain, less fear, more satisfaction and perhaps even more willingness to stay on schedule with vaccines.

One energetic young family practice nurse told us about how she has implemented these strategies in her clinic and the great success she is having.  Her enthusiasm was infectious.

Not one of my sons, but a cute child nonetheless, blowing bubbles

The group who hosted the workshop are about to publish what is known as an Evidence-based Clinical Practice Guideline so that immunizers will have this information and will hopefully be able to incorporate it into their busy practices.  But in the meantime, we, as parents, can take this info to our doctor’s and public health nurses, and use some of the strategies ourselves.

The next time my boys are due for vaccines, I will:

1) Bring juice for them to drink a couple of minutes before (this would be sugar in water for babies).

2)  Bring bubbles.

3)  Buy Emla patches at my local pharmacy and apply them 45 minutes before their appointment.

4)  Bring Derek’s iPhone cause the kids love playing with it.

5)  Hold them during the shot (I usually do this anyway).

6)  Ask the nurse to do it quickly and ask her not to aspirate first (if she does; I kinda remember that she doesn’t but I just want to be sure).

7)  If they are having multiple injections, I’ll make sure she uses the more painless one first (I’m pretty sure she already does this).

8)  Distract them with discussion about something unrelated to the moment.

9)  Rub the injection site for a couple of seconds before the shot.

A couple of interesting points about techniques that DO NOT work to reduce pain:

1)  Analgesics prior to immunization (Tylenol or ibuprofen).

2)  Reassurance from the parent.  It does not help to tell your child it will be over or they’ll be okay.  Apparently research has shown that this makes them more anxious.  I am definitely guilty of this.

These techniques also work for blood tests and IVs.

Do you have any other great tricks that work to distract your kids or reduce their pain during immunization, blood tests or other injections?

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12 Comments Add your own

  • 1. Helen  |  April 16, 2010 at 2:55 pm

    My son has to have a lot of needles and also has to have blood drawn and IVs for meds because of his medical condition. I find that the worst thing to do is to discuss it first – I constantly have to tell nurses to JUST DO IT, and do it quickly. When you spend time talking about how it is not going to hurt, or how it’s just going to hurt for a second, the child has time to get worked up. They get anxious and start panicing, and are crying and screaming before the needle is anywhere near them. I say jab them before they know what is happening – it’s over before they know what hit them!

    Getting blood drawn or having an IV put in is a major problem I haven’t been able to solve – because the needle is in for an extended period of time, and especially because he can see it, my son really hates it. Of course he sits on my lap, and I always ask for the numbing cream, which seems to work a bit, but any ideas would be helpful…

    • 2. fitforakid  |  April 16, 2010 at 3:25 pm

      Hey Helen,

      They really encouraged Ipods, Itouch, etc. for music, videos, games… have you tried that? Get him into the game before the nurse or tech comes into the room?

      • 3. Helen  |  April 23, 2010 at 11:01 pm

        I will try that next time. Usually when he is in the hospital for more than a couple of hours, they wheel these big video game machines into the room. It definitely helps to distract him.
        Believe it or not, he will do almost anything for one of the hospital popsicles, or for one of the donuts from the cafeteria. Go figure.

  • 4. Tracey  |  April 23, 2010 at 2:36 am

    Neither of my kids have ever really had a problem with getting needles. That said, we’ve used many of the techniques listed just “naturally”. My kids always sat in my lap, I always distracted them and my doctors office always rewarded them afterwards. My nurse always did the less painful first as well. I have no idea how they’d be with an IV or repeated needles though. One other thing I think has helped us-building a relationship with your doctor and nurses. My kids have been getting their needles by the same nurse their whole lives. I think that familiarity helps as well.

  • 5. Dr. Amy  |  September 5, 2010 at 2:01 am

    All the counter stimulation ideas are excellent; you can also let your child have as much choice as possible. Vibration and cold (like in Buzzy) block pain the same way a dentist wiggling a lip decreases sharp pain, or water soothes a burn. Having options that your child and you can dispassionately discuss later can help if a chronic condition is going to require ongoing blood work. “Do you want to try the cold drink, Bee-Stractor distraction, or blowing bubbles today?” Try to address local nerves, overwhelm sensation bandwidth, give alternate pleasant sensations, and then praise some aspect that they did well afterwards.

  • 6. Lucy  |  September 22, 2010 at 5:32 pm

    In our house, we get immunization presents. Usually markers or craft supplies – I hand the girls a small, gift bag as the nurse is prepping their arm and tell them they can open it as soon as the needle is in their arm. So far, this has worked great – not a tear or a whimper for all our H1N1 shots last year or regular immunizations this spring.

    • 7. fitforakid  |  September 22, 2010 at 11:55 pm

      That is an amazing idea! I’m going to do that this year at flu shot time… Thanks so much for commenting.

  • […] increase in the immunization-related search terms that bring people here.  I also noticed that the post I wrote about reducing pain in childhood immunization has gotten a lot of play lately.   And […]

  • […] increase in the immunization-related search terms that bring people here.  I also noticed that the post I wrote about reducing pain in childhood immunization has gotten a lot of play lately.   And […]

  • […] increase in the immunization-related search terms that bring people here.  I also noticed that the post I wrote about reducing pain in childhood immunization has gotten a lot of play lately.   And […]

  • 11. San  |  December 13, 2010 at 3:56 pm

    For my dtg’s 18 month immunization..i implimented the interventions I could use to reduce her pain during vaccination. I went and bought enmal and rubbed her arms….and then i also took out my iphone and played her faviorite ‘row row row your boat” clip while the doc gave her a check up and needle…and it really helped a lot! she used to cry the whole time in the doc’s office, but this time..she would cry, and there would be a break while she’s watching youtube….and then she’ll cry again..and she’ll stop. So she was more distracted…and less pain ??(hopefully)…..

    So i really think and hope that parents would be comfortable and learn to comfort their child during immunization to prevent any phobia in the future… =) so i think it’s a role for us who read about and learn tell their friends and families the diff techniques. Because you wouldn’t be surprised how many parents out there jus t dont’ know what to do!

  • 12. San  |  December 13, 2010 at 3:59 pm

    sorry…in the above post…i meant EMLA…not enmal! ha..don’t know where i got that name from!


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