Reducing the Ouch During Vaccination

Column Author: Christine Symes, MSN, APRN, CPNP | Infectious Diseases

Column Editor: Angela Myers, MD, MPH | Pediatric Infectious Diseases; Division Director, Infectious Diseases; Medical Director, Center for Wellbeing; Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Pediatric clinicians are committed to providing recommended vaccines to their patients. But vaccine hesitancy continues to be an obstacle to providing some or all recommended vaccines. One factor that impacts immunization uptake is the pain associated with vaccination.¹ Pain is a concern for children and their parents. Research has shown that fear of needles is one of the top concerns for parents in the health care setting and that one of the most important ways to mitigate this fear is to keep their child comfortable.² Some patients may go on to develop phobias around procedures and health care in general due to worries about pain and fear associated with needle procedures. The World Health Organization (WHO) has asserted that children have the right to pain mitigation with vaccinations.³ Institutions and organizations are creating evidence-based clinical practice guidelines to reduce vaccination-associated pain to mitigate this barrier to vaccination.

Several strategies have been shown to reduce pain during vaccination. Allowing infants and young children to breastfeed or bottle-feed during or immediately following vaccination has been shown to decrease pain associated with vaccines, as evidenced by a shorter period of crying following the injection and significantly faster reduction in perceived level of pain.⁴ The WHO position paper, as well as many clinical practice guidelines on this subject, recommends encouraging children <2 years of age to breastfeed during vaccine injection.

Positioning for vaccine administration is important, especially in younger children. Allowing a caregiver to hold children <3 years of age should be encouraged. Children >3 years of age should be allowed to sit for vaccinations when possible and preferably in a caregiver’s lap, if this is appropriate.

Vibratory stimulation is effective in reducing needle-related pain. A review of 21 randomized controlled trials with 1727 pediatric patients <18 years of age showed the effectiveness of this method to decrease pain with needle procedures, including vaccination.⁵ Vibratory stimulation can be accomplished by small mechanical vibrating devices, a topical device that has blunt tips that distract pain receptors, or by simple mechanical stimulation at the site by pinching the area of injection and rubbing just prior to injection.

In older patients, distraction techniques can be useful. Research has shown that adolescents allowed to listen to the music of their choice during vaccination were less likely to report pain with vaccination than a control group.⁶ Allowing children to hold/watch a toy, look at a book, listen to music, or watch a video or show during vaccination are all options that can be used as distraction during vaccination.

Some procedural interventions can also be used to minimize pain with injections. Do not use aspiration after needle entry, as aspiration can increase pain by increasing needle dwelling time and create a sheering action of the needle.⁷ If multiple injections are going to be given, give them in the order of least painful to most painful. Warming the injection solution briefly in your hands prior to administration can reduce pain due to injecting a cold solution.

Pharmacologic interventions can also be used. At Children’s Mercy Kansas City, providing topical anesthetics is the first intervention in our Comfort Promise Initiative, a bundle of evidence-based strategies used to reduce or eliminate pain caused by needle sticks that is our standard of care with all patients. This intervention can be accomplished with numbing gels, creams, or patches or with needle-free injection devices that administer numbing medication into the subcutaneous tissue. In infants up to 18 months of age, giving oral sucrose solution either on a pacifier or administered orally by syringe has been shown to decrease pain scores, and the analgesic effect peaks at two to three minutes after ingestion and lasts for five to eight minutes.⁸

Finally, it is important to acknowledge and address pain associated with vaccines with patients and caregivers prior to and at the time of vaccination. Discussing fears and relating strategies that will be used to reduce pain with vaccinations can provide reassurance. Having a practice guideline that standardizes vaccine administration and strategies to mitigate pain and making this guideline known to patients and caregivers can provide reassurance and lessen the fear around needle-related pain. These strategies can help those who are vaccine hesitant for pain-related reasons and reassure them that pain will be managed – and hopefully will increase vaccination acceptance.

Here is a link to the Children’s Mercy Kansas City information page regarding our Comfort Promise.

This page can be used as a reference for developing a needle procedure plan for your practice setting.

References:

1. Shen SC, Dubey V. Addressing vaccine hesitancy: clinical guidance for primary care physicians working with parents. Can Fam Physician. 2019;65(3):175-181.
2. Spigel MG. There’s a Snake on My Head! Strategies for Alleviating Fear and Anxiety in Healthcare. BookableMedia; 2022.
3. Reducing pain at the time of vaccination: WHO position paper, September 2015-Recommendations. Vaccine. 2016;34(32):3629-3630. doi:10.1016/j.vaccine.2015.11.005
4. Bos-Veneman NGP, Otter M, Reijneveld SA. Using feeding to reduce pain during vaccination of formula-fed infants: a randomised controlled trial. Arch Dis Child. 2018;103(12):1132-1137. doi:10.1136/archdischild-2017-313488
5. Ueki S, Yamagami Y, Makimoto K. Effectiveness of vibratory stimulation on needle-related procedural pain in children: a systematic review. JBI Database System Rev Implement Rep. 2019;17(7):1428-1463. doi:10.11124/JBISRIR-2017-003890
6. Kristjansdottir OB, Kristjánsdóttir G. Randomized clinical trial of musical distraction with and without headphones for adolescents’ immunization pain. Scand J Caring Sci. 2011;25(1):19-26. doi:10.1111/j.1471-6712.2010.00784.x
7. Taddio A, McMurtry CM, Shah V, et al. Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015;187(13):975-982. doi:10.1503/cmaj.150391
8. Harrison D, Loughnan P, Manias E, Johnston L. The effectiveness of repeated doses of oral sucrose in reducing procedural pain during the course of an infant’s prolonged hospitalization. J Paediatr Child Health. 2007;43:A20.