47 Ways to Reduce Injection Pain During Vaccinations

By Will Boggs MD

NEW YORK (Reuters Health) - A multidisciplinary group in Canada has issued a new clinical practice guideline with nearly four dozen recommendations for reducing pain during vaccine injections.

"Mitigating pain is considered part of good vaccination practice and shows patients that their health care provider cares about them," Dr. Anna Taddio from University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada told Reuters Health. "Mitigating pain also makes vaccination a more positive experience for everyone - not just for patients, but for onlookers and immunizers as well."

Dr. Taddio and colleagues in HELPinKids&Adults, an expansion of the Help Eliminate Pain in Kids group, considered 49 clinical questions in their expanded update of the 2010 HELPinKids guideline. Perhaps the most significant change was the addition of recommendations to include all age groups, including adults.

Fifteen recommendations received strong support, including these two that deal with injection techniques: (1) no aspiration should be used during intramuscular vaccine injections (it increases pain and has no apparent benefit) and (2) inject the most painful vaccine last rather than first (more pain at the beginning makes all the subsequent injections more painful).

Particularly for young children, physical contact during the vaccine injection is important. Breastfeeding should be used during injections in children younger than 2 years and there should be skin-to-skin contact in children 3 years and younger.

For children 12 years and younger, the guideline recommends topical anesthetics before vaccine injections, and for children 2 years and younger, sucrose solutions given before the vaccine injections can reduce pain.

Education about pain management prior to the vaccine injection can also be an effective means of reducing pain, according to the August 24 CMAJ online report.

"Information should mostly be given in advance," Dr. Taddio explained. "They should be told what will happen, how it will feel, and how to cope. At the time of the procedure, the focus should be on neutral information about the procedure and coping strategies rather than threatening sensory information that can increase fear. Patients can also be told strategies are going to be employed to make vaccinations as comfortable as possible."

"Pain from vaccine injections is a newly recognized harm of vaccination," Dr. Taddio said. "Failure to mitigate pain contributes to vaccine hesitancy. At present, it is estimated that across all ages, about 10% of individuals are not vaccinated because of concerns about pain and/or needle fear. There are a lot of tools that immunizers can employ to mitigate the pain -- most are cost-neutral and feasible across clinical settings."

Dr. Helen Petousis-Harris, from the University of Auckland's Immunization Advisory Center, Auckland, New Zealand, told Reuters Health by email, "The work on managing pain and distress at vaccination sessions is highly valued and welcomed by vaccinators all over the world who grapple with this every day. While there are a range of useful recommendations that may fit with a vaccinators practice, it should be kept in mind that the level of evidence for many of these recommendations is still low and the evidence is evolving."

"It is impossible to know which particular aspect of delivering an injection will make the most difference in a given individual vaccination session; there are just so many variables," she explained. "It can also be more of a matter of what not to do. Three general themes around this are a confident vaccinator, a relaxed parent, and good injection technique."

"I think that well-informed parents can make a big difference along with having something useful to do, such as bringing in a favorite toy as a distraction or breastfeeding, depending on the age of baby," Dr. Petousis-Harris said. "Distraction is a useful technique. Don't make a mountain over it, or the vaccination experience can become stressful when it does not need to be."

Dr. Denise Harrison, from Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada, told Reuters Health by email, "This report once again highlights vaccination pain as a problem. Most of the strategies included were recommended years ago. Embedding pain treatment as a normalized part of the vaccination procedure in diverse settings where vaccinations take place is vital for public health."

The Canadians Institutes of Health Research and the Mayday Fund supported this research. Five coauthors reported relationships with pharmaceutical companies or other entities.

SOURCE: http://bit.ly/1NCUo98

CMAJ 2015.

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