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Vaccines are a pain: What to do about it

As much as I support vaccines, I see the short term consequences. Vaccines can be painful. Kids don’t like them, and parents don’t like seeing their children suffer. That this transient pain is the most common consequence of gaining  protection from fatal illnesses seems like a fair trade-off to me. But that’s not the case for every parent.

Today’s post isn’t going to focus on the extremes of the anti-vaccination movement. Rather, it’s going to look at ways to make vaccines less painful and more acceptable to children. The pain of vaccines can lead to anxiety, fear, and even nonadherence with vaccination schedules. Fear of needles and injections is not uncommon, it’s estimated that 10% of the population avoids vaccinations for this reason.

The vaccine schedules are intense. Where I live, the public vaccination schedule specifies seventeen injections of six different products over six visits in the first 18 months of life, plus influenza vaccinations and one-offs like H1N1. That’s a lot of visits, and a lot of tears if a child doesn’t handle them well.

In light of what’s known about the prevalence of needle fears, their potential effect on vaccination adherence (that could persist through adult life), and the possible impact on public health because of unvaccinated individuals, it makes sense to do whatever we can to minimize the pain and discomfort of vaccines, increasing their acceptance to children and their parents. But what works? I’ve personally found Smarties (the real ones) and Dora the Explorer stickers are effective distractions and bribes. But I’m not about to call my n=2 trial good science. Nicely, there’s much more evidence to guide our recommendations.

A systematic review and practice guideline has just been published on vaccine pain: Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. The lead author, Anna Taddio, is a pharmacist and professor at the University of Toronto, and coauthors include large team of academics and health professionals.The guideline is lengthy and detailed, so I’m going to summarize the highlights. There are also some practical handouts for health professionals and parents developed by the authors: links are at the bottom.

Distilling the Evidence

The systematic review looked at both pain and distress (collectively, “pain”) related to vaccine administration. An interdisciplinary team of physician, pharmacists, academics, stakeholders (including parents) were convened, who identified 32 focused clinical questions (later reduced, because of the evidence base). The review didn’t consider post-injection pain and discomfort, which is common yet transient. As pain management is typically based on a “3-P” approach (pharmacologic, physical, and psychological), three systematic reviews and three meta-analyses, one for each domain, were conducted for each clinical question. Evidence was restricted to RCTs. Recommendations were graded based on level of evidence and grade of recommendation according to a standardized format:

Overall, 71 studies involving 8050 children were reviewed. All recommendation were externally reviewed according to a validated process, by vaccination, public health, and medical associations. The study was publicly funded, and disclosed conflicts of interest were minor.

The Findings

Fourteen clinical questions were answered. The guideline has more detail and specific clinical considerations.

1. Does breastfeeding during vaccination reduce pain at the time of injection?

Yes. Breastfeeding has been shown to provide analgesic effects, possibly through the combination of holding, skin-to-skin contact, the sweetness of the milk, and the process of sucking. To reduce pain, breastfeeding mothers should be encouraged to breastfeed during the vaccination procedure. (Grade I-A)

2. Does administration of a sweet-tasting solution reduce pain at the time of injection?

Yes. Sweet oral solutions provide analgesic effects in infants, reducing signs of pain. Up to 12 months of age, infants who cannot be breastfed during vaccination may be administered a sweet-tasting solution during vaccination (Grade I-A). A simple formula is one packet/cube of sugar in two teaspoons (10 mL) of water. Place in the infant’s mouth with an oral syringe 1-2 minutes before injection. The process is well tolerated, and side effects, like coughing and gagging, are infrequent. Because of conflicting data, there is insufficient evidence to support this strategy in children older than 12 months.

3. Are there pain-related differences between different brands of the same vaccine?

There is only evidence for the MMR vaccine, where differences have been observed between brands. (Grade I-A) Differences may be due to formulation, adjuvants, and pH. Given this is a Canadian-based systematic review, it’s not clear what differences might exist in other countries. Greater knowledge that differences do exist may guide vaccine selection by health authorities. But little choice usually exists at the point of care.

4. Do different body positions results in different pain levels?

The very limited evidence that exists suggests that children are should not be in a supine (lying down) position. (Grade I-E) Sitting upright, or being held, seems preferable. This may be due to anxiety, which could impact perceived pain. Excessive restraint can increase distress, so holding and support without force is probably preferable.

5. Should slow injection, with aspiration be avoided?

Yes. Intramuscular injections should be given with a rapid injection technique without aspiration (drawing back on the plunger). (Grade I-B). As injection sites do not have large blood vessels, there’s no rationale for aspiration. Slow injection and aspiration may add to the pain due to longer contact time and possible needle wiggle in tissue.

6. When multiple vaccines are to be given in one visit, which first? The most painful, or the least?

This is a common situation. Where differences exist, give the most painful vaccine last. (Grade I-B). Based on limited information, MMR II and Prevnar appear to be more painful than other vaccines. (This may be specific to Canada. Anyone that administers vaccines routinely will probably know which are more painful.) Giving the more painful vaccine last seems to decrease the overall pain from both injections, based on the results of a single RCT.

7. Does rubbing the skin near the injection site, before and during the procedure, reduce the perception of pain?

Probably, in those 4 years of age and older. Rubbing and stroking the skin may reduce pain. (Grade B-II-1) The mechanism of the analgesia may be the “white noise” created at the site of injection. It’s not clear if this effect is present in young children. The optimal method of rubbing (frequency, intensity, pattern) isn’t known. Rubbing the injection site after injection is thought to increase vaccine reactions and isn’t recommended.

8. Does parental distraction or coaching result in less pain?

There’s insufficient evidence to say. (Grade I-B) Different interventions have been systematically studied, but don’t provide persuasive evidence that it’s effective. This could be due to a number of reasons, including inadequate training or preparation. Given distraction and coaching are cheap and can engage the parent in a formal role, they are reasonable interventions to make. Parent-led distraction is not as effective as clinician- or child-led distraction, however. See the references for a parental tip sheet.

9. Do topical anaestheics reduce injection pain?

Yes. (Grade I-A). Several topical anaesthetics (EMLA, Ametop, Maxilene) are available, and in some countries, without a prescription. They must be applied 20-40 minutes before the procedure. There is no evidence they interfere with vaccine immunogenicity.

10. Does clinician-led distraction result in less pain?

Probably, and is recommended in all age groups. (Grade B-I) See below for a training sheet for health professionals. The same health professional that is administering the vaccine can also administer the distraction, so the intervention does not consume more resources. See the tip sheet in the references for suggested distractions that may be used by clinicians.

11. Do child-led distractions result in less pain?

Yes, in children three years of age or older. (Grade B-I). Child-led distraction effectively reduces pain, however there’s not enough information to determine what’s most effective. See the tip sheets in the references for suggested distractions.

12. Do breathing strategies (deep breathing, blowing) reduce the pain of injection?

Probably. Slow, deep breathing helps relax children and seems to reduce pain. (Grade B-I). Deep breathing and slow blowing may be effective. Using distractions like bubbles, pinwheels or party blowers can serve dual purposes.

13. Do combined interventions (e.g., cognitive AND behavioural techniques) work?

They seem to, based on limited evidence (grade B-I) Combine different interventions in children 3 years of age and older.

14. What about telling the child, “It won’t hurt”?

Not recommended. This has been evaluated, and has not been shown to be effective. (grade D-I)

15. What about cooling sprays or ice packs?

There is insufficient evidence for or against cooling. While vapocoolant sprays are marketed to reduce pain, there’s no persuasive evidence these products are effective in children. Ice packs also may be ineffective. This could be because children perceive coldness as pain.

16. Do simultaneous injections cause less pain than sequential vaccine administration?

Insufficient evidence. Given the the difficulty blinding such an intervention, I’d expect this would be difficult to determine. Given the resource requirements to administer, there seems to be little rationale to consider this approach.

17. Is intramuscular injection less painful than subcutaneous, if the choice is available?

Insufficient evidence. RCTs have provided conflicting evidence. Manufacturer’s prescribing evidence should be followed.

18. What about acetaminophen or ibuprofen before the injection?

Insufficient evidence. There are no RCTs that have evaluated the common practice of giving analgesics in advance of an injection. There is evidence that analgesics do reduce the post-injection side effects of pain. As there’s some data suggestive that this may reduce the immune response to the vaccine itself, the practice is now questioned by some.

Conclusion

Not all arguments against vaccines are are amenable to the simple provision of education or evidence about their efficacy and safety.  In some cases, simple interventions may be able shift perceptions of the benefits and consequences.

Compared to what we’d expect for other types of health interventions, the quality of the evidence for some of these recommendations is weak. Yet that shouldn’t stop us from considering them if they’re plausible and easy to implement: There’s little downside risk. By taking steps to reduce vaccine pain we can improve vaccine acceptance, completion of the vaccination schedule, and overall improvements in public health outcomes.

Resources

A guide for parents, caregivers and children on how to reduce vaccine injection pain in children

Reducing vaccine injection pain in children: a guide for health care providers

Health care provider pain assessment and documentation tool

Video based on guidelines: Help Eliminate Pain in Kids

Reference

ResearchBlogging.org Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, Macdonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J, & Shah V (2010). Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary). CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 182 (18), 1989-95 PMID: 21098067

Posted in: Vaccines

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28 thoughts on “Vaccines are a pain: What to do about it

  1. Al Morrison says:

    David, great post. Sometimes a discussion about vaccination does not have to be controversial. In fact, I wonder if turning from the most divisive questions, to the more practical, is more persuasive to those who sit on the fence. I think we need a balance of taking on antivax directly and vaccination information.

  2. hat_eater says:

    As a parent of two, I’d like to thank you for this informative and clear summary. I’m lucky that my children don’t make much of the needling, especially because when I tried initially to ask nurse about using a topical anesthetic she said that’s precluded by the procedure (here in Poland).
    And as a mild trypanophobe (I’m routinely offered a chair before having blood drawn because I turn white like a sheet), I have one suggestion I haven’t seen mentioned. In my childhood (1970s) ether was used as a disinfectant before vaccination. I developed a strong fear response to its distinct smell. Today, I see alcohol solution being used, and it’s harder to connect needles with a smell that’s encountered so much more often in other circumstances. So it’d seem reasonable to avoid using ether as a disinfectant before vaccination – if it’s still used somewhere.

  3. Rick says:

    Perhaps the most practical was in to reduce the number of injections. I know that there a an increasing amount of multiple vaccine mixture injections. However, an article I came across (on Medscape I think) had noted that these are a substantial higher cost to offices which are reimbursed for one injection. This is a barrier that needs to be worked out.

  4. Jann Bellamy says:

    In my little collection of chiropractic patient literature, there is a booklet directed at children called “Jake Goes to the Chiropractor.” It uses children’s fear of needles as an incentive to see a chiropractor.

    Act I: Jake’s mother is going to take him to a chiropractor for his headaches.

    “Jake was hopeful, year fearful and scared
    For his vist tomorrow, he was not prepared.
    He dreamed of white coats, needles and pain.
    Next morning Jake’s bravery went down the drain!”

    Act II: At the chiropractor’s office.

    “Dr. Hale was was as yet nowhere to be found,
    So Jake decided to take a look around.
    I’ll find those needles, if they’re anywhere near,
    And when I do I’ll yell so everyone can hear!

    “In drawers and supboards Jake looked in vain.
    Not one needle he found, so he started again.
    ‘Stop that at once!’ his mother exclaimed.
    ‘This is quite rude, you must be ashamed!’

    “At that moment Dr. Hale entered the room.
    He was big and jolly and his voice seemed to boom.
    ‘Young man, just what are you looking for?
    Do you think you’ll find needles behind that door?’

    “Astonished, Jake asked, ‘Did you read my mind?’
    ‘No,’ Dr. Hale laughed, ‘But I know your kind.
    Children always think it’s a needle they’re getting.
    They come in here scared, and somethimes sweating.’

    “‘Nothing here will hurt you, my little friend,
    You’ll only feel better, on that you can depend.’
    Jake said, “All right doctor, now I believe you,
    But to help my headaches, what will you do?’”

    Act III: Jake gets an adjustment and says he feels better, although he is admonished by Dr. Hale that “Your bones have been out of line for so long, you’ll need more adjustments so nothing goes wrong.”

    B. Kenton, “Jake Goes to the Chiropractor,” Kitchener, Ontario, Canada, B.O. Antoniou and M. Beattie (2006), http://www.jakegoestothechiropractor.com.

    So, there may be another benefit of reducing the pain of vaccination (or any childhood shot). The mothers of the little Jakes of the world won’t be influenced to take their children to chiropractors.

  5. hat_eater says:

    I’d add Act IV in which little Jake succumbs to measles, then meningitis, has his neck adjusted as a last resort and dies when a blood clot from a ruptured artery reaches his tired brain, but I can’t bring myself to descend to the comparable level of graphomany.

  6. windriven says:

    What about the needle-less pneumatic injectors? Are they only practical for mass inoculations? Are they less painful than needle and syringe injections?

  7. Rick says:

    @windrivenon

    I am not sure you could use those for peds patients. As I remember from my years as a corpsman in the Navy those did hurt more. Also I have seen a lot or errors in use with the pneumatic injectors and people getting a laceration from them when they moved, and not enough power to get the vaccine fully into the patient. Lastly I though they had stopped using them due to concerns over cross blood contamination from one person to another.

    On the other had something we had in the military was auto-injectors for nerve gas antidote (atropine and 2-pam-cl). I wonder if these would be quicker than a hand given injection and I don’t believe the patient would see the needle since you hold it against the skin and push the trigger?

  8. TsuDhoNimh says:

    windriven – Air guns are NOT less painful.

    Distractions work. My old GP used to give us the shots while we were standing, and step on our toes (not painful, just pressure) as a distraction right before the needle went in.

    You can also flick a different site on the arm with your finger immediately before the injection to confuse the patient.

    What fails spectacularly: Having a hovering parent anxiously telling the child that it won’t hurt at all.

    I did worse than give shots, I mostly drew blood. The children usually reacted well to a calm explanation that they would feel a little poke when the needle went in, but it was not nearly as bad as falling off a bicycle or getting scratched by a cat.

    And shots or vaccines, NEVER let them see the needles! Sadistically waving that thing around drives the anxiety and pain sensitivity up.

  9. windriven says:

    @ Rick and TsuDhoNimh

    Thanks for the info. I’ve never had an injection from the pneumatics so I appreciate your insights.

    The autoinjectors are a cool idea as the needle isn’t seen and operator technique is largely taken out of the equation. Expense would be an issue though. A disposable needle and syringe is half a buck.

  10. Harriet Hall says:

    I don’t think the actual pain of the injection is much of a problem – I think it’s more the surrounding psychological factors, which can be exacerbated by apprehension on the part of the parents and the provider. IMHO a straightforward, matter-of-fact approach is best.

    If you give a shot without any warning and startle the child, he will not trust you next time. If you distract him, he may resent being fooled. If you say it won’t hurt he will know you lied. If you say it will only hurt a little, he may fixate on the idea of “hurt.” I prefer to say there will be just a little prick and it will be over with in an instant.

    My daughter didn’t cry, didn’t even flinch, when she got her 1-year shots; then when we got home she cried and was very distressed about a trapped fly that was buzzing under the window screen. Go figure!

  11. Draal says:

    Just need to wait for the invention of the hypospray. Problem solved.

  12. aeauooo says:

    Thank you for calling my attention to this review and guidelines.

    I suspect that a very large proportion of people who administer vaccines are aware that the ACIP no longer recommends aspirating before IM injection. It’s enough of a sacred cow in nursing that I had to look it up for myself the first time I was told not to aspirate, and some of my colleagues reacted as if I were a heretic when I passed that information along to them.

    http://www.immunize.org/askexperts/experts_general.asp

  13. “I think it’s more the surrounding psychological factors, which can be exacerbated by apprehension on the part of the parents and the provider. IMHO a straightforward, matter-of-fact approach is best.”

    I agree. My son has shown distress and will shed a few tears after shots, but it’s my daughter (age 7) that has a really difficult time. She tends to be intense and she gets very worked up and anxious over shots. In the past she has struggled, tried to kick the nurse. She also giggles uncontrollably (something she seems to do when she’s sort of overflowing with stress or anxiety). Once she starts getting stressed, I start getting stressed because I worry her movement will make the pain worse or break the needle (or she will hurt the nurse). Of course I know my tension does not help the situation any.

    Luckily, this last time she seemed a little bit calmer, so I’m hoping she will just grow out of it. She was also quite curious about what the vaccination was and how it worked. Maybe the explanation will help to some extent.

    I have tried giving her small gifts or letting pick a treat after, but that didn’t seem to make much difference. Perhaps a lollipop to suck on during the shot would be a good distraction for the future.

  14. Reductionist Nurse says:

    Excellent article, taking this to work with me.

    I cluster the injection-site pressure/rubbing with the alcohol swabbing to help the process flow faster, along with a good darting technique.

    Wasn’t ever sure whether honesty was the best policy with the young ones, but the issue of building trust is a good point. Thanks again Scott!

  15. magra178 says:

    I’ve been thinking about this lately. I’m a bit spoiled because my 2 yr old has handled vaccination superbly; I’m sure I’d feel different if my child flipped out every time. But, for her first round at 2 months, I was anxious and cried when she got them. I realize now that was silly, I didn’t even know how she’d react. When put into perspective, she had just been born two mo earlier, and the stress of that was much worse than a shot. I agree we should find ways to make vaccines less traumatic, but I think sometimes it’s worse on the parent because they’re psyching themselves out. Thanks for the post, it gives me lots of suggestions for future vaccinations for her and a possible 2nd child (who will probably be the opposite and flip out!).

  16. TsuDhoNimh says:

    Harriet –
    Often, my explanation of “It’s not as bad as falling off a bicycle” would get a smile from the child. “Not as bad as getting stepped on by a dinosaur” also works.

    Also a valid technique – tell them it’s OK to yell, scream and cuss, but they have to hold still.

  17. cranmerepool says:

    What many medics and others fail to take on board is that for some needle phobics the pain is not a factor in the fear and any preparations may make the fear worse by feeding on the whole process.

  18. cranmerepool says:

    What many medics and others fail to take on board is that for some needle phobics the pain is not a factor in the fear and any preparations may make the fear worse by feeding on the whole process.

    Magra178′s comment also illustrates a very powerful way of seeding a phobia. If theparent is distressed it is no wonder that the child comes to beleive that what is happening should be feared. Parents who are themselves emotional about the process should be kept out of sight and sound of their children during such procedures.

    1. Harriet Hall says:

      cranmerepool said “for some needle phobics the pain is not a factor in the fear”

      True. I had a young patient who required multiple blood tests. He had no problem with the insertion of the needle, but he would panic and scream when he saw the blood appear in the syringe. I always wondered what was going on in his mind… Apparently he wasn’t a needle phobic, but a sight-of-blood phobic.

  19. Werdna says:

    My four year old handled the flu shot both this year and last (including the H1N1) rather well. I tend to think that children receive emotional cues from their parents. Even if the parent is simply worried that their child might experience some pain. The message that gets sent is: “There is something to worry about” and the child gets anxious in response.

    All we did, is have the doc give me the vaccine first then her. Acting as if everything that was happening was routine. This year she actually asked “will it hurt”. We told her “Yes, a little”.

  20. Werdna – “Even if the parent is simply worried that their child might experience some pain. The message that gets sent is: “There is something to worry about” and the child gets anxious in response.

    All we did, is have the doc give me the vaccine first then her. Acting as if everything that was happening was routine.”…

    I’ve always heard that children can pick up their parent’s fears by observation, but it never seems to work out that way for me. The things that I’m genuinely anxious over (like walking through a busy parking lot, swimming, climbing unsafe objects, etc) don’t seem to phase my children a bit, It’s the things I find unremarkable that seem to bother them (shots, bees, frogs, seaweed, people who look different..). I’ve always wondered, if fear is so contagious, why don’t kids pick up on the sensible fears more? :)

    This is not to say that I don’t believe that parental calmness is a valuable approach…just saying.

  21. “I always wondered what was going on in his mind… Apparently he wasn’t a needle phobic, but a sight-of-blood phobic.”

    My guess would be something like this. ‘Every time I see blood I panic, It feels awful when I panic, I hate it, it makes me feel like I’m going to die, Oh no there’s the blood, now I feel awful, etc’

    I’m no expert, but my understanding is that phobias are just as much a fear of the conditioned fear response (which is miserable) as they are the actual object. That’s why gradual exposure therapy is important in phobias. In that way, people can re-habituate a new, more comfortable, conditioned response (neural pathways and all that jazz).

  22. Since fainting at the sight of blood is relatively common – particularly among men??? – my thought is that it’s an involuntary homeostatic response. Some fears are easy to develop (bugs, snakes) and others are just there (heights). I think fear of the sight of blood is a basic fear for some people. Fear of penetration may be a basic fear or an easy fear.

    The fact that it’s so common to see someone faint at a blood drive when they are getting that initial finger stick – it couldn’t possibly be allow blood pressure thing – is what makes me think it’s distinct from a panic attack. People who are consciously terrified (as opposed to uncomfortable) at the sight of blood would just not go go a blood drive.

  23. Alison, I’m sure the medical folks are much more able to comment on this, but I’ve usually heard fainting at the sight of blood as vasovagal response, which can be triggered by stress/ triggering the flight or fight instinct (as well as a number of other things, pain, standing up quickly, etc). I recall a nurse family mentioning this because, as she recounts, large men seem particularly prone to it.

    http://en.wikipedia.org/wiki/Vasovagal_response

    I had it once when a friend accidentally slammed my finger in a locker door. The funny thing was that the first aid person took one look at me and said “Now don’t you faint on me.” I thought “How silly, why would I faint?” and then keeled over.

    My understanding is that it is, as you said, different from a panic attack.

  24. nopalea says:

    I appreciate the insight. I have always dreaded taking my children to get their vacs done. I did try the dora bandaid on my daughter and it brought a smile to her face.

  25. TsuDhoNimh says:

    The blood never bothered me, but those damned shiny pointy things … I hates them!

    The marvelous woman who taught me how to draw blood samples taught me how to do it so the vial was not visible to the patient – she always had her hand or arm or a fold of blanket between the apparatus and the patient. Then the filled vials were placed in her pocket and labeled later, with her body between the patient and the vials. If they needed mixing with an anti-coagulant that was done below mattress level. Sleight of hand (or sleight of Vacu-Tainer) is a good thing.

    Fortunately for my planned career as a med tech, she also got me over my tendency to faint at the sight of needles by suggesting that needles pointed towards other people were not the same thing.

    One of our students had to switch majors because after several weeks she was still passing out at the sight of blood – even the stuff in vials in the lab.

  26. Werdna says:

    @michele – Well like I said it’s simply a suspicion and like a lot of human responses quite possibly rather complicated. If true it may only be certain modalities of expression (tone might be for some children, volume for others, repetition, etc…) and our observations as to how much we utilize these might be hard to track. With regard to things that children aren’t afraid of that we are those might well have a emotional “payoff” i.e. Climbing something we view as unsafe might be considered “fun” however it’s unreasonable to expect a child to see the payoff in receiving a vaccination.

    Still even if true I’m not so naive to reduce childhood fears down to a single cause. Furthermore there’s no reason my observations are immune to the “tyranny of the small sample” any more than anyone elses.

    …and now I hear a call to come play barbies.

  27. MOI says:

    What a great piece! I shared on FB. =)

    I was very happy to see that my first thought of “breastfeeding” was #1 on the list. It helped my son with a heal-poke (biliruben test). Ugh, those are just awful.

    My children do quite well with injections. My older child was actually kind of excited about her latest vaxes (she’s 4). I’m not sure why. She asked if it was going to hurt and I told her “probably a little bit”. I wrapped my arms around her and the nurse was very quick with the two injections. She whimpered a bit but never shed a tear. I was proud. My son (who is only 9 months) yelps but then is fine. But I think I may try breastfeeding him while they take his blood for lead testing at the age of 1 (if feasible).

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