Group Offers Guidelines to Lessen Vaccination Pain

Diedtra Henderson

August 28, 2015

Clinicians who administer vaccines can take a series of proactive actions, including shuffling the order of injections, leveraging the calming influence of parents and breast-feeding, and routinely applying topical anesthetic, to alleviate pain for patients of all ages, according to a new clinical practice guideline.

Anna Taddio, PhD, from the Leslie Dan Faculty of Pharmacy, Uni¬versity of Toronto, Ontario, Canada, and 24 other experts make up the independent multidisciplinary team that calls itself HELPinKids&Adults. "No single intervention included in this guideline is expected to prevent all pain (i.e., achieve a level of pain of '0'). Individual interventions can be combined, as appropriate, to improve pain relief," Dr Taddio and coauthors write in new pain-reduction guidelines published online August 24 in CMAJ.

According to HELPinKids&Adults, patients of all ages are concerned about pain from vaccine injections, and such worries can dampen adults' interest in vaccination. The group adopted a multifaceted approach to pain management that factored in procedural, physical, pharmacologic, psychological, and process interventions.

The group strongly recommends that aspiration not be used during intramuscular vaccination for patients of all ages, as letting the needle linger in the tissue longer and wiggling it can increase pain. In addition, they strongly recommended that patients of all ages receive the most painful vaccination, such as pneumococcal conjugate vaccine or live measles, mumps, and rubella virus vaccine, last in the series, rather than as the first shot.

Because the mother's warmth and sweet-tasting breast milk are associated with reduced distress in infants, the authors strongly recommended breast-feeding during vaccination of children aged 2 years and younger. A 2-mL dose of 24% to 50% strength sucrose solution can be given about 2 minutes before the injection in children aged 2 years and younger who do not breast-feed. Alternatively, the oral rotavirus can be provided first in the series, as it contains sucrose.

Children aged 3 years and younger should be held in a comfortable position during the shot, with neonates who are not breast-fed held skin-to-skin. The recommendation that patients sit upright holds for patients as young as 3 years, as the seated position decreases fear and can confer a sense of control.

Ideally, parents should accompany children aged 10 years and younger during vaccination, and the parents should be educated in advance, as well as on the day of the vaccination, about how to help allay their child's fear and distress. On the day of the vaccination, children aged 3 years and older should be informed how the inoculation will occur, what they should expect to feel, and strategies for managing pain.

Robert L. Wergin, MD, a family physician who practices in Milford, Nebraska, a small town where he was born and raised, said the guidelines make sense and mirror the pragmatic approach he takes in treating his patients. He already saves the most painful shot for last, as "some hurt more than others"; invites parents' presence as part of family-centered care; and suggests breast-feeding or sucrose, including for infants to be circumcised.

"Trying to make the experience as positive as you can is a good thing, and it looked like nothing in [the guidelines] would cause any harm," Dr Wergin, who is also president of the American Academy of Family Physicians, told Medscape Medical News.

However, he noted that the guidelines have the potential to "increase cost and time" and were not backed by strong evidence. In addition, the authors "really didn't provide any data that indicates this will increase vaccination rates."

One recommendation that would be new for his practice would be applying topical anesthetic before vaccinating children aged 12 years and younger. According to the guideline authors, topical anesthetic should be applied routinely, as most children fear needles and cannot effectively advocate on their own behalf.

Topical creams take at least 30 minutes to numb skin compared with quicker action when dentists use them inside the mouth, and Dr Wergin has recommended them for select patients, such as patients taking chemotherapy. "I hadn't thought of using the same type of thing for children" seeking vaccination, he said.

"Pain during vaccination is an important concern across the lifespan," the guideline authors write. "This guideline provides rec¬ommendations for interventions that can miti¬gate vaccination pain. Many interventions are feasible across vaccination settings."

Financial support for the research was provided by the Canadian Institutes of Health Research and the Mayday Fund. Collectively, four of the 25 authors disclosed having received consultation fees from AbbVie; grants from Folia Biotech, GlaxoSmithKline, Immunovaccine, Janssen, Merck, Novartis, Novavax, Pfizer, Pan-Provincial Vaccine Enterprise Inc, and Sanofi; and study supplies from Natus and Ferndale. A fifth author disclosed being a member of the Grading of Recommendations Assessment, Development and Evaluation working group and being a paid consultant for the International Liaison Committee on Resuscitation. The remaining authors have disclosed no relevant financial relationships.

CMAJ. Published online August 24, 2015. Full text


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