Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations

Abstract

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Learning About Pain From Others: An Observational Learning Account

“…7 In children, parental reassurance, criticism and apologizing have been shown to be associated with higher expressed children's distress. 53,71 The types of pain behaviors observed in others throughout life would be expected to have a cumulative impact on the repertoire of behaviors available to observers when confronted with comparable painful situations.…”

What are the Trues in Applicating of Intramuscular Injection to Children?: Review

“…2 Literatürde, başparmak ve işaret parmağı arasında kalan cilt bölgesini düz ve gergin tutarak femurun uzun eksenine enjektörü 90 o uygulamanın aşılara bağlı sistemik ve lokal reaksiyonlara daha az neden olduğu, enjeksiyon uygulanan bölgedeki cildin gerilmesinin sadece doğru iğne yerleştirmesini sağlamadığı, aynı zamanda ağrı hissini azaltan ağrı yönetim stratejisi olarak da kullanılabileceği belirtilmektedir. 12 Yenidoğanlar için güvenli ilaç hacmi uygulayabilmek için küçük enjektörlerin (0,5 mL vb) kullanılması tercih edilmelidir. İlaç cam ampulden çekilecek ise, uygulama sırasında iğne ucu değiştirilmelidir.…”

“…Böylece cam parçacıkları ile bebeğin potansiyel yaralanma riski engellenecektir. 5,12,13 Yapılan randomize kontrollü bir çalışmada, 59 makrozomik yenidoğandan (doğum ağırlığı 4.000 g'dan fazla) 25 mm iğne ile aşılananlarda hepatit B aşısı sonrası oluşan antikor seviyesi, 16 mm iğne ile aşılanan yenidoğanlara göre belirgin olarak daha yüksek seviyelerde belirlenmiştir. Bu sonuç ile aşı-lama sırasında yeterince kas derinliğine ulaşılma-sının önemi ortaya konulmuştur.…”

Pain-Relieving Effect of Music on Preschoolers during Immunization: A Randomized Controlled Trial

“…Before reaching the age of 6, they receive 20 or more immunizations, including polio, BCG, measles, and rubella vaccines, in Japan [1] [2]. As each immunization involves pain [3], insufficient pain management may result in future medical fear or pain [4]. Therefore, it is important to develop effective methods to reduce pain during immunization.…”

“…The latter include: musical interventions [5] [8], distraction using videos [5] [8], breathing techniques [5] [9], sucrose administration [8] [10], and positioning [10]. In a systematic review to examine the pain-relieving effect of music, it was shown to reduce pain and anxiety in children (aged 1 -18) when receiving medical care [11].…”