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Letter to the Editor: Praise for article on reducing immunization pain :

June 27, 2016

It is both appropriate and timely to pay attention to immunization pain, given the recent political controversies aroused by compliance legislation. A few comments may serve to expand the excellent article “How to reduce pain at the time of vaccination” by H. Cody Meissner, M.D., FAAP, in the April issue of AAP News.

Topical anesthetic agents by themselves do not seem effective for intramuscular injections, and when used for venipuncture or intravenous starts should be applied and occluded for 90 minutes to achieve full numbing (Taddio A, et al. Clin J Pain. 2015;31(10 Suppl):S20-S37). Longer applications of lidocaine 4% also seem to work better.

Ethyl chloride is flammable and has largely been supplanted by a pentafluoropropane/tetrafluoroethane product that is more convenient to apply as a spray, is warmer and less noxious, and is nonflammable, albeit more expensive (Franck LS, Berberich FR. Clin Pediatr. 2015;54:228-235). An evidence-based technique that makes use of these vapocoolants as part of a distraction sequence can be found at

Children under age 3 should indeed be held but not supine on an exam table and not pinned down. Rather, they should be held securely and lovingly by a parent or caregiver, seated on the lap and held close (Taddio A, et al. CMAJ. 2015;1871:975-982).

Jet injectors can be effective for those who have needle phobia, but they emit a noisy pop, which may be more frightening than anticipated and cause a young child to start and recoil. It seems these devices find more use in the delivery of lidocaine for procedures.

The importance of taking the time to attend to pain-reducing measures in common pediatric practice procedures cannot be over-emphasized (Berberich FR, Schechter NL. Pediatrics. 2012;129:e1057-e1059). Kudos to Dr. Meissner for being a pain reduction champion!

F. Ralph Berberich, M.D., FAAP

Berkeley, Calif.

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