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.
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May 01 2007
Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations
Neil L. Schechter, MD;
Neil L. Schechter, MD
aPain Relief Program, Connecticut Children's Medical Center, Hartford, Connecticut
bDepartment of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
cDepartment of Pediatrics, St Francis Hospital and Medical Center, Hartford, Connecticut
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William T. Zempsky, MD;
William T. Zempsky, MD
bDepartment of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
cDepartment of Pediatrics, St Francis Hospital and Medical Center, Hartford, Connecticut
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Lindsey L. Cohen, PhD;
Lindsey L. Cohen, PhD
dDepartment of Psychology, Georgia State University, Atlanta, Georgia
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Patrick J. McGrath, PhD;
Patrick J. McGrath, PhD
eCentre for Research in Pediatric Pain, IWK Health Centre, Halifax, Nova Scotia, Canada
fDepartment of Psychology, Dalhousie University, Halifax, Nova Scotia, Canada
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C. Meghan McMurtry, BA;
C. Meghan McMurtry, BA
eCentre for Research in Pediatric Pain, IWK Health Centre, Halifax, Nova Scotia, Canada
fDepartment of Psychology, Dalhousie University, Halifax, Nova Scotia, Canada
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Nancy S. Bright, BSN
Nancy S. Bright, BSN
aPain Relief Program, Connecticut Children's Medical Center, Hartford, Connecticut
cDepartment of Pediatrics, St Francis Hospital and Medical Center, Hartford, Connecticut
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Address correspondence to Neil L. Schechter, MD, Pain Relief Program, Connecticut Children's Medical Center, 282 Washington St, Hartford, CT 06106. E-mail: [email protected]
Pediatrics (2007) 119 (5): e1184–e1198.
Article history
Accepted:
November 15 2006
Citation
Neil L. Schechter, William T. Zempsky, Lindsey L. Cohen, Patrick J. McGrath, C. Meghan McMurtry, Nancy S. Bright; Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations. Pediatrics May 2007; 119 (5): e1184–e1198. 10.1542/peds.2006-1107
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Comments
Child Life Specialists
I enjoyed reading your article as it validates the work I do every day as a Certified Child Life Specialist. I work in a pediatric emergency department and my daily responsibilities include providing developmentally appropriate preparation to patients and families before they receive treatments in the hospital, empowering patients to develop an individualized coping plan, working to ensure their parents have a role in the experience, advocating for comfort positions and enabling patients to cope effectively during procedure- by providing distraction, redirection and appropriate verbal responses. Although, I’m encouraged that research is being done on non-pharmacological pain management, I found it disheartening that no mention was given in your research to our Professional Discipline, as we are already working to advocate for many of the suggestions you presented.
Erin McNevan Certified Child Life Specialist
Conflict of Interest:
None declared