Procedural Pain Management
Vaccinations are the most common source of procedural pain for healthy children and can be a stressful experience for persons of any age. It has been estimated that up to 25% of adults have a fear of needles, with most needle fears developing during childhood. If not addressed, these fears can have long-term effects such as preprocedural anxiety.
Inject Vaccines Rapidly Without Aspiration
Aspiration is not recommended before administering a vaccine. Aspiration prior to injection and injecting medication slowly are practices that have not been evaluated scientifically. Aspiration was originally recommended for theoretical safety reasons and injecting medication slowly was thought to decrease pain from sudden distention of muscle tissue. Aspiration can increase pain because of the combined effects of a longer needle-dwelling time in the tissues and shearing action (wiggling) of the needle. There are no reports of any person being injured because of failure to aspirate.
The veins and arteries within reach of a needle in the anatomic areas recommended for vaccination are too small to allow an intravenous push of vaccine without blowing out the vessel. A 2007 study from Canada compared infantsโ pain response using slow injection, aspiration, and slow withdrawal with another group using rapid injection, no aspiration, and rapid withdrawal. Based on behavioral and visual pain scales, the group that received the vaccine rapidly without aspiration experienced less pain. No immediate adverse events were reported with either injection technique.
Inject Vaccines that Cause the Most Pain Last
Many persons receive two or more injections at the same clinical visit. Some vaccines cause more pain than others during the injection. Because pain can increase with each injection, the order in which vaccines are injected matters. Some vaccines cause a painful or stinging sensation when injected; examples include measles, mumps, and rubella; pneumococcal conjugate; and human papillomavirus vaccines. Injecting the most painful vaccine last when multiple injections are being administered can decrease the pain associated with the injections.
Pain Relievers
Topical anesthetics block transmission of pain signals from the skin. They decrease the pain as the needle penetrates the skin and reduce the underlying muscle spasm, particularly when more than one injection is administered. These products should be used only for the ages recommended and as directed by the manufacturer. Because using topical anesthetics may require additional time, some planning by the healthcare provider and parent may be needed. Topical anesthetics can be applied during the usual clinic waiting times, or before the patient arrives at the clinic provided parents and patients have been shown how to use them appropriately. There is no evidence that topical anesthetics have an adverse effect on the vaccine immune response.
The prophylactic use of antipyretics (e.g., acetaminophen and ibuprofen) before or at the time of vaccination is not recommended. There is no evidence these will decrease the pain associated with an injection. In addition, some studies have suggested these medications might suppress the immune response to some vaccine antigens.
Follow Age-Appropriate Positioning Best Practices
For both children and adults, the best position and type of comforting technique should be determined by considering the patientโs age, activity level, safety, comfort, and administration route and site. Parents play an important role when infants and children receive vaccines. Parent participation has been shown to increase a childโs comfort and reduce the childโs perception of pain. Holding infants during vaccination reduces acute distress. Skin-to-skin contact for infants up to age 1 month has been demonstrated to reduce acute distress during the procedure.
A parentโs embrace during vaccination offers several benefits. A comforting hold:
Avoids frightening children by embracing them rather than overpowering them
Allows the health care professional steady control of the limb and the injection site
Prevents children from moving their arms and legs during injections
Encourages parents to nurture and comfort their child
A combination of interventions, holding during the injection along with patting or rocking after the injection, is recommended for children up to age 3 years. Parents should understand proper positioning and holding for infants and young children. Parents should hold the child in a comfortable position, so that one or more limbs are exposed for injections.
Research shows that children age 3 years or older are less fearful and experience less pain when receiving an injection if they are sitting up rather than lying down. The exact mechanism behind this phenomenon is unknown. It may be that the childโs anxiety level is reduced, which, in turn, reduces the childโs perception of pain.
Tactile Stimulation
Moderate tactile stimulation (rubbing or stroking the skin) near the injection site before and during the injection process may decrease pain in children age 4 years or older and in adults. The mechanism for this is thought to be that the sensation of touch competes with the feeling of pain from the injection and, thereby, results in less pain.
Route and Site for Vaccination
The recommended route and site for each vaccine are based on clinical trials, practical experience, and theoretical considerations. There are five routes used to administer vaccines. Deviation from the recommended route may reduce vaccine efficacy or increase local adverse reactions. Some vaccine doses are not valid if administered using the wrong route, and revaccination is recommended.
Acknowledgements
The editors would like to acknowledge Beth Hibbs and Andrew Kroger for their contributions to this chapter.