Management of Pain in Vaccinations

 I was going to write about the effects of childhood family environment this week but MissC had her vaccinations yesterday. Earlier in the week I had been reading about a study on methods to minimalise pain in vaccinations and I decided to try out some of their techniques.
In the past I have attempted to comfort her after the vaccination by breastfeeding her or giving her her favourite books and songs. 
Clearly that has worked brilliantly

However the studies I have read suggested that the best effect is found not by attempting to comfort them afterwards but by providing comfort or distraction before and during the vaccination. 
Things that are shown to work:
Sitting upright (ish). Low-cut top for breastfeeding

-Positioning: Sitting upright and holding your child is associated with less child pain (Taddio et al 2009)

-EMLA cream (Taddio et al 1993, Dilli, Goker Kucuk & Dallar 2009, probably a gazilliion other studies) - a local anasthetic it is easy to source from a chemist or medical practice. It takes an hour to work effectively though so bear that in mind

-Breastfeeding (Dilli, Goker, Kucker & Dallar 2009)

-Sugar Water (Dilli, Goker, Kucuk & Dallar 2009):  Mix a cube of sugar with two teaspoons of water and offer it to your child using a syringe/eyedropper or on a dummy immediately before the vaccination

-Rubbing the skin - near/at the injection site before or during the vaccination (Sparks 2001)

-Distraction: This is what I did in combination with parental coaching since I forgot to get EMLA cream from work, didn't want to breastfeed her and wasn't sure about the whole offering sugar as comfort thing. I just put on her favourite song and talked to her about a picture on my iPhone and it worked brilliantly, she didn't cry at all but that's just a bit of anacdata.
Distraction techniques vary by age and your childs personal preference but ideas are
           Babies: Mobiles and mirrors
           Toddlers/Young Children: Bubbles, musical toy, pop up books
           Older Children: Any chosen favourite activity e.g. computer game, playing with mum's phone.
                                    Relaxation techniques such as breathing exercises. (Jeavons 2009)

-Parental coaching: Talking to them about nonprocedure things, suggesting ways to cope with the pain and the use of humour has been indicated to decrease distress and pain while reassurance and apologies have been shown to increase distress and pain (Taddio et al 2009). 

Currently most doctors clinics do not routinely offer any of these as options preferring to attempt to distract them afterwards (Harris et al 2013). If you're in Canada, there are new guidelines being considered that may change this but everybody else will need to take the initiative and organise it themselves.. 
It is always a bit difficult I feel to speak up in medical settings and part of the reason I didn't breastfeed or use sugar water with MissC was out of awkwardness about speaking up. Obviously it is better to speak up and ask the clinic to help manage the pain since it will show a need for new procedures but if you don't want to do that (and I don't) here's the tips in what I consider a good trade off of effectiveness and ease of implementation.

Unscientific Guide to Pain Management for Parents (who don't want to be thought of as a bother) 

1.  Positioning: Make sure you're holding the baby/child in an upright position before they start the procedure. They may not ask you to pick the baby up but they're unlikely to tell you to put it down.

2. EMLA cream: Get it from a pharmacy before hand, put it on approximately an hour before the procedure remembering to take into account sitting around time. Rub it on the outer of both upper arms and thighs and you won't even need to tell anyone that its there.

3. Rubbing: Rub at the injection site before the injection and near the site during. Do not rub the injection site afterward.

3. Breastfeeding for under 12 months old: Breastfeeding is the recommending feeding method for this age so just pretend that they're hungry/organise their appointment for a time when they're normally breastfed and put them on the boob then tell the nurse to do the injection while they're feeding. If they say something about being worried about the baby choking/having breast refusal just reassure them that is not going to be the case (Taddio et al 2010) and encourage them to do the injection.

4. Parental distraction/coaching: Use whatever technique you feel is appropriate for your child given their age. Say hello to the doctor/nurse and have a little chat to them to be polite but then engage fully with your baby/child focusing on them and drawing their attention to whatever you are using to distract them while the procedure is taking place. If there is only one needle and you are using an object to distract them put this on the other side to where they are going to get the needle to focus their attention away from the injection.

5. Breastfeeding for over 12 months old: The World Health Organisation recommends breastfeeding until at least two and for as long as you both want to after that. Any good medical practice should be aware of these guidelines and not say anything negative to you. Also, in my experience, if you wear a low cut top and your child is sitting people often don't even realise that you're breastfeeding.

6. Sugar water: Bring your own from home since they may not have the ability to make it for you. Bring the syringe/dummy too. Dosing syringes from children painkillers will be fine. I recommend the dosing syringe from baby nurofen.  I think it is probably easiest to just tell them that you have brought it when they are getting ready and just administer it yourself before they give the injection. As with breastfeeding they are unlikely to choke or gag (Shah, Taddio, Rieder 209) so if the nurse raises this as a concern reassure them that this is not the case. 

With all of these techniques, it is also probably worth thinking about the benefits to your child beyond the removal of immediate pain. I personally believe a little discomfort is good for children but vaccinations and other medical procedures as pain is a learning experience and the pain from vaccinations teaches that needles and medical procedures are painful and undesirable. 25% of the population have needle fears mostly stemming from childhood and 10% avoid health care procedures due to these fears (Taddio et al 2009). This can have far reaching consequences for their health both now and as an adult. 

Chamber S. Taddio A. Uman L. McMurtry C. 2009. Psychological Interventions for Reducing Pain and Distress during Routine Childhood Immunizations: A Systematic Review. Clinical Therapeutics. Volume 31 (Suppl 2) S77-103

Dilli D. Goker Kucuk I. & Dallar, Y. 2009 Interventions to Reduce Pain during Vaccination in Infancy. Journal of Pediatrics. Volume 154, 3. 385-390. Abstract here:

Jeavons M. 2009. Distraction (Online)

Harrison D. Elias S. Royle J. & Manias E. 2013. Pain Management Strategies Used during Early Childhood Immunisation in Victoria. Journal of Paediatrics and Child Health. Volume 43. 313-318. Abstract here:;jsessionid=A4D836309671B9837BD2D2EA34038A80.f02t02

Sparks L. Setlik J. & Luhman J. 2007. Parental Holding and Positioning to Decrease IV Distress in Young Children: A Randomized Controlled Trial. Journal of Paediatric Nursing. Volume 22. 440-447.

Taddio A. Nulman I. Goldbach M. Ipp M. & Koren G. 1994 Use of Lidocaine-Prilocaine Cream for Vaccination Pain in Infants. Journal of Pediatrics. Volume 124, 4. 643-8

Shah V. Taddio A. & Reider M. 2009. Effectiveness and Tolerability of Pharmacologic and Combined Interventions for Reducing Injection Pain During Routine Childhood Immunizations: Systematic Review and Meta-analyses. Clinical Therapeutics. Volume 31 (Suppl 2): S104-47

Taddio A. Appleton M. Bortolussi R. Chambers C. Dubey V. Halperin S. Hanrahan A. Lockett D. MacDonald N. Midmer D. Mousmanis P. Palda V. Pielak K. Riddell R. Rieder M. Scott M. & Shah V. 2010. Reducing the Pain of Childhood Vaccination: An Evidence-Based Clinical Practice Guideline. Canadian Medical Association Journal. Volume 182. Page. 18.  Read online:

  1. Taddio A. Chambers C. Halperin S. 2009. Inadequate Pain Management During Childhood
  1.  Immunizations. 
The Nerve of It. Clinical Therapeutics. Volume 31 (Suppl 2): S152-67


Popular Posts