For many children, needle procedures can be a painful and distressing experience. Such negative experiences can further develop into fear of needles (McMurtry et al., 2015) with a possibility of adverse consequences, such as health care avoidance behavior and vaccine hesitancy. Given the current combat with the COVID-19 pandemic and global vaccination campaign, which since recently also includes children, reducing fear of needles is important to consider and manage (Love and Love, 2021).
Painful procedures, such as vaccinations, can have an impact on children even long after the painful stimulus is removed (Noel et al., 2012a). In particular, children’s memories of a painful experience are shown to be a powerful predictor of future pain experiences and to even have a greater impact on future pain experiences than the initial pain experience (Noel et al., 2012b; von Baeyer et al., 2004). Multiple factors have been indicated to be able to influence the development and maintenance of children’s pain memories (Noel et al., 2012a; Noel et al., 2015a), including age (Noel et al., 2015b) and sex (Hechler et al., 2009), but also state (i.e., situation specific) anxiety (Noel et al., 2012c), catastrophic worry about pain (Noel et al., 2015b), and pain-related self-efficacy (Marche et al., 2016). Recalling higher levels of pain compared to initially reported pain is associated with higher subsequent pain, distress, medical non-compliance, and future pain expectancies (Noel et al., 2012b; von Baeyer et al., 2004; Arntz et al., 1990).
That being said, what can parents and health care providers do to minimize pain and stress in children during vaccinations, so that we can counteract the development of negatively estimated pain memories? Many evidence-based strategies to mitigate pain during needle-procedures exist, yet most are not routinely used (Harrison et al., 2013; Taddio et al., 2007). Based on two clinical practice guidelines (Taddio et al., 2010; Taddio et al., 2015) and additional evidence (e.g., Rheel et al., 2021), some tips and tricks to minimize pain and distress during vaccinations in children are listed below.
Infants (birth to 1 year of age)
Breastfeeding during vaccination, starting before and continuing up to a few minutes after the vaccination is a combined analgesic intervention, as several aspects of breastfeeding (e.g., holding the child, skin-to-skin contact, sweet-tasting milk, and the act of sucking) may all individually minimize pain. Some infants may refuse breastfeeding and some mothers may not wish to breastfeed during the vaccination. However, feeding the infant with breast milk or formula via a bottle cannot be considered a substitute for breastfeeding as a method of pain reduction.
Oral sweet-tasting solutions have an analgesic effect. Sucrose water is inexpensive and easy to prepare. The most common dose of sucrose water is 2ml of 25% strength. For example, mix one cube of sugar with 10ml water and administer this orally by means of an oral syringe, medicine cup or pacifier about two minutes prior to the injection.
Children (>1 year old)
Avoid supine position
Children may be vaccinated in various positions (e.g., lying supine, sitting upright, being held). We often see that parents instinctively pick up their children when trying to comfort them, which is a good thing, as lying supine results in more pain compared to sitting upright or being held by a parent.
Rapid intramuscular injection
To minimize pain at the time of injection, intramuscular vaccines in children should be administered by a rapid injection technique, without aspiration. Aspiration was initially proposed for safety reasons, preventing penetration of blood vessels during injection, while slow injection was recommended to minimize pain from sudden tissue distension. However, the combination of aspiration and slow injection may actually increase vaccination pain because of longer needle-tissue contact time and through “wiggling” of the needle within the tissue.
Tactile stimulation near the injection site
To reduce pain during the injection among children ≥ 4 years old, offer to rub/stroke the child’s skin near the injection site before and during vaccination, with moderate intensity. Tactile stimulation is a cost-neutral intervention that has the ability to reduce the sensation of pain. However, it is important to distinguish between stroking or rubbing the skin near the injection site before and during injection versus after; rubbing the injection site after injection may increase the risk of vaccine reactogenicity.
Overall, evidence indicates beneficial effects of parental presence versus absence with regard to children’s self-reported pain intensity and pain-related physiological parameters (e.g., heart rate). On the other hand, findings on the impact of parental presence versus absence on children’s self-reported fear, anxiety and distress. However, no overall adverse effects of parental presence before, during, or after a painful medical procedure on children’s self-reported fear, anxiety, or distress have been reported.
To reduce pain at the time of injection, parents can be encouraged to apply topical anesthetics on the skin of their children shortly before the vaccination. Examples are: lidocaine-prilocaine 5% cream or patches (EMLA), amethocaine 4% gel (Ametop), and liposomal lidocaine 4% cream (Maxilene). Education of parents (e.g., by the pharmacist) is recommended, including specifying the exact site or sites of administration. Topical anesthetics should be applied about 20-60 minutes before the injection, depending on the product being applied.
Parent-led, clinician-led, or child-led distraction (see for example Chambers et al., 2009) can help to reduce pain at the time of injection, including toys, humor, singing, … depending on the age of the child and available time.
To reduce pain at the time of injection in children ≥ 3 years old, engage them in slow, deep breathing or blowing during vaccination. Slow, deep breathing serves as a relaxation strategy. In case of facilitating such breathing techniques by toys or activities (e.g., blowing bubbles), they also simultaneously serve as a distraction by focusing attention away from the procedure. Instruct the child to take a deep breath in and then blow it out slowly. Also remind or prompt the child during the procedure.
Optimal parent-child reminiscing about a past pain experience results in children remembering their pain more accurately or positively. Here are three important parts of positive reframing: 1) emphasize on positive things that happened during the vaccination procedure (e.g., friendly nurse, funny music in the background), 2) when your child is exaggerating what happened (e.g., “I was crying for 10 minutes”) while it actually was only 1 minute, help them correct these exaggerations, and 3) tell the child that they did well and were brave, but also tell them how (e.g., “You blew such big bubbles during the injection, that’s so cool! You helped yourself by doing that.”), to build a sense of self-efficacy and confidence.
Several of the practice recommendations listed above can be implemented immediately by health care providers in all vaccination practice settings, as they do not require any planning or additional resources, such as money or extra time per vaccination (e.g., positive reframing). Other recommendations listed above (e.g., administration of sugar water) require some planning and additional resources, yet might be worth considering.
If you want to learn a bit more about the importance of pain memories and positive reframing, watch the latest One Thing video with Melanie Noel: https://onething.painsci.org/the-way-you-talk-abou...
PhD researcher at the Pain in Motion research group (PAIN), Vrije Universiteit Brussel, and Ghent Health Psychology Lab (GHP-Lab), Ghent University
2022 Pain in Motion
References and further reading:
McMurtry CM, Pillai Riddell R, Taddio A, Racine N, Asmundson GJ, Noel M, Chambers CT, Shah V; HELPinKids&Adults Team. Far From "Just a Poke": Common Painful Needle Procedures and the Development of Needle Fear. Clin J Pain. 2015 Oct;31(10 Suppl):S3-11. https://pubmed.ncbi.nlm.nih.gov/26352920/
Love AS, Love RJ. Considering Needle Phobia among Adult Patients During Mass COVID-19 Vaccinations. J Prim Care Community Health. 2021 Jan-Dec;12:21501327211007393. https://pubmed.ncbi.nlm.nih.gov/33813931/
Noel M, Chambers CT, Petter M, McGrath PJ, Klein RM, Stewart SH. Pain is not over when the needle ends: a review and preliminary model of acute pain memory development in childhood. Pain Manag. 2012a Sep;2(5):487-97. https://pubmed.ncbi.nlm.nih.gov/24645865/
Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The influence of children's pain memories on subsequent pain experience. Pain. 2012b Aug;153(8):1563-1572. https://pubmed.ncbi.nlm.nih.gov/22560288/
von Baeyer CL, Marche TA, Rocha EM, Salmon K. Children's memory for pain: overview and implications for practice. J Pain. 2004 Jun;5(5):241-9. https://pubmed.ncbi.nlm.nih.gov/15219255/
Noel M, Palermo TM, Chambers CT, Taddio A, Hermann C. Remembering the pain of childhood: applying a developmental perspective to the study of pain memories. Pain. 2015a Jan;156(1):31-34. https://pubmed.ncbi.nlm.nih.gov/25599297/
Noel M, Rabbitts JA, Tai GG, Palermo TM. Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall. Pain. 2015b May;156(5):800-808. https://pubmed.ncbi.nlm.nih.gov/25630028/
Hechler T, Chalkiadis GA, Hasan C, Kosfelder J, Meyerhoff U, Vocks S, Zernikow B. Sex differences in pain intensity in adolescents suffering from cancer: differences in pain memories? J Pain. 2009 Jun;10(6):586-93. https://pubmed.ncbi.nlm.nih.gov/19386554/
Noel M, Chambers CT, McGrath PJ, Klein RM, Stewart SH. The role of state anxiety in children's memories for pain. J Pediatr Psychol. 2012c Jun;37(5):567-79. https://pubmed.ncbi.nlm.nih.gov/22362922/
Marche TA, Briere JL, von Baeyer CL. Children's Forgetting of Pain-Related Memories. J Pediatr Psychol. 2016 Mar;41(2):220-31. https://pubmed.ncbi.nlm.nih.gov/26666267/
Arntz A, van Eck M, Heijmans M. Predictions of dental pain: the fear of any expected evil, is worse than the evil itself. Behav Res Ther. 1990;28(1):29-41. https://pubmed.ncbi.nlm.nih.gov/2302147/
Harrison D, Elia S, Royle J, et al. Pain management strategies used during early childhood immunisation in Victoria. J Paediatr Child Health 2013;49:313-8. https://pubmed.ncbi.nlm.nih.gov/23489548/
Taddio A, Manley J, Potash L, et al. Routine immunization practices: use of topical anesthetics and oral analgesics. Pediatrics 2007;120:e637-43. https://pubmed.ncbi.nlm.nih.gov/17766503/
Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J, Shah V. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ. 2010 Dec 14;182(18):E843-55. https://pubmed.ncbi.nlm.nih.gov/21098062/
Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin SA, Bowles S, Halpert C, Ipp M, Asmundson GJG, Rieder MJ, Robson K, Uleryk E, Antony MM, Dubey V, Hanrahan A, Lockett D, Scott J, Bleeker EV; HELPinKids&Adults. Reducing pain during vaccine injections: clinical practice guideline. CMAJ. 2015 Sep 22;187(13):975-982. https://pubmed.ncbi.nlm.nih.gov/26303247/
Rheel E, Malfliet A, Van Ryckeghem DML, Pas R, Vervoort T, Ickmans K. The Impact of Parental Presence on their Children during Painful Medical Procedures: A Systematic Review. Pain Med. 2021 Aug 28 (https://pubmed.ncbi.nlm.nih.gov/34453832/)
Pavlova M, Lund T, Nania C, Kennedy M, Graham S, Noel M. Reframe the Pain: A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention. J Pain. 2022 Feb;23(2):263-275. (https://pubmed.ncbi.nlm.nih.gov/34425247/)
Chambers CT, Taddio A, Uman LS, et al.; HELPinKIDS Team. Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther 2009;31(Suppl 2):S77-103. https://pubmed.ncbi.nlm.nih.gov/19781437/