C. Meghan McMurtry

Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations

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 childs 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.

Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review.

BACKGROUND Immunizations are a common source of pain and distress for children. Psychological interventions consist of a variety of techniques for relaxing and distracting children during immunization with the goal of reducing pain and distress. OBJECTIVE We conducted a systematic review to determine the efficacy of various psychological strategies for reducing pain and distress in children during routine immunizations. METHODS MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi-RCTs that determined the effect of psychological interventions on pain and distress during injection of vaccines in children 0 to 18 years of age, using validated child self-reported pain or observer-reported assessments of child distress or pain. We examined the efficacy of 7 psychological interventions: (1) breathing exercises; (2) suggestion; (3) child-directed distraction; (4) parent-led distraction; (5) nurse-led distraction; (6) parent coaching; and (7) combined cognitive-behavioral interventions. All meta-analyses were performed using a fixed-effects model. RESULTS Twenty RCTs involving 1380 infants and children (1 month to 11 years of age) were included in the systematic review. Breathing exercises were effective in reducing childrens self-reported pain (standardized mean difference [SMD], -0.43; 95% CI, -0.76 to -0.09; P = 0.01), observer-rated distress (SMD, -0.40; 95% CI, -0.68 to -0.11; P = 0.007), and nurse-reported distress (SMD, -0.57; 95% CI, -0.98 to -0.17; P = 0.005). Self-reported distress ratings appeared to be lower with breathing exercises, but the difference was not statistically significant. No evidence was found to support suggestion as a psychological intervention for reducing pain associated with pediatric immunization. Child-directed distraction was effective in reducing self-reported pain (SMD, -0.28; 95% CI, -0.54 to -0.03; P = 0.03). Parent-led distraction was effective in reducing observer-rated distress (SMD, -0.50; 95% CI, -0.82 to -0.19; P = 0.002), but not other measures of pain or distress. Nurse-led distraction was effective in reducing distress ratings as assessed by the observer (SMD, -0.40; 95% CI, -0.68 to -0.12; P = 0.005), the parent (SMD, -0.37; 95% CI, -0.66 to -0.07; P = 0.01), and the nurse (SMD, -0.42; 95% CI, -0.70 to -0.14; P = 0.004). Parent coaching was effective in reducing observer-rated distress (SMD, -0.71; 95% CI, -1.02 to -0.39; P < 0.001), but not other measures of pain or distress. Combined cognitive-behavioral interventions were effective in reducing childrens self-reported pain (SMD, -0.75; 95% CI, -1.03 to -0.48; P < 0.001), observer-rated distress (SMD, -0.53; 95% CI, -0.83 to -0.23; P < 0.001), and parent-rated distress (SMD, -0.97; 95% CI, -1.37 to -0.57; P < 0.001). The methodologic quality of the included trials was generally poor, with 18 (90%) of the 20 studies rated as having a high risk of bias. CONCLUSIONS Evidence suggests that breathing exercises, child-directed distraction, nurse-led distraction, and combined cognitive-behavioral interventions are effective in reducing the pain and distress associated with routine childhood immunizations. Although additional well-designed trials examining psychological interventions are needed, parents and health care professionals should be advised to incorporate psychological interventions to reduce the pain and distress experienced by children during immunization.

When ''don't worry" communicates fear: Children's perceptions of parental reassurance and distraction during a painful medical procedure

&NA; Childrens distress during painful medical procedures is strongly influenced by adult behavior. Adult reassurance (e.g., “its okay”) is associated with increased child distress whereas distraction is associated with increased child coping. It is unknown why reassurance shows this counterintuitive relationship with child distress. The present research investigated whether children perceive their parents as fearful when they reassure using complementary observational and experimental methodologies. One hundred children (40 boys, 60 girls) 5–10 years old (M = 8.02, SD = 1.69) and their parents (86 mothers, 14 fathers) participated. First, spontaneous parent–child interactions during pediatric venipuncture were captured and used for a video‐mediated recall task in which the children viewed instances of parental reassurance and distraction and rated their parents’ fear and happiness. Second, the children were asked to rate the intensity of parental fear and happiness for 12 video vignettes showing an actor posing as a parent during venipuncture. To determine whether the childrens perceptions varied with the qualities of the behavior, the vignettes manipulated: facial expression (happy vs. fearful), vocal tone (rising vs. falling), and content (informative reassurance vs. uninformative reassurance vs. distraction). For both tasks, the children provided higher ratings of fear during reassurance than distraction. In response to the vignettes, the children gave higher ratings of parental fear for a fearful facial expression, but the influence of vocal tone differed with the verbal content of the utterance. The results provide insight into the complexity of adult reassurance and highlight the important role of parental facial expression, tone, and verbal content during painful medical procedures.

Children's Memory for Painful Procedures: The Relationship of Pain Intensity, Anxiety, and Adult Behaviors to Subsequent Recall

OBJECTIVE To examine whether childrens experience of pain intensity and anxiety, and adult behaviors during venepuncture, were related to childrens memories of the procedure. METHODS Participants were 48 children (24 males, 24 females) between the ages of 5 and 10 years who underwent venepuncture. The venepunctures were videotaped and adult behaviors were coded. Children self-reported their pain intensity and anxiety immediately and 2 weeks following venepuncture and answered contextual questions at follow-up. RESULTS Children who initially reported higher levels of pain tended to over-estimate their anxiety at follow-up, whereas children who reported lower levels of pain accurately- or under-estimated their anxiety. Staff coping-promoting behaviors predicted the accuracy of childrens contextual memories. Staff and parent behaviors did not predict childrens recalled pain intensity and anxiety. CONCLUSIONS Results indicate that childrens direct experience of pain intensity and staff behaviors during venepuncture are related to their memories. These data highlight the importance of effective pain management during medical procedures.

Reducing pain during vaccine injections: clinical practice guideline

Pain from vaccine injections is common, and concerns about pain contribute to vaccine hesitancy across the lifespan.[1][1],[2][2] Noncompliance with vaccination compromises the individual and community benefits of immunization by contributing to outbreaks of vaccine-preventable diseases. Individuals

Far from “just a poke”: common painful needle procedures and the development of needle fear

Background:Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress. Objective:The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established. Results:First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue. Discussion:Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis.

Background:This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan. Design/Methods:Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI). Results:Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD −1.78 (CI, −2.35, −1.22) and (2) before vaccination (n=100): SMD −1.43 (CI, −2.14, −0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD −0.91 (CI, −1.36, −0.47) and self-reported pain in adults (n=60): SMD −0.85 (CI, −1.38, −0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD −0.76 (CI, −1.19, −0.34) or glucose (n=818): SMD −0.69 (CI, −1.03, −0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD −0.78 (CI, −1.08, −0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone. Conclusions:Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

Developing and Modifying Behavioral Coding Schemes in Pediatric Psychology: A Practical Guide

OBJECTIVES To provide a concise and practical guide to the development, modification, and use of behavioral coding schemes for observational data in pediatric psychology. METHODS This article provides a review of relevant literature and experience in developing and refining behavioral coding schemes. RESULTS A step-by-step guide to developing and/or modifying behavioral coding schemes is provided. Major steps include refining a research question, developing or refining the coding manual, piloting and refining the coding manual, and implementing the coding scheme. Major tasks within each step are discussed, and pediatric psychology examples are provided throughout. CONCLUSIONS Behavioral coding can be a complex and time-intensive process, but the approach is invaluable in allowing researchers to address clinically relevant research questions in ways that would not otherwise be possible.

Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials.

Background:This systematic review evaluated the effectiveness of physical and procedural interventions for reducing pain and related outcomes during vaccination. Design/Methods:Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Data were extracted according to procedure phase (preprocedure, acute, recovery, and combinations of these) and pooled using established methods. Results:A total of 31 studies were included. Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) −0.82 (95% confidence interval [CI]: −1.18, −0.46). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD −0.69 (95% CI: −0.98, −0.4). Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD −0.56 (95% CI: −0.87, −0.25). There was no benefit of simultaneous injections in children. Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. deltoid) injections (n=185): SMD −0.70 (95% CI: −1.00, −0.41). Skin-to-skin contact in neonates (n=736) reduced acute distress: SMD −0.65 (95% CI: −1.05, −0.25). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD −1.25 (95% CI: −2.05, −0.46). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD −0.65 (95% CI: −1.08, −0.22). Self-reported fear was reduced for children positioned upright (n=107): SMD −0.39 (95% CI: −0.77, −0.01). Non-nutritive sucking (n=186) reduced acute distress in infants: SMD −1.88 (95% CI: −2.57, −1.18). Manual tactile stimulation did not reduce pain across the lifespan. An external vibrating device and cold reduced pain in children (n=145): SMD −1.23 (95% CI: −1.58, −0.87). There was no benefit of warming the vaccine in adults. Muscle tension was beneficial in selected indices of fainting in adolescents and adults. Conclusions:Interventions with evidence of benefit in select populations include: no aspiration, injecting most painful vaccine last, simultaneous injections, vastus lateralis injection, positioning interventions, non-nutritive sucking, external vibrating device with cold, and muscle tension.

Psychological Interventions for Vaccine Injections in Children and Adolescents: Systematic Review of Randomized and Quasi-Randomized Controlled Trials.

Background:This systematic review evaluated the effectiveness of psychological interventions for reducing vaccination pain and related outcomes in children and adolescents. Design/Methods:Database searches identified relevant randomized and quasi-randomized controlled trials. Data were extracted and pooled using established methods. Pain, fear, and distress were considered critically important outcomes. Results:Twenty-two studies were included; 2 included adolescents. Findings showed no benefit of false suggestion (n=240) for pain (standardized mean difference [SMD] −0.21 [−0.47, 0.05]) or distress (SMD −0.28 [−0.59, 0.11]), or for use of repeated reassurance (n=82) for pain (SMD −0.18 [−0.92, 0.56]), fear (SMD −0.18 [−0.71, 0.36]), or distress (SMD 0.10 [−0.33, 0.54]). Verbal distraction (n=46) showed reduced distress (SMD −1.22 [−1.87, −0.58]), but not reduced pain (SMD −0.27 [−1.02, 0.47]). Similarly, video distraction (n=328) showed reduced distress (SMD −0.58 [−0.82, −0.34]), but not reduced pain (SMD −0.88 [−1.78, 0.02]) or fear (SMD 0.08 [−0.25, 0.41]). Music distraction demonstrated reduced pain when used with children (n=417) (SMD −0.45 [−0.71, −0.18]), but not with adolescents (n=118) (SMD −0.04 [−0.42, 0.34]). Breathing with a toy (n=368) showed benefit for pain (SMD −0.49 [−0.85, −0.13]), but not fear (SMD −0.60 [−1.22, 0.02]); whereas breathing without a toy (n=136) showed no benefit for pain (SMD −0.27 [−0.61, 0.07]) or fear (SMD −0.36 [−0.86, 0.15]). There was no benefit for a breathing intervention (cough) in children and adolescents (n=136) for pain (SMD −0.17 [−0.41, 0.07]). Conclusions:Psychological interventions with some evidence of benefit in children include: verbal distraction, video distraction, music distraction, and breathing with a toy.