The World Health Organization (WHO) has declared the week of April 21, 2012 to be World Immunization Week. The purpose of the initiative is to spread information about the importance and safety of vaccines.
Immunizations protect children and save lives. However, the idea of a shot (or two, or three) can be intimidating to young people, and the shots themselves are generally uncomfortable. In a recent blog post, I discussed the analgesic properties of sugar and — to a certain extent — of breast milk. For young infants, sugar water before or nursing during immunizations can provide significant analgesia. For older babies, toddlers, and young children, however, sugar water loses its analgesic properties. A study published in Pediatrics (Schechter et al) reviews some of the pain relief options that parents and doctors can use to help reduce the discomfort of vaccinations. These techniques not only reduce the perception of pain during the procedure, they also lessen the extent to which children associate the doctor’s office with discomfort, which reduces the likelihood of battles on the way to the pediatrician’s office.
The authors found that the effective techniques for reducing pain during immunizations included better preparation for both parent and child. Nervous parents make for a nervous child, so the authors recommend that health care providers review with parents the facts about vaccinations, including the reason for each shot, the benefits conferred by the shot, and a realistic discussion of side effects and discomfort associated with the injection. The parents can then use this information to educate their children in an age-appropriate way. For the youngest patients (those younger than two years of age), there’s not much in the way of pre-shot coaching that is helpful or relevant. Nevertheless, an informed, relaxed parent provides a reassuring presence. Older toddlers and preschoolers tend to anticipate upcoming events (which increases anxiety), so the authors suggest waiting until as close to the shot as possible to talk to them about what’s coming. In talking to a child about vaccinations, parents should address what will happen (in specific terms, including how many shots and where they’ll be given), what it will feel like (during and afterward), and various coping strategies (deep breathing, thinking about something pleasant, etc).
The authors also found that the injection site can make a difference. While the thigh is the vaccination site of choice for children younger than 18 months, and the deltoid is common in children older than three, there’s ambiguity regarding the best site for children between 18 months and three years. Generally, however, injection in the thigh is considered more painful, so the authors recommend making the switch to the upper arm as soon as the arm has adequate musculature. Further, they note, there is some compelling research to suggest that the “hip site,” which sits on the lateral buttock, is much less painful than many other injection sites. There isn’t currently enough research on the delivery of vaccinations in this location to recommend its routine use, but hopefully research will support the use of the hip site in coming years.
During the injection, parental behavior appears to significantly impact a child’s ability to cope. Children respond best to parents who interact in a calm, distracting way with the child (telling an interesting story, for instance, or using humor), or who help the child remember coping skills. Parents who are overly critical, apologetic, or — strangely — overly empathetic tend to increase their child’s distress. The best thing a parent can do during a child’s shot(s) is to stay calm and relaxed, help the child use pre-determined coping skills, or talk about something totally unrelated to the shot.
Another simple technique that can reduce pain is applying pressure to the injection site after a shot. There is not a significant body of controlled scientific research on the effectiveness of this technique, but anecdotal evidence suggests it’s effective, and there appear to be no risks, so it’s worth trying. Parents can ask the health care provider to put pressure (with a finger) on the shot site after withdrawing the needle. The idea here is that the brain can’t process multiple types of stimulation at once, so the sharp pain of the injection is “lost” beneath the more powerful stimulus of pressure. This is the same reason that people instinctively rub a bumped shin or funny bone.
Science Bottom Line:* Being informed, informing your child (in an age-appropriate way), encouraging coping skills, and helping to provide distraction can all reduce immunization-associated pain. Pressure on the site afterward also helps. Remember, vaccinations save lives; the discomfort associated with the shot is not a reason to skip or delay vaccinations!
How do you help your kids cope with shots?
Schechter et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics. 2007 May;119(5):e1184-98.