Vaccinating children: planning to reduce pain

Immunising children, whether as part of the routine childhood immunisation programme or in the context of a travel consultation, is a key role for the vast majority of general practice nurses, but the prospect of probably inflicting pain can be off-putting

Following on from last month’s article, Childhood immunisations: Dealing with the out of the ordinary (Practice Nurse, February 2018) this guide aims to provide some pointers on reducing the child’s experience of pain during immunisations, and includes a guide for parents that you can cut out and keep.

Like myself, the majority of nurses come into travel medicine or general practice with training in adult nursing. With limited paediatric practice, starting to consult with children and families can be a daunting task. However, with consideration of the clinical evidence, good consultation preparation and some practice in family consults there is no reason that adult-trained nurses cannot become accomplished in carrying out children’s immunisations and travel health risk assessments with just as much compassion as our paediatric-trained peers.

Research suggests that minimising pain during childhood vaccination can help to prevent distress, development of needle phobias and subsequent health care avoidance behaviours and that more positive experiences during injections also maintains and promotes trust in health care providers.¹

In order to carry out the smoothest and least traumatic vaccination experience, health care professionals should be well prepared, practise excellent technique and display confidence in their abilities in order that parents and children are also confident in the procedure. So how does this look in practice?

BEFORE THE CONSULTATION

Clinic planning is essential – having paperwork is in place ensures an efficient pre-vaccine consultation. Prolonged administrative tasks with patients present may add to anxiety of an impending vaccine.

If it is expected to be a lengthy consultation, such as a travel consultation, it can be useful to have distraction aids available. These could take the form of a book, a toy or a YouTube video of nursery rhymes. This relaxes the child during the consultation while allowing you time to carry out the required assessment with a focused parent. If there is the benefit of an additional adult attending, the child could also sit outside the procedure room until the risk assessment is completed with the primary carer.

If it is a routine vaccine, the required paper work can be filled out prior to the child and carer entering the clinic room and verbally confirmed before the vaccine is administered. For this reason, some practitioners still prefer to do paper forms before inputting into the relevant database.

PROFESSIONAL ASPECTS

• The patient or carer must be fully informed about the vaccines to be given and understands the vaccination procedure
• Consent is obtained from the legally responsible carer (mother, married father or legal guardian – a signed instruction can be used if another carer is attending)
• There are no contraindications to the vaccines being given
• The patient or carer is aware of possible adverse reactions and how to treat them.
• The correct legal framework for administration is in place – PGD or PSD
• The medicine to be administered has been stored correctly and is given as directed in the Summary of Product Characteristics.

A FRIENDLY APPROACH

A calm, confident manner and a friendly welcome will set the tone of the consultation. Avoid telling a child that ‘it won’t hurt’ – this sort of statement is not shown to reduce pain-associated distress,2 and can lead to mistrust of medical procedures.

Each child is an individual – distraction appears to be key but a brief explanation may help in older children, for example, ‘I am going to give you your medicine so that you can stay nice and healthy’. Or if the child specifically asks about pain, you could say, ‘you will feel it, but we will do it as quickly as possible so you can enjoy your holiday safely’.

Acknowledge the child who is upset – it is OK for them to be upset and for pain to be recognised. Reinforcing that they did really well may be helpful.

EVIDENCE-BASED PAIN REDUCTION

Breastfeeding

Evidence suggests that breastfeeding should start at least 1 minute prior to injection, to ensure a good latch, and continue throughout/after the procedure. The effects of breastfeeding in pain reduction are multifaceted, due to holding position, skin-to-skin, sweet tasting solution and suckling. In studies of several hundreds of babies there was no evidence of gagging, or risk of association of pain with breastfeeding.² Giving breast or formula milk in a bottle should not be substituted for pain relief as it has not been shown to be effective.²

For infants up to 12 months of age who cannot be breastfed during vaccination, administration of a sugar-water solution (5g in 10 ml of water) via a syringe into the side of the infant’s cheek, about 1 minute prior to vaccination is shown to be effective.² Alternatively, a pacifier can be dipped in sugar water to suckle during the procedure. This provides sweet taste and suckling relief. Of course this should only be used for procedural pain – not for general comforting. The use of a pacifier alone provides the benefit of suckling.

Babies should be held by their primary carer or someone they are familiar with. Holding in a feeding position or upright in a sitting position exposes the required limbs. Evidence suggests that babies held closely by a parent show the least signs of distress. Lying a baby flat is associated with more distress.²

Injection technique

To reduce pain at the time of injection, administer intramuscular vaccines to children using a rapid injection technique (1 second for 0.5ml) without aspiration.²

When administering multiple vaccine injections to children sequentially, inject the most painful vaccine last to reduce pain at the time of injection.² This will require a little experience of giving vaccines to determine the order – most adults mention that vaccines with higher volume are more uncomfortable so I usually start with the one with the smallest volume.

Distraction

In young children, use clinician-led or parent-led distraction techniques during administration. In older children, aged three years or older, use child-led distraction techniques during vaccination.²

Another technique to reduce pain at the time of injection is to have children aged ≥ 3 years engage in slow, deep breathing or blowing during vaccinations.² In babies, a carer can hold the baby close and practise slow breathing themselves – this can have a soothing effect on the baby.³

Use of topical anaesthetics during vaccination of children reduces pain.² This requires prior planning by the parent or carer, who will need to collect lidocaine/prilocaine (EMLA) cream, and apply it according to the pack insert instructions an hour before the procedure.

SAFE HOLDING

Safe holding is one of the key aspects of a safe injection. Holding is beneficial in making children feel safe, secure and comforted and it assists with the safe delivery of vaccines by preventing movement of arms and legs during injections. A comforting hold avoids the feeling of being overpowered, encourages nurturing by the parent and provides a steady injection site.⁴ I provide my parents with a copy of the information sheet overleaf and ask them to note the holding positions.

VACCINATION PROCEDURE

Select the most appropriate site – deltoid or anterolateral thigh for intramuscular vaccines. For children up to age 3 years, the anterolateral thigh is preferred. From 3 years, the deltoid is the first option, but anterolateral thigh can also be used.⁵ In anxious children the thigh may be useful if they are pulling away or fearful of seeing the procedure so closely.

• Check that the site is visually clean: swabbing is not routinely necessary.
• 23G or 25G needles at a length of 25mm are associated with less risk of local reaction
• Vaccinate rapidly (1 second per 0.5ml) with no aspiration required.²
• Inject the site at a 90-degree angle with the skin stretched for intramuscular injections and 45-degree angle for subcutaneous injections.
• If more than one vaccine is required then vaccinations should be given at sites separated by 2.5cm, preferably in a different limb.⁶ In multiple injection procedures make sure all sites required are exposed and ready for quick procedure
• Monitor the patient for any immediate adverse reactions – there is no reason to keep them in the treatment room or practice for extended observation.⁶ If breastfeeding continues, accommodate the mother and child while you complete the paperwork, or offer a comfortable spot to continue elsewhere.

CONCLUSION

As time pressured as we are, nurses know the benefit of a calm and straightforward procedure and the evidence is available to back us up. Many of these things take a few seconds to implement but make a huge difference. With a little bit of preparation we can transform a potentially stressful consultation into something less daunting for everyone involved.

• Download the accompanying information leaflet that you can print out and keep or photocopy to give to parents and carers to help prepare for their children's immunisations.

RESOURCESImmunisation (The Green Book)https://www.gov.uk/government/collections/immunisationsWhat to expect after vaccinations (under 5s)https://www.gov.uk/government/publications/what-to-expect-after-vaccinationsReduce the pain of vaccination in babies (video)https://www.youtube.com/watch?v=50qa1Fag5eQRCN. Immunisationhttps://www.rcn.org.uk/clinical-topics/public-health/specialist-areas/immunisationGP Infant Feeding Network UKNational network of primary care professionals advocating for improvements in infant feeding practice. https://gpifn.org.uk/

REFERENCES

1. Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S152-67

2. Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ 2010;182(18): E843–E855

3. Hensel D, Morson GL, Preuss EA. Best practices in newborn injections. Am J Matern Child Nurs 2013;38:163–7

4. Centers for Disease Control. How to hold your child during vaccines, 2012. https://www.cdc.gov/vaccines/parents/tools/holds-factsheet.html

5. Immunization Action Coalition. Administering Vaccines, 2017. http://www.immunize.org/askexperts/administering-vaccines.asp

6. Public Health England. Immunisation procedures: The Green Book, Chapter 4. https://www.gov.uk/government/publications/immunisation-procedures-the-green-book-chapter-4