Pain Management for Immunisations Dr Kathryn Russell Senior Clinical Psychologist Paediatric Consult Liaison Team – Whirinaki/Kidz First Date: Created by:

Why does procedural pain matter? Procedural pain causes distress for children and their parents. Procedural pain can lead to procedural anxiety, needle fears and health care avoidance (Taddio et al, 2009). Medical procedures are among the most feared of all childhood experiences. Needle procedures are the most common and feared type of iatrogenic medical pain. (Broome et al, 1990). Immunisations are the most common recurring health procedure in childhood (Taddio et al, 2009).

Can immunisation pain cause non-compliance? Parents withhold or delay vaccination to try to avert suffering (Mills et al, 2005) Older children and adolescents may refuse vaccinations because of fear of pain (Omar et al,2009) Up to 25% of adults have a fear of needles that developed in childhood. 10% of population avoids needle procedures and dental care because of needle phobia, and 2/3rds of those people are less likely to vaccinate their own children (Wright et al, 2009).

Do babies feel pain? Newborns have pathways for detection, transmission & reaction to noxious stimuli Infants lack mature descending inhibitory pathways (Fitzgerald et al 1991) Pain experiences can have permanent changes in the nervous system that will affect future pain experience and development.

Pain pathways Ascending sensory pathways are functioning in preterm and term infants, yet descending inhibitory pathways mature during the first 12 months. Infants may experience pain from the same stimulus more intensely than older children (Kennedy et al 2008).

Do infants and young children remember pain? Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. (Taddio et al, 1997) Newborns (diabetic mothers) exposed to repeated heel pricks in the first 24 - 36 hrs had more intense pain responses during venipuncture than controls (Taddio, 2002). Children report greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures (Kennedy et al, 2008). Babies and young children remember pain, even if not consciously. Among the circumcised group, preoperative treatment with EMLA attenuated the pain response to vaccination.

GOOD NEWS Fortunately, both pharmacologic and non-pharmacologic techniques have been found to reduce children's acute pain and distress and subsequent behaviours and anxieties during vaccination. The following is taken from systematic reviews by Taddio et al 2010, 2009 and Shah et al 2009.

Vaccination Quiz: True or False Giving sucrose up to 12 months of age can reduce pain and distress. Using medicines like paracetamol or ibuprofen can reduce pain and distress. Putting ice on the skin can reduce pain and distress. Breastfeeding can reduce pain and distress. Bottle feeding can reduce pain and distress. Holding the baby can reduce pain and distress. Using EMLA can reduce pain and distress. Distracting the baby can reduce pain and distress. Parent acting calm can reduce pain and distress. Rubbing (or vibration) on the skin nearby can reduce pain and distress. Aspiration is important for routine vaccination safety. Slow delivery is less painful.

True/False Giving sucrose up to 12 months of age can reduce pain and distress. Using medicines like paracetamol or ibuprofen can reduce pain and distress. Putting ice on the skin can reduce pain and distress. Breastfeeding can reduce pain and distress. Bottle feeding can reduce pain and distress (maybe but research unclear. Formula taste less effective the EBM or Sucrose less). Holding the baby can reduce pain and distress (but not too tight). Using EMLA can reduce pain and distress. Distracting the baby can reduce pain and distress. Parent acting calm can reduce pain and distress. Rubbing (or vibration) on the skin nearby can reduce pain and distress. Aspiration is important for routine vaccination safety. Slow delivery is less painful.

Sucrose Oral sweet-tasting solutions (with or without pacifiers) are analgesic for infants up to 12 months. Mechanism: release of endogenous opioids and distraction Systematic review: 11 trials with 1452 infants and children getting single or multiple vaccination showed a reduction in pain expression (facial expressions, crying intensity, and crying duration). One study showed pain reduction up to 18 months – however systemic review only supports use till 12 months of age. (babies of mother’s on methadone do not have an analgesic effect of sucrose).

Sucrose method Give 1-2 mls of 25% strength solution. Buy pre-prepared (Toot-sweet), or make with 1 teaspoon of sugar and two teaspoons of cooled boiled water. Give with oral syringe 1-2 minutes before immunisation. Pacifier can be used. Discard remaining portion. Analgesic effect lasts for 5- 10 minutes only. Coughing and gagging may occur in <5% of patients Stress that use is for medical procedures only and not for general comfort or as food supplement.

Topical Anaesthetics (EMLA) Systematic review of 10 trials (1156 infants and children up to 15 yrs) showed pain reduction with topical anaesthetic for vaccinations. Seven studies were blinded & placebo controlled, 6/7 of these suggested topical anaesthetic was superior to placebo. EMLA is the only cream available without prescription in NZ (approximately $20).

EMLA method Parents need preparation on how to use this product. exact site apply 60 minutes before vaccination, must be removed by 90 minutes. cream must be covered with a dressing or glad wrap and a little tape. Be gentle pulling off the dressing – stretch it out to avoid discomfort. Skin whitening or redness is common. Allergic reaction is uncommon. However prolonged exposure can lead to serious adverse events so remove cream by 90 minutes.

Breastfeeding Breastfeeding has an analgesic effect equivalent to Sucrose. It is a combination intervention of holding the child, skin-to-skin contact, the sweet tasting milk, and the act of sucking. Each which are individually shown to attenuate pain responses. Three RCTs studies totally 478 infants up to 12 months of age showed less pain when breastfeeding DURING immunisation. Start before immunisation and continue during and after if at all possible. Make sure latch is established, and let down has occurred. Offering breast milk or formula via a bottle has some analgesic affect but is less effective than breastfeeding. Harder to stop flow. Expressed Breast Milk is less effective than sucrose.

Holding (and the 5 S’s) Parents instinctively pick up their children when trying to comfort them Systemic review of four RCTs with 281 infants found lying down resulted in more pain than sitting upright or being held by a parent. Infants and children should be held by a parent in a comfortable position for both of them. Excessive restraint increases distress, so don’t hold tightly. For infants under 6 months 5 S’s study (Swadling, Sidelie, Sushing, Swinging, sucking) can be effective to sooth a non-breastfeeding baby after vaccination (no pain relief provided during immunisation with this method). Study limitations for which aspects are effective. (Harrington et al 2012)

Gate control theory (Melzack and Wall 1965) Descending inhibition strategies: Distraction Relaxation Hypnosis Guided imagery Ascending inhibition strategies: Cold Vibration Warm Rubbing Massage

Rubbing (or Vibration) Tactile stimulation creates ‘white noise’. Paediatric and adult studies found rubbing or applying pressure to the injection site before and during injection reduced pain. No evidence for use with infants. Do not use excessive rubbing on infants as they can not provide feedback. Toddlers and preschoolers can provide feedback so rubbing or vibration might be useful (about age 2 and up). Offer to rub or stroke the skin with moderate intensity on the site, then above injection site during injection (a parent can help with this). DO NOT RUB THE INJECTION SITE AFTER THE INJECTION (increases risk of vaccine reactogenicity). Vibration devises such as the Buzzy can be used instead (See www.buzzy4shots.com, order at www.moosebaby.co.nz)

Distraction Systematic review of 4 RCT of 324 children showed age appropriate parent led distraction reduced distress from about 6 months. However a reduction in pain has not been clearly shown. Distraction for reducing pain and distress of other procedures has been found to be more effective if it involves active participation by the child (e.g., blowing bubbles, manipulating a game, pointing to an eye spy book). Clinician led distraction has been shown to be more effective than parent led distraction at reducing pain (4 studies, 284 children - however children and parents should be involved in the choosing of the distraction and how it will be used. Child led distraction is effective for over 4 year olds (choosing and using a toy or electronic devise)

Mean ratings of expected, experienced, and recalled anxiety and pain by condition. Society of Pediatric Psychology Cohen L L et al. J. Pediatr. Psychol. 2001;26:367-374

What distraction to use? Involve parents and children in the selection of distraction. Interact with the child throughout the procedure. Provide verbal and physical reminders – direct to the distraction. Can use multi-sensorial distractions. Praise the child for engaging in distraction behaviours. Infants: (3 months and over): show something that might be interesting e.g. jingly toy Toddlers: kaleidoscopes, bubbles, singing, interesting toy, non-procedural talk (favourite book, etc.) School-aged children: counting, non-procedural talk (favourite movie, etc.), IPads/Tablets!!! Adolescents: games, videos, books, joking, music (iPods, MP3 players), non-procedural talk (favourite video game, etc.)

Breathing techniques Cheep and effective Slow deep breaths (for parents too!) Breathing techniques useful in over 3 year olds to reduce pain (blowing bubbles, pin wheel/wind mill are both a distraction and breathing technique). Instruct child to take deep breath in and the blow it out slowly ( tummy breathing), remind or prompt the child during the procedure

Parental reactions Non-procedural talk, suggestions on how to cope, and appropriate humour decrease children’s distress and pain. Reassurance and apologies increase children’s distress and pain. However it is difficult to train parents to do the right things in the moment, especially if they are distressed themselves. Two RCTs of parent coaching during immunisation (distraction and appropriate parent behaviours) with 212 children aged 2 months to 2 years. This resulted in no difference in pain, but some reduction in child distress.

Fast delivery/ No aspiration/Injection order Aspiration and slow injection add to pain probably because of longer contact time between needle and tissue and through lateral movement of the needle. Aspiration is not necessary because vaccination sites are devoid of large blood vessels. When aspiration is omitted there is no increased risk of harm. RCT of injection technique showed rapid technique resulted in less pain (1 second for 0.5ml) versus slow technique with aspiration (up to 9 seconds). One RCT showed giving the more painful vaccination last decreased overall pain from both injections. More painful injections include MMR and Previnar.

Managing infant pain-helpful tips. (You tube video) https://www.youtube.com/watch?v=jxnDc2PxGUc&feature=youtube_gdata_player

What doesn’t work Vapocoolants work for adults receiving vaccines, but not children under 3 years (no studies for in-between age groups). No difference with ice packs in young children. Simultaneous injections showed no reduction of pain compared to sequential No evidence that Subcutaneous/IM are any different in pain No evidence for or against oral analgesics for immunisation pain; but more importantly there is some indication that these drugs may interfere with the immunogenicity of the vaccines.

See 3P’s of Helping http://www.aboutkidshealth.ca/En/HealthAZ/TestsAndTreatments/GivingMedication/Pages/Pain-Free-Injections.aspx Proposed NZ adaptation.

Pain management for Rheumatic Fever Injections at Counties Manukau Health Russell, Nicholson, Naidu (In press) 405 Rheumatic Fever patients offered intervention Intervention: Added 0.25 mls of lignocaine 2% to Benzathine Penicillin. Buzzy® device -cold and vibration ($42.50 per unit). Reduction in pain and fear 5 months after offering intervention 66% of 405 RF patients were using Lignocaine, 43% were using “Buzzy®” and 73% were choosing to use one or both interventions. Acknowledgements: L. Legge (Kidz First CNS), E. Leauanae (Play Specialist), A. Olsen, S. Marsh (District Nurses), and the Rheumatic Fever District Nurses Resource Group.

Reduction in pain and fear

Fear of injections

References Broome M, Bates T, Lillis P, McGahee T (1990) Children's medical fears, coping behaviors, and pain perceptions during a lumbar puncture. Oncology Nursing Forum 17:361-367. Chambers C, Taddio A, Uman L, McMurtry C, HELPinKIDS Team (2009). Psychological interventions for reducing pain and distress during childhood immunizations: a systematic review. Clinical Therapeutics 31 (Suppl B): S77-103 Cohen L, Blount R, Cohen R, Ball C, McClellan C, Bernard R (2001) Children's Expectations and Memories of Acute Distress: Short- and Long-Term Efficacy of Pain Management Interventions. Journal of Pediatric Psychology 26: 367-374 Fitzgerald M(1991) Development of pain mechanisms. British Medical Bulletin 47:667-75. Harrington J, Logan S, Harwell C, Gardner J, Swingle J, McGuire E, Santos R (2012) Effective Analgesia using Physical Interventions for Infant Immunizations. Pediatrics 129: 815-822 Kennedy A, Basket M, Sheedy K (2008) Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics 127: S92-9 Melzack R, Wall P (1965) Pain mechanisms: A New Theory. Science 150 (971-979) Mills E, Jadad A, Ross C, Wilson K (2005) Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. Journal of Clinicial Epidemiology 58: 1081-8 Omar S, Salmon D, Orenstein W, DeHart P, Halsey N (2009) Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New England Journal of Medicine 360: 1981-1988 Russell K, Nicholson R, Naidu R (In Press) Managing the pain of Rheumatic Fever Injections in the CMDHB population.

References Cont’d Shah, V., Taddio, A., Rieder, M. HELPinKIDS Team (2009) Effectiveness and Tolerability of Pharmacologic and Combined Interventions for Reducing Injection Pain During Routine Childhood Immunizations: Systemic Review and Meta-Analyses. Clinical Therapeutics. 31 (Suppl B): S104-151. Taddio A, Katz J, Ilersich AL, Koren G. (1997) Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 349: 599-603. Taddio A, Shah V, Gilbert- MacLeod C, Katz J (2002) Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA 288: 857-61 Taddio A, Ilersich A, Ipp M, Kikura A, Shah V HELPinKIDS Team (2009) Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clinical Therapeutics 31 (Supplement B) S48-76 Taddio A, Chambers C, Halperin S, Ipp M, Lockett D, Rieder M, Shah V (2009) Inadequate pain management during childhood immunization: the nerve of it. Clinical Therapeutics 31 (Suppl 2): S152-67 Taddio A, Appleton M, Bortolussi B, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Pillai Riddell R, Rieder M, Scott J, Shah V (2010) Reducing the apin of childhood vaccination – an evidence- based clinical practice guideline. Canadian Medical Association Journal 182: E843-55 Wright S, Yelland M, Heathcote K, Shu-Kay N (2009) Fear of needles: nature and prevalence in general practice. Australian Family Physician 38: 172-6