1. Journal Club Presentation Bonnie Sawyer-Banda, RN, BSN

2. What is a journal club? It is a group of nurses that meet regularly to discuss and critique research articles appearing in scientific journals. A journal club is a good way to get started using evidence based practice (Beyea and Slattery, (2009).

3. Today’s Article: Pain Reduction During Pediatric Immunizations: Evidence Based Review and Recommendations Journal: Pediatrics Authors: Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N. Published: May, 2007 A literature review

4. Background Children receive between 14 and 20 separate injections before the age of 2 Immunizations are the most frequently occurring painful procedures performed in pediatric patients Pain of injections causes stress and anxiety in the patients, their parents and in the nurses that must administer the injections. All children have a pain memory and react more intensely if they have had previous painful experiences without analgesia.

5. Background (cont) There are many variables that can heighten or lessen the response to injections. Parents – concern about injection pain can affect compliance with medical care Physicians – have strong concerns about giving 3-4 injections per visit Physicians and nurses are 6 times less likely to administer all immunizations at one visit if the child is scheduled for ≥3 injections than if the child were schedule for ≤2 injections.

6. PICOT question: (Population, Intervention, Control, Outcome, Time) In pediatric patients, what effects do pain reduction techniques have compared to no pain reduction interventions during routine immunizations?

7. Before the injections Preparation for Immunization Studies have shown that preparation for procedural pain can reduce the anxiety and pain of many medical events, such as Venipuncture Dental procedures Surgery VCUG However, there are few studies that look at preparation for immunizations. 2 studies were inconclusive (Vapo-coolant and training video).

8. Recommendations based on preparation for other painful procedures For Parents: Reason for the vaccine Emphasis on benefits Realistic information about he pain that is to be expected Provide parent with coaching and coping techniques – breathing, story telling

9. Recommendations based on preparation for other painful procedures (cont) For Children: Preparation is guided by age. More relevant >2 Preparation should consist of What will happen (where, how long, what will be done) How it will feel (pressure, temperature, level of discomfort to be expected) Strategies to cope – (Give choices of strategies) Optimal timing for particular age ranges: Toddlers and pre-schoolers – as close to actual administration as possible Older children – depends on their coping styles There are no clear guidelines because there are limitations specific to pediatric immunizations

10. Injection site selection Anterolateral thigh – large muscle mass and lack of vital structures When to shift to arm? At 18 months, more severe pain, decreased movement and limping when given in thigh. Option: ventrogluteal Lower rates of systemic reaction and local reactions

11. Needle length Longer needles cause less pain and fewer adverse reactions Studies indicate that there is greater redness and swelling when immunizations are administered with smaller needle rather than a longer needle. Conclusion: Individualization of needle length based on patient size and injection technique.

12. Injectate Properties Temperature – in patients >16, no difference in pain scores whether the vaccine was cold, rubbed or warmed. Injectate formulation – Vaccines with higher pH cause less pain. If there is a choice

13. During the injection Parental behavior Parental behavior during the immunization significantly influences the amount of pain and distress children experience

14. Parental behaviors that increase coping: Commands to use coping strategies Distraction techniques Humor Non procedural talk

15. Parental behaviors that increase child distress: Empathy Criticism Apologies Giving control to the child Reassurance – most common adult vocalization during immunizations - it is counter intuitive that reassurance causes more distress, but fathers believe “comforting encourages more crying”

16. Educate the parents Teaching parents techniques to promote coping can reduce their sense of helplessness and benefit the child by reducing distress and increasing mastery.

17. Securing the child Young children: Parent holds the child in his or her lap Older children: Sit in parent’s lap facing forward or face the parent with legs wrapped around the parent (big-hug)

18. Distraction Recognized as a key intervention Possible explanations: Gate control theory – cognitive attention might affect processing and perception of pain. If some attention is allocated to a distracting task, then there are fewer resources available to attend to the pain

19. Examples of distraction stimuli Movies Party blowers Non procedural talk Virtual reality goggles Kaleidoscopes Bubble blowing Short stories Music

20. Distraction A meta analysis showed that distraction decreased distress behavior but had minimal impact on self-reported pain. Most effective in children <7. Interactive distraction decreased children’s pain more effectively. The more the children are engaged in the distraction (regardless of the type) the lower the pain. Most research has been done in pre-school age children. More research is needed in non pre school aged children.

21. Things to consider when choosing a distraction stimulus Age and cognitive maturity of the patient Age appropriate and engaging stimuli Cost Time Space Children’s natural coping tendencies and temperament Patient preferences

22. Clinicians should routinely use distraction for pediatric immunizations Ease of use Growing body of evidence Lack of negative consequences

23. Use of Sucrose Sucrose water (1 packet of sugar mixed in 10ml of water) has been shown to decrease pain in neonates. It has been suggested that Sucrose interacts with opioid pathways to accomplish this phenomenon. Can be administer with a pacifier or instilled directly into the mouth. Loses efficacy by 4-6 months. Nonnutritive sucking also has analgesic properties. Combination of direct parental contact and sucrose have an additive effect Breastfeeding also provides analgesia There seems to be sufficient data to recommend sucrose use as a routine part of immunization administration for infants ≤6 months of age.

24. Topical anesthetics Should be Safe Inexpensive Should have rapid onset Should have effect on vaccine immunogenicity

25. Examples EMLA Decreases pain as needle penetrates the skin Reduction of underlying muscle spasm Onset of action – 1 hour Vapo-coolant sprays Provides anesthesia in 30 seconds and are inexpensive Some studies show them to be no better than placebo Universal use of local anesthetics can not be endorsed as there is lack of availability of one that is rapid acting.

26. Technical Variables Injection technique For Intramuscular Injections Hold skin taunt Inject dart-like at 90° Do not pull back on the plunger Inject vaccine at steady pressure Withdraw needle at the same angle For Subcutaneous Pinch or bunch the skin Insert needle at 45°

27. Site Pressure 10 seconds of direct pressure at the injection site - reduction of immediate pain

28. Simultaneous injections No decrease in discomfort, but parents preferred

29. References Beyea, S and Slattery, M.J. (2009). Ask the expert: What is a journal club? Retrieved 07/02/2012 from http://www.hcpro.com/NRS-243376-975/Ask-the-expert- What-is-a-journal-club.html http://www.hcpro.com/NRS-243376-975/Ask-the-expert- What-is-a-journal-club.html Grady, D. (n.d.) a recommended journal club format Retrieved 07/02/2012 from http://www.unmc.edu/intmed/geriatrics/docs/journalclubf ormat.pdf http://www.unmc.edu/intmed/geriatrics/docs/journalclubf ormat.pdf Red Book (2010) Site and needle length by age for intramuscular injections. Retrieved 07/02/2012 from http://www.unboundmedicine.com/redbook/ub/view/Red Book/187027/all/Table_1_4__Site_and_Needle_Length_by_A ge_for_Intramuscular_Immunization?q=needle%20length http://www.unboundmedicine.com/redbook/ub/view/Red Book/187027/all/Table_1_4__Site_and_Needle_Length_by_A ge_for_Intramuscular_Immunization?q=needle%20length Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N. (2007). Pain reduction during pediatric I mmunizations: Evidence based review and recommendations. Pediatrics. 119(5). e1184-e1198.

30. The end