Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

Efficacy of topical lidocaine-prilocaine (EMLA®) for management of infant pain during pneumococcal vaccination: A randomized controlled trial

Few studies have evaluated whether topical anesthetic cream reduces pain during pneumococcal vaccination. This is crucial, since effective pain management should be evidence-based. Previous studies have shown that topical lidocaine-prilocaine (EMLA^®) reduces vaccination-related pain, measured using pain-rating instruments and observation of crying time. This intervention study aimed to compare the efficacy of topical lidocaine-prilocaine cream with that of the standard of care on the expression of pain during the first pneumococcal vaccination administered at age 3 months under the Swedish national vaccination program. A randomized controlled trial included 72 infants receiving their first pneumococcal vaccination (Prevenar 13^®). The study showed that topical lidocaine-prilocaine before pneumococcal vaccination significantly reduced infants' expression of pain according to the Face, Legs, Activity, Cry, Consolability (FLACC) score (P = .006) and increased latency to cry (P = .001). There were no statistically significant differences in the total crying time (P = .146) between the groups. Topical lidocaine-prilocaine cream reduced pain expression and increased latency to cry in infants receiving their first pneumococcal vaccine. Systematic efforts are needed to successfully implement the use of topical anesthetic cream and other effective non-pharmacological pain-relieving strategies during infant vaccination procedures.

A Randomised Controlled Trial of Ice to Reduce the Pain of Immunisation-The ICE Trial

Background and objectives: vaccine injections are a common cause of iatrogenic pain and anxiety, contributing to non-compliance with scheduled vaccinations. With injection-related pain being recognised as a barrier to vaccination uptake in both adults and children, it is important to investigate strategies to effectively reduce immunisation pain. This prospective randomised controlled trial investigated the effects of applying an ice pack on vaccine-related pain in adults. Methods: medical students receiving the flu vaccination were randomised to receive an ice pack (intervention) or placebo cold pack (control) at the injection site for 30 s prior to needle insertion. Immediate post-vaccination pain (VAS) and adverse reactions in the proceeding 24 h were recorded. Results: pain scores between the intervention (n = 19) and control groups (n = 16) were not statistically significant (intervention: median pain VAS = 7.00, IQR = 18; control: median pain VAS = 11, IQR = 14 (p = 0.26). There were no significant differences in the number of adverse events between the two groups (site pain p = 0.18; localised swelling (p = 0.67); bruising p = 0.09; erythema p = 0.46). Discussion: ice did not reduce vaccination-related pain compared to cold packs. COVID-19 related restrictions impacted participant recruitment, rendering the study insufficiently powered to draw conclusions about the results.

The Effects of Caressing and Hugging Infants to Manage the Pain during Venipuncture

The aim of this study is to investigate the effects of caressing in infants for pain management during venipuncture. This is a randomized control trial, carried out on 120 infants between 2 and 6 months of age, that included 30 males and 30 females in the hugging and control group, respectively. Parameters such as percentage blood saturation of blood, crying, and the duration of pain felt was evaluated. The venipuncture between the control and experimental groups showed that, less pain is felt by females when caressed by their mother. However, this difference does have statistical significance. Overall, caressing in infants had positive effect on pain-relief after venipuncture.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS)

PROBLEM

Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use.

ELIGIBILITY CRITERIA

Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included.

SAMPLE

Twenty-eight studies (8 psychometric and 20 RCTs) were included.

RESULTS

Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS.

CONCLUSIONS

It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children.

IMPLICATIONS

Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

Differences in Immunization Site Pain in Toddlers Vaccinated With Either the 10- or the 13-Valent Pneumococcal Conjugate Vaccine

BACKGROUND

Immunization site pain is a common and unpleasant experience for both children and adults. It is a source of anxiety and distress and may ultimately result in nonadherence to vaccination schedules. There is limited information on how different brands of vaccines affect the intensity of immediate pain at the time of vaccine injection.

METHODS

Children in the United Kingdom (n = 178) were randomized to receive a booster dose of either the 10- or the 13-valent pneumococcal conjugate vaccine (PCV-10 or PCV-13). Immediate immunization site pain was assessed using validated pain assessment tools and crying time to investigate factors that may interfere with parental compliance to vaccination.

RESULTS

Pain measurements were available for n ≥ 74 and n ≥ 78 PCV-10 and PCV-13 recipients, respectively. PCV-13 recipients had significantly higher scores on the observer-rated modified behavioral pain scale than did those receiving PCV-10. No significant differences in the induction of pain between the 2 vaccines were found when a parent-rated pain assessment tool or crying time was used.

CONCLUSIONS

PCV-10 administration was associated with slightly less acute pain compared with the injection of PCV-13, but the size of the difference was small and is of unknown clinical significance.

Effects of Rapid Vaccine Injection Without Aspiration and Applying Manual Pressure Before Vaccination on Pain and Crying Time in Infants

AIM

To compare effects of rapid injection without aspiration and 10-second manual pressure before injection on pain severity and crying time in 4- to 6-month-old infants given the vaccine DTaP/IPV/Hib.

METHODS

This is a randomized double-blind controlled study. The study population included all the infants presenting for DTaP/IPV/Hib to two family health centers between April and August in 2015. The study sample included 128 infants based on confidence interval of 95% and statistical power of 80%. The sample was divided into four groups: manual pressure, rapid injection without aspiration, manual pressure combined with rapid injection without aspiration, and control groups. There were 32 infants in each group. Gender was adjusted in all groups. Stratified and block randomizations were used.

RESULTS

Pain severity scores and crying time during and after the injections were significantly lower in the three intervention groups than in the control group (p = .001). The lowest increase in the mean heart rate during and after the injections occurred in the rapid injection without aspiration group (p < .05). In addition, the mean oxygen saturation before, during and after the injections was significantly lower in this group than in the other groups (p < .05). However, two infants in the rapid injection without aspiration group had low oxygen saturation levels starting before the injections. In fact, mean oxygen saturations did not change across time. This suggests that lower oxygen saturation in the rapid injection without aspiration group cannot be due to vaccines or the techniques used.

LINKING EVIDENCE TO ACTION

Manual pressure and rapid injection without aspiration are effective and useful in relief of pain and reduction of crying time due to vaccine injections in 4- to 6-month-old infants.

Comparative Survey of Holding Positions for Reducing Vaccination Pain in Young Infants

Background. Infant holding position may reduce vaccination pain. However, the optimal position for young infants remains controversial. Objectives. To compare the effectiveness of holding infants in the supine position and the effectiveness of holding infants in upright position for relieving acute pain from vaccine injection. Methods. This prospective cohort study enrolled 6-12-week-old healthy infants. We examined infant pain responses by evaluating the following three categories: (1) crying, (2) irritability, and (3) facial expression. Results. In total, 282 infants were enrolled, with 103 and 179 held in the supine and upright positions, respectively. At 30 s after vaccination, the infants in the supine position showed a larger decrease in crying (p < 0.001), irritability (p = 0.002), and pained facial expression (p = 0.001) than did those in the upright position. However, there was no significant difference in pain response between two groups at 180 s after intervention. Conclusion. In 2-month-old infants, the supine position may reduce acute pain more effectively than does the upright position. Our findings provide a clinical strategy for relieving vaccination pain in young infants.

Comparison of iatrogenic pain between rotavirus vaccination before and after vaccine injection in 2-month-old infants

Oral rotavirus vaccine (RV) administration in conjunction with other injectable vaccines has been used worldwide. However, whether the sequence of RV administration is associated with the reduction of injection-induced pain remains unclear.

In this randomized controlled trial, we enrolled 6–12-wk-old healthy infants. The pain response of the infants was scored on the basis of their crying, irritability, facial expression, gagging and distress. A multivariate logistic regression model was used to compare the pain response after adjustment for possible confounders.

We enrolled 352 infants, of whom 176 infants received RV before injection (experimental group) and 176 infants received an RV after injection (comparison group). Sex, number of injections, main caregiver, feeding type, and RV type did not differ significantly between the 2 groups. Multivariate regression analyses showed that, at 30 s after the intervention, the episode of gagging was more frequent in the comparison group than in the experimental group (p = 0.004). At 180 s after the intervention, the infants cried more often in the comparison group (p < 0.001). Furthermore, the infants in the experimental group more often relaxed (p < 0.001), rested quietly (p = 0.001), and were smiling (p = 0.001) than did those in the comparison group.

Our results indicate that compared with oral RV administration after injection, oral RV administration before injection is more effective in reducing injection-induced pain in 2-mo-old infants. The findings can provide a clinical strategy for relieving pain from vaccination in young infants.

Relative effectiveness of additive pain interventions during vaccination in infants

BACKGROUND

Vaccine injections can cause acute pain and distress in infants, which can contribute to dissatisfaction with the vaccination experience and vaccine hesitancy. We sought to compare the effectiveness of additive pain interventions administered consistently during vaccine injections in the first year of life.

METHODS

We conducted a multicentre, longitudinal, double-blind, add-on, randomized controlled trial. Healthy infants were randomly assigned to 1 of 4 levels of pain management for all vaccine injections at 2, 4, 6 and 12 months: (i) placebo control; (ii) parent-directed video education about infant soothing; (iii) the video plus sucrose administered orally or (iv) the video plus sucrose plus liposomal lidocaine applied topically. All infants benefit from injection techniques that minimize pain. We used a double-dummy design; hence all parents watched a video (active psychological intervention or placebo) and all infants received oral solution (sucrose or placebo) and topical cream (lidocaine or placebo). We assessed infant distress during 3 phases - preinjection (baseline), vaccine injection (needle), and 1 minute postinjection (recovery) - using the Modified Behavioural Pain Scale (range 0-10). We compared scores between groups and across infant ages using a mixed-model repeated-measures analysis.

RESULTS

A total of 352 infants participated in the study, from Jan. 17, 2012, to Feb. 2, 2016. Demographics did not differ among intervention groups (p > 0.05). Baseline pain scores did not differ among intervention groups (p = 0.4), but did differ across ages (p < 0.001). Needle pain scores differed among groups (p = 0.003) and across ages (p < 0.001). The mean (± standard deviation) needle score was 6.3 (± 0.8) in the video-sucrose-lidocaine group compared with 6.7 (± 0.8) in each of the other groups. There were no other between-group differences. Recovery scores did not differ among groups (p = 0.98), but did differ across ages (p < 0.001).

INTERPRETATION

Only liposomal lidocaine provided consistent analgesia within an additive pain intervention regimen during vaccinations in infants. Trial registration: ClinicalTrials.gov, no. NCT01503060.

Evaluation of Vaccines Injection Order on Pain Score of Intramuscular Injection of Diphtheria, Whole Cell Pertussis and Tetanus Vaccine

OBJECTIVE

To determine, whether or not intramuscular injection of diphtheria, pertussis and tetanus (DwPT) vaccine should be given first and subcutaneous injection of measles, mumps and rubella (MMR) thereafter or vice versa and can this cause less pain of DwPT vaccine injection.

METHODS

In a randomized parallel group clinical trial, seventy 18-mo-old healthy children who were referred for routine vaccination to Akbari Health Care Center, Yazd, Iran from September 2014 through March 2015 were randomly allocated to two groups to receive DwPT and then MMR vaccines or MMR first, and then DwPT. Primary outcomes included pain score during DwPT injection, pain score during MMR injection, overall pain score of vaccination and obtaining a pain score of less than three during DwPT injection. Pain scores were assessed based on Modified Behavioral Pain Scale. Secondary outcome was crying duration during DwPT injection.

RESULTS

Thirty seven girls and 33 boys were evaluated in two groups. Pain scores of DwPT and MMR injections, the frequency of pain score obtained to be less than three during DwPT injection and the crying duration were not different in both groups. But, overall pain score of vaccination was lower when subcutaneous injection of MMR vaccine was given before intramuscular injection of DwPT vaccine. (14.23 ± 1.35 vs. 15.61 ± 2.65; P = 0.04).

CONCLUSIONS

Overall pain score of vaccination in multiple vaccine injection at the same visit might be reduced if subcutaneous vaccine is injected before intramuscular one.

Effect of change in sequence of administration of DTwP and Hepatitis B vaccines on perception of pain in infants: A randomized control trial

OBJECTIVE

This study was designed with objective to study pain response of infants to change in sequence of administration of Hepatitis B and DTwP vaccines.

METHODS

This was a randomized parallel control trial. The study was carried out in the immunization clinic of the Department of Pediatrics, LLRM Medical College, Meerut. One hundred and thirty healthy term infants up to 4 months of age were injected either DTwP vaccine first or Hepatitis B vaccine first, followed one minute later by the other vaccine.

RESULT

Baseline characteristics did not differ between the groups. The mean (SD) of AUC of MFCS and NIPS was significantly more in DF group as compared to HF group (for MFCS 25.5 ± 5.4 versus 22.5 ± 5.5, p<0.01; for NIPS 31.77 ± 5.5 versus 27.64 ± 6.9, p < 0.01). Similarly mean (SD) of AUC of Heart rate and saturation of oxygen showed significant variation in DF group as compared to HF group (for heart rate 591.6 ± 55 versus 559.6 ± 49, p< 0.01; for SpO2 326.4 ± 12 versus 335 ± 8, p < 0.01).

CONCLUSION

These results showed that infant experienced lesser pain when Hepatitis B was administered first than when DTwP vaccine was given first.

Effect of flick application on pain level and duration of crying during infant vaccination

BACKGROUND

The aim of the research is to determine the effect of flick application to reduce pain on pain level and duration of crying during vaccination.

METHOD

This research was carried out on one-month-old babies in a family health center between March and June 2015. The babies coming for the second dose of Hepatitis B vaccine were divided into experiment and control groups. The babies in experiment group were flicked just before they were vaccinated. On the other hand, the babies in control group were vaccinated in usual way, with no other application. The pain level of babies in both groups was determined using "Neonatal Infant Pain Scale". In addition, babies' duration of crying was recorded.

RESULTS

In the study, it was detected that there was not a significant difference between pain score averages of babies in experiment and control groups (p > 0.05) before the application, however a significant difference in pain score average was detected during the application (p < 0.01) and after the application (p < 0.001). Babies' duration of crying was compared and it was determined that babies in experiment group cried for shorter period, but no relevance was found (p > 0.05).

CONCLUSIONS

Flick application at vaccination area could be used to reduce pain during vaccination at babies.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

DATA COLLECTION AND ANALYSIS

Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

MAIN RESULTS

Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

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.

Pain in adolescent girls receiving human papillomavirus vaccine with concomitantly administered vaccines

Using the Faces Pain Scale - Revised, we assessed injection site pain 10 minutes after vaccination in young females randomized to receive either quadrivalent human papillomavirus vaccine (HPV4) before or after concomitantly administered vaccines. Although pain was modestly more after HPV4 injection than after other vaccines, the pain intensity after HPV4 injection was significantly less in those who received HPV4 before receiving other concomitant vaccines.

Cortical activity evoked by inoculation needle prick in infants up to one-year old

Inoculation is one of the first and most common experiences of procedural pain in infancy. However, little is known about how needle puncture pain is processed by the central nervous system in children. In this study, we describe for the first time the event-related activity in the infant brain during routine inoculation using electroencephalography. Fifteen healthy term-born infants aged 1 to 2 months (n = 12) or 12 months (n = 5) were studied in an outpatient clinic. Pain behavior was scored using the Modified Behavioral Pain Scale. A distinct inoculation event-related vertex potential, consisting of 2 late negative-positive complexes, was observable in single trials after needle contact with the skin. The amplitude of both negative-positive components was significantly greater in the 12-month group. Both inoculation event-related potential amplitude and behavioral pain scores increased with age but the 2 measures were not correlated with each other. These components are the first recordings of brain activity in response to real-life needle pain in infants up to a year old. They provide new evidence of postnatal nociceptive processing and, combined with more traditional behavioral pain scores, offer a potentially more sensitive measure for testing the efficacy of analgesic protocols in this age group.

A randomized controlled trial of clinician-led tactile stimulation to reduce pain during vaccination in infants

BACKGROUND

Clinician-led tactile stimulation (rubbing the skin adjacent to the injection site or applying pressure) has been demonstrated to reduce pain in children and adults undergoing vaccination.

OBJECTIVE

To evaluate the analgesic effectiveness of clinician-led tactile stimulation in infants undergoing vaccination.

METHODS

This was a partially blinded randomized controlled trial that included infants undergoing vaccination in a private clinic in Toronto. Infants were randomly allocated to tactile stimulation or no tactile stimulation immediately prior to, during, and after vaccination. The primary outcome was infant pain, assessed using a validated observational measure, the Modified Behavioral Pain Scale (MBPS; range = 0-10).

RESULTS

Altogether, 121 infants participated (n = 62 tactile stimulation; n = 59 control); demographics did not differ (P > .05) between groups. MBPS scores did not differ between groups: mean = 7.2 (standard deviation = 2.4) versus 7.6 (1.9); P = .245.

CONCLUSION

Tactile stimulation cannot be recommended as a strategy to reduce vaccination pain in infants because of insufficient evidence of a benefit.

Too many crying babies: a systematic review of pain management practices during immunizations on YouTube

Background

Early childhood immunizations, although vital for preventative health, are painful and too often lead to fear of needles. Effective pain management strategies during infant immunizations include breastfeeding, sweet solutions, and upright front-to-front holding. However, it is unknown how often these strategies are used in clinical practice. We aimed to review the content of YouTube videos showing infants being immunized to ascertain parents’ and health care professionals’ use of pain management strategies, as well as to assess infants’ pain and distress.

Methods

A systematic review of YouTube videos showing intramuscular injections in infants less than 12 months was completed using the search terms "baby injection" and "baby vaccine" to assess (1) the use of pain management strategies and (2) infant pain and distress. Pain was assessed by crying duration and pain scores using the FLACC (Face, Legs, Activity, Cry, Consolability) tool.

Results

A total of 142 videos were included and coded by two trained individual viewers. Most infants received one injection (range of one to six). Almost all (94%) infants cried before or during the injections for a median of 33 seconds (IQR = 39), up to 146 seconds. FLACC scores during the immunizations were high, with a median of 10 (IQR = 3). No videos showed breastfeeding or the use of sucrose/sweet solutions during the injection(s), and only four (3%) videos showed the infants being held in a front-to-front position during the injections. Distraction using talking or singing was the most commonly used (66%) pain management strategy.

Conclusions

YouTube videos of infants being immunized showed that infants were highly distressed during the procedures. There was no use of breastfeeding or sweet solutions and limited use of upright or front-to-front holding during the injections. This systematic review will be used as a baseline to evaluate the impact of future knowledge translation interventions using YouTube to improve pain management practices for infant immunizations.

[Impact of the instrumental vaginal delivery on pain perception at two months]

INTRODUCTION

Although instrumental vaginal delivery reduces the risk of neonatal mortality, it increases the risk of specific morbidity including prolonged neonatal discomfort. Previous studies suggest that neonatal exposure to acute pain could have long-term effects on the pain response later in life. The aim of the study was to investigate whether instrumental vaginal delivery may alter the response to a noxious stimulus at the age of two months.

METHOD

Newborn infants were enrolled in this prospective observational study after parental consent. A group of children born by instrumental vaginal delivery (group 2) were compared to matched controls born by vaginal delivery (group 1). Pain was assessed in each newborn infant between two and four hours after birth using the scale of pain and discomfort of the newborn baby (EDIN). These children were reassessed for pain response to immunizations (Infanrix(®) and Prevenar(®)) at two months of age using the DAN scale.

RESULTS

Thirteen children were enrolled in this study, six in group 1 and seven in group 2. Gestational age, birth weight, Apgar score, and umbilical arterial blood were similar in both groups. The EDIN measured between H2 and H4 was significantly higher in group 2 (median, 4 [IQ, 3] versus 0 [3.25], P<0.05). While the DAN score before and during immunization was similar in the two groups, it was statistically higher in group 2 than in group 1 (4 [3] versus 2 [2.25], P<0.01) within the15 min following the injections.

CONCLUSION

These results indicate that birth by instrumental vaginal delivery causes discomfort after birth and increases the pain response to immunization at the age of two months. This study supports the hypothesis that instrumental vaginal delivery may alter pain perception later in life.

Nonpharmacological management of procedural pain in infants and young children: an abridged Cochrane review

BACKGROUND

Acute pain and distress during medical procedures are commonplace for young children.

OBJECTIVE

To assess the efficacy of nonpharmacological interventions for acute procedural pain in children up to three years of age.

METHODS

Study inclusion criteria were: participants <3 years of age, involved in a randomized controlled or crossover trial, and use of a 'no treatment' control group (51 studies; n=3396). Additional studies meeting all criteria except for study design (eg, use of active control group) were qualitatively described (n=20).

RESULTS

For every intervention, data were analyzed separately according to age group (preterm-born, term-born neonate and older infant ⁄ young child) and type of pain response (pain reactivity, immediate pain-related regulation). The largest standardized mean differences (SMD) for pain reactivity were as follows: sucking-related interventions (preterm: -0.42 [95% CI -0.68 to -0.15]; neonate -1.45 [CI -2.34 to -0.57]), kangaroo care (preterm -1.12 [95% CI -2.04 to -0.21]), and swaddling ⁄ facilitated tucking (preterm -0.97 [95% CI -1.63 to -0.31]). For immediate pain-related regulation, the largest SMDs were: sucking-related interventions (preterm -0.38 [95% CI -0.59 to -0.17]; neonate -0.90 [CI -1.54 to -0.25]), kangaroo care 0.77 (95% CI -1.50 to -0.03]), swaddling ⁄ facilitated tucking (preterm -0.75 [95% CI -1.14 to -0.36]), and rocking ⁄ holding (neonate -0.75 [95% CI -1.20 to -0.30]). The presence of significant heterogeneity limited confidence in nonsignificant findings for certain other analyses.

CONCLUSIONS

Although a number of nonpharmacological treatments have sufficient evidence supporting their efficacy with preterm infants and healthy neonates, no treatments had sufficient evidence to support efficacy with healthy older infants ⁄ young children.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan. 

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding breastmilk, sucrose, and music. Analyses accounted for infant age (preterm, neonate, older) and pain response (pain reactivity, pain-related regulation). 

SEARCH STRATEGY

We searched CENTRAL in The Cochrane Library (2011, Issue 1), MEDLINE (1966 to April 2011), EMBASE (1980 to April 2011), PsycINFO (1967 to April 2011), Cumulative Index to Nursing and Allied Health Literature (1982 to 2011), Dissertation Abstracts International (1980 to 2011) and www.clinicaltrials.gov. We also searched reference lists and contacted researchers via electronic list-serves.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomized controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results.

DATA COLLECTION AND ANALYSIS

We refined search strategies with three Cochrane-affiliated librarians. At least two review authors extracted and rated 51 articles. Study quality ratings were based on a scale by Yates and colleagues. We analyzed the standardized mean difference (SMD) using the generic inverse variance method. We also provided qualitative descriptions of 20 relevant but excluded studies.

MAIN RESULTS

Fifty-one studies, with 3396 participants, were analyzed. The most commonly studied acute procedures were heel-sticks (29 studies) and needles (n = 10 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (preterm: SMD -0.42; 95% CI -0.68 to -0.15; neonate: SMD -1.45, 95% CI -2.34 to -0.57), kangaroo care (preterm: SMD -1.12, 95% CI -2.04 to -0.21), and swaddling/facilitated tucking (preterm: SMD -0.97; 95% CI -1.63 to -0.31). For immediate pain-related regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.38; 95% CI -0.59 to -0.17; neonate: SMD -0.90, 95% CI -1.54 to -0.25), kangaroo care (SMD -0.77, 95% CI -1.50 to -0.03), swaddling/facilitated tucking (preterm: SMD -0.75; 95% CI -1.14 to -0.36), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). The presence of significant heterogeneity limited our confidence in the lack of findings for certain analyses.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures.

How parents' negative experiences at immunization visits affect child immunization status in a community in New York City

OBJECTIVE

Little is known about how families' experiences with immunization visits within the medical home may affect children's immunization status. We assessed the association between families' negative immunization experiences within the medical home and underimmunization.

METHODS

We surveyed parents (n = 392) of children aged 2-36 months about immunization experiences at community health centers, hospital-based clinics, private practices, and community-based organizations in New York City. We used Chi-square tests and odds ratios (ORs) to assess the relationship between medical home elements and parental immunization experience ratings. We used multivariable analysis to determine the association between negative experiences during immunization visits and underimmunization, controlling for insurance, maternal education, and receipt of benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children.

RESULTS

The majority of children were of Latino race/ethnicity and had Medicaid and a medical home. One-sixth (16.9%) of families reported a previous negative immunization experience, primarily related to the child's reaction, waiting time, and attitudes of medical and office staff. Parents' negative immunization experiences were associated with the absence of four components of the medical home: continuity of care, family-centered care, compassionate care, and comprehensive care. In addition, children in families who reported a negative experience were more likely to have been underimmunized (adjusted OR = 2.00; 95% confidence interval 1.12, 3.58).

CONCLUSIONS

In a community in New York City, underimmunization of young children was associated with negative immunization experiences. Strategies to improve family experiences with immunization visits within the medical home (particularly around support for the family), medical and ancillary staff attitudes, and reduced waiting time may lead to improved immunization delivery.

Pain response in newborns to the order of injecting BCG and Hepatitis-B vaccines: a randomized trial

OBJECTIVE

To determine if acute pain response after administration of the BCG vaccine and the Hepatitis-B vaccine is affected by the order in which they are given.

METHODS

This Single-center randomized clinical trial was conducted in the Vaccination room in the Pediatrics Outpatient Department at KVG Medical College; Karnataka, India. 76 healthy term neonates undergoing routine immunization were included in this study. Newborns received either BCG vaccine or the Hepatitis-B vaccine first, followed by the other vaccine. The primary outcome was neonatal pain during vaccine injection as assessed by a validated measure, the Neonatal Infant Pain Scale (NIPS), scored by resident doctors blinded to the study purpose and hypothesis. In addition, a nurse rated pain using a 10-cm visual analog scale(VAS).

RESULTS

A total of 76 infants participated: 38 received the BCG vaccine first and 38 received the Hepatitis-B vaccine first. Demographic characteristics did not differ between the groups. Overall mean (SD) pain scores per neonate were significantly lower when BCG was administered first compared to the order when Hepatitis-B vaccine was administered first (for NIPS 5.55 [0.54] vs. 5.84 [0.29], P = .005; for VAS, 6.25 [0.80] vs. 6.58 [0.54], P = .04). When given first, the BCG vaccine caused significantly less pain (P < .001)than the Hepatitis-B, as assessed by the NIPS and VAS (P < .001).

CONCLUSIONS

Pain was reduced when the BCG vaccine was administered before the Hepatitis-B in neonates undergoing routine vaccination. The authors recommend that the order of vaccine injections be the BCG vaccine followed by Hepatitis-B.

Vaccine related reactogenicity for primary immunization: a randomized controlled trial of 23(wider) vs. 25(narrower) gauge needles with same lengths

OBJECTIVES

To compare vaccine related reactogenicity during primary immunization in healthy infants using 23 vs. 25 gauge needles.

METHODS

This randomized controlled trial was conducted in Vaccination Room of the Advanced Pediatrics Center. 155 participants for primary immunization were assigned to two intervention groups (23 vs. 25 gauge). Parent-reported local and systemic reactions were recorded daily for three days after the immunization.

RESULTS

Swelling (24%) and tenderness (21%) were the two most common parent-reported local symptoms followed by restriction of movements (18%) and redness (10%) on day 1. Any local reaction on day 1 was statistically similar in 25 gauge vs. 23 gauge group (RR 0.77; 95% CI: 0.32 to 1.82) (P = 0.54), but fever (day 1) showed higher trend in 23 gauge needle group (RR 2.24; 95% CI: 0.92-5.47) (P = 0.07). Furthermore, on analysis of serially reported local and systemic reactions for 3 consecutive days by generalized estimating equations, odds of redness, swelling, tenderness, restricted movement and fever were statistically similar between two needle groups. On the other hand, median (± SE) crying time (in seconds) was significantly prolonged in the 25 gauge needle (39 ± 2) as compared to 23 gauge group (30 ± 1.3) (log rank test, P = 0.001).

CONCLUSIONS

The use of same length needles with narrower (25) or wider (23) gauge did not show significant differences in local reactogenicity during primary immunization. Fever, however, was reduced marginally in 25 gauge group whereas crying duration was significantly shorter with 23 gauge needle. Finally, larger studies are needed to further evaluate objectively the outcome of reactogenicity.

Safety, immunogenicity and immediate pain of intramuscular versus subcutaneous administration of a measles-mumps-rubella-varicella vaccine to children aged 11-21 months

This study compared intramuscular and subcutaneous administration of two doses of measles-mumps-rubella-varicella (MMRV) combination vaccine (Priorix-Tetra, GlaxoSmithKline Biologicals) in children. Healthy children (N = 328) were randomised to receive MMRV either intramuscularly or subcutaneously. Reactogenicity was similar between treatment groups for immediate vaccination pain, vaccination site pain, redness and incidence of fever and rashes. Slightly less vaccination site swelling occurred during days 0-3 of the post-vaccination period after intramuscular administration. Seroconversion rates for all components, 42-56 days post-dose 2, ranged from 99.3% to 100% in the intramuscular group and from 98.6% to 100% in the subcutaneous. Cell-mediated immunity data supported the humoral immunogenicity findings. In summary, the MMRV vaccine is well tolerated and highly immunogenic when administered either subcutaneously or intramuscularly to children in the second year of life.

Microneedle-based transcutaneous immunisation in mice with N-trimethyl chitosan adjuvanted diphtheria toxoid formulations

Purpose

The purpose of this study was to gain insight into the delivery and immunogenicity of N-trimethyl chitosan (TMC) adjuvanted diphtheria toxoid (DT) formulations applied transcutaneously with microneedles.

Methods

Mice were vaccinated with DT-loaded TMC nanoparticles, a solution of TMC and DT (TMC/DT) or DT alone. The formulations were applied onto the skin before or after microneedle treatment with two different 300-µm-long microneedle arrays and also injected intradermally (ID). As a positive control, alum-adjuvanted DT (DT-alum) was injected subcutaneously (SC). Ex vivo confocal microscopy studies were performed with rhodamine-labelled TMC.

Results

Independent of the microneedle array used and the sequence of microneedle treatment and vaccine application, transcutaneous immunisation with the TMC/DT mixture elicited 8-fold higher IgG titres compared to the TMC nanoparticles or DT solution. The toxin-neutralising antibody titres from this group were similar to those elicited by SC DT-alum. After ID immunisation, both TMC-containing formulations induced enhanced titres compared to a DT solution. Confocal microscopy studies revealed that transport of the TMC nanoparticles across the microneedle conduits was limited compared to a TMC solution.

Conclusions

In conclusion, TMC has an adjuvant function in transcutaneous immunisation with microneedles, but only if applied in a solution.

Electronic Supplementary Material

The online version of this article (doi:10.1007/s11095-010-0182-y) contains supplementary material, which is available to authorized users.