Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials

Oral and topical analgesia in pediatric electrodiagnostic studies

INTRODUCTION/AIMS

Electrodiagnostic examinations, such as nerve conduction studies (NCS) and needle electromyography (EMG), are perceived as painful by children and their parents/guardians. Methods to reduce peri-procedural pain improve compliance and have neurocognitive and neuropsychiatric benefits. This study aimed to assess the efficacy of combined oral and topical analgesics (COTA), oral analgesics (OA), and placebo in reducing pain during NCS/EMG in children.

METHODS

We performed a double-blind, randomized, placebo-controlled trial on children presenting to our neurophysiology lab. Patients were stratified into two age groups (6M-6Y and 7Y-18Y) and randomized into three arms: COTA, OA, and placebo. Pain scores post-NCS/EMG were assessed using the Modified Behavioral Pain Scale (MBPS) and Faces Pain Scale-Revised (FPS-R).

RESULTS

One hundred thirteen participants were enrolled. A comparison of participants from both age groups combined revealed no significant differences in guardian FPS-R scores across all arms for NCS and EMG. A significant difference in the distribution of post-NCS FPS-R score severities in children aged 7Y-18Y was noted between OA and placebo (p = .007). EMG was more painful than NCS across all arms (p < .05). In children aged 6M-6Y undergoing at least 10 muscle samplings during EMG, those receiving COTA had significantly lower pain scores (p = .014).

DISCUSSION

This study reveals the complexity of pediatric pain perception during NCS/EMG and highlights that other methods to reduce experienced pain are required. Our findings suggest that procedural characteristics, such as number of muscles sampled, may influence the effectiveness of analgesia and serve as a foundation for future research aimed at optimizing pain management strategies.

Goldfish or aquatic turtle? Impact of two animal assisted interventions on children's pain, anxiety, and fear during IV catheterization: A randomized controlled trial

PURPOSE

This study aimed to determine the effect of goldfish and aquatic turtle nursing interventions on children's pain, anxiety, and fear during IV catheter insertion.

DESIGN AND METHODS

The randomized controlled trial included 98 children (control group = 32, goldfish group = 33, aquatic turtle group = 33) aged 5-6 years, attending outpatient clinic for blood sampling and catheterisation procedures. Pain was measured using the Wong Baker Facial Pain Scale, anxiety was measured using the Child Anxiety Scale-State, and child fear was measured using the Child Fear Scale, before, during, and after catheterization.

RESULTS

When analyzing the pain, anxiety, and fear findings, no statistical difference was found between the scores of the mother, child, and researcher before the procedure. During the catheterization procedure, the pain, anxiety, and fear scores of the children in the fish and turtle groups increased statistically less than those in the control group. When analyzing the post-procedure findings, the pain, anxiety, and fear scores of the control group were similar to those before the procedure. In the fish and turtle groups, anxiety and fear scores were statistically the lowest (p < 0.05).

CONCLUSION

It can be concluded that animal-assisted practices reduce anxiety and fear during and after the catheterization procedures while diverting attention from pain.

PRACTICE IMPLICATIONS

Goldfish or aquatic turtle intervention improve children's attitudes toward pain, anxiety, and fear during IV catheter insertion. Pediatric nurses could consider incorporating, such as the animal assisted intervention, into their clinical practice to reduce the pain, anxiety, and fear experienced by children during medical/nursing procedures.

Thermal imaging of local skin temperature as part of quality and safety assessment of injectable drugs

Injection of high-quality drugs can occasionally cause unexpected and unexplained local complications. As the current standard for drug quality control does not include an assessment of the local irritation effects of drugs, this effect may cause postinjection complications. Simultaneously, local irritation effects of the drugs can be assessed based on local tissue inflammation. The dynamics of local temperature can assess inflammation. Infrared monitoring of local skin temperature dynamics at subcutaneous, intramuscular, and intravenous injection sites of drugs under experimental and clinical conditions can improve their quality and safety. Therefore, there is a need to include dynamic thermography in the standard of biological evaluation of the quality and safety of drugs in the dosage form "solution for injections." This eliminates the local irritation and necrotizing activity of drugs and minimizes the development of local pain syndrome, aseptic inflammation, necrosis, and abscess.

The Effectiveness of the Buzzy Device in Reducing Pain in Children Undergoing Venipuncture: A Single-Center Experience

OBJECTIVES

Needle-related procedures are among the most important sources of pain in children in different health care settings. Our study was aimed to evaluate the effectiveness of Buzzy (MMJ Labs, Atlanta, Ga.), a palm-sized bee/ladybug-shaped device combining vibration and cold, as a nonpharmacological strategy to manage needle-related pain in children.

METHODS

In this single-center, randomized (1:1) controlled open-label study, we enrolled patients aged from 1 month to 18 years who had to undergo a planned outpatient blood sampling in Pisa University Hospital's Department of Pediatrics and randomly allocated them to either the BUZZY group (intervention group) or NO BUZZY group (control group). Pain was estimated using proper pain scales according to age.

RESULTS

Between May 2021 and January 2022, 234 children aged 8.8 ± 5.1 years (50.8% girls) were enrolled and 117 were treated with the Buzzy device. In the study population, pain inversely correlated with age (r = -0.52, P < 0.001); the intervention group showed significantly lower pain (2.5 ± 2.4 vs 4.7 ± 2.8, P < 0.001) and no difference was found between boys and girls. Significant reduction in pain scores was confirmed when stratifying children by age (29 days to <3 years, P = 0.002; ≥3 to ≤8 years, P < 0.001; >8 years, P < 0.001).

CONCLUSIONS

The Buzzy device effectively reduces pain caused by percutaneous antecubital venipuncture in children in different age groups and represents a cheap and easy-to-use strategy to manage routine needle-related procedures.

Massaging as a pain-relieving intervention before performing intravenous access

PURPOSE

Pain is "an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of damage". Stimulating the skin by rubbing, stroking, massaging, or applying pressure near the injection site is pain-relieving. Needle-related procedures induce anxiety, distress, and fear in children and adults. The present study aimed to test the effectiveness of massaging the access site in reducing pain associated with intravenous access.

DESIGN

After obtaining institutional ethics committee approval, this prospective randomized single-blinded study was performed on 250 ASA I-II patients 18 to 65 years old, scheduled for elective minor general surgery under general anaesthesia.

METHODS

Patients were randomized into the Massaging Group (MG) and the Control Group (CG). A Situational Trait Anxiety Inventory (STAI) was conducted to evaluate the anxiety levels of the patients. In addition, the skin adjacent to the intravenous access site was massaged for 15 s in circular motions with moderate intensity by the investigator's right thumb before performing the intravenous access in the MG. The CG did not receive any massage adjacent to the access site. The primary endpoint, the intensity of perceived pain, was rated on a non-graduated 10-cm Visual Analogue Score (VAS).

FINDINGS

The groups' demographic data and STAI I-II scores were similar. There was a significant difference between the VAS scores of the two groups (p < 0.05).

CONCLUSIONS

Our results support massaging as an effective pain-relieving technique before intravenous intervention. As massaging is a universal and non-invasive intervention that requires no advanced preparation, we recommend massaging before each intravenous cannulation to reduce pain caused by intravenous access.

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.

Effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections: a systematic review and meta-analysis

OBJECTIVE

The objective of this review was to synthesize the best available research evidence regarding the effectiveness of physical stimulation for reducing injection pain in adults receiving intramuscular injections.

INTRODUCTION

Pain associated with intramuscular injections continues to be a challenge for nurses. Various physical stimulation methods to alleviate pain and improve satisfaction for patients receiving intramuscular injections have been reported; however, the evidence surrounding the effectiveness of these methods remains inconclusive.

INCLUSION CRITERIA

This systematic review considered randomized and quasi-experimental studies that used any physical stimulation strategies (eg, skin tapping, manual pressure, massage, pinch, traction) for adults aged 18 years and over receiving intramuscular injections. Studies that evaluated pain using validated instruments were considered for inclusion.

METHODS

A three-step search strategy was conducted. MEDLINE, Embase, CINAHL, the Cochrane Library (Cochrane CENTRAL), Google Scholar, Dissertation Abstracts International, ProQuest Dissertations and Theses, and MedNar were searched from inception until 2020. We restricted the inclusion of studies to trials published in English. Two independent reviewers conducted the critical appraisal of eligible studies using the JBI checklists for randomized controlled and quasi-experimental trials. Data were extracted using the JBI data extraction tool, and meta-analysis and subgroup analysis were undertaken, where appropriate.

RESULTS

Twenty-five studies were included with a total sample size of 1956 patients. Pooled results demonstrated that pain was significantly less with the use of the Helfer skin tap technique compared to no intervention (two studies; RR 0.73; 95% CI 0.66, 0.81; P <0.00001) or standard intervention (three studies; SMD -2.25; 95% CI -3.65, -0.85; P =0.002). Intervention with acupressure using standard treatment as control showed significant reduction in pain intensity (MD -4.78; 95% CI -5.32, -4.24; P <0.00001). Similarly, pain was significantly lower with manual pressure (two studies; SMD -0.42; 95% CI -0.69, 0.15; P =0.002) when compared to standard treatment. Pain scores were significantly lower in patients who received pinch technique, ShotBlocker, massage, or combination intervention (skin traction, pressure, and rapid muscle release) compared with no intervention, standard treatment, or placebo control.

CONCLUSIONS

The evidence from this review demonstrates that physical stimulation - particularly the Helfer skin tap technique, acupressure, manual pressure, pinch technique, ShotBlocker, massage, and combination - can significantly lower intramuscular injection pain; however, this is based on low or very low certainty of evidence.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020168586.

Investigation of the Necessity of Aspiration During the Intramuscular Injection Administered in the Ventrogluteal Site and Its Effect on Pain: A Randomized Controlled Trial

This experimental study, which was conducted to examine the necessity of aspiration procedure and its effect on pain in intramuscular (IM) injections made into the ventrogluteal site (VGS), is randomized controlled and double-blind. The patients in the study group ( n = 834) were assigned to the IM group with the aspiration period of 5 to 10 seconds (Implementation Group A-IGA), the aspiration period of 1 to 2 seconds (Control Group-CG), and no aspiration (Implementation Group B-IGB) according to stratified block randomization list. Patients’ pain levels were evaluated with the Visual Analog Scale (VAS). No bleeding was observed when aspiration periods of 1 to 2 and 5 to 10 seconds were followed during the injections administered to the VGS. The difference between the pain medians of patients in IGB and the CG were not significant ( p = .521). It can be said that there is no need to apply aspiration in IM applied into the VGS if the correct site is determined.

Impact of hair type, hair sample weight, external hair exposures, and race on cumulative hair cortisol

The biomarker cortisol assesses the impact of biopsychosocial stressors that activate the stress response system. Hair has emerged as a valid and non-invasive means of gauging cumulative cortisol deposited over month-long periods of time. Established protocols for the extraction of hair cortisol are being validated and refined in humans, yet methodological information about hair characteristics on cortisol remains limited. In addition to external hair exposures (e.g. dye, time spent outside), we examined hair categorization or type (e.g. kinky, straight) by extending a hair typing methodology for scientific use that is currently popular among hair care professionals. We then examined the interaction between hair type and race on cortisol levels with a hair questionnaire. Three studies were pooled to investigate how sample weight, hair type, race, heat exposures, and hair treatments impacted cumulative hair cortisol concentrations. Study 1 consisted of Adult Kenyan Medical Workers (N = 44); Study 2 Mexican and Mexican Americans (N = 106); and Study 3 American Youth (N = 107). We found significantly higher cortisol in 5 mg of hair when compared to larger sample weights, and higher cortisol in those who spent more time outdoors. Cortisol concentrations differed between racial groups and varied by hair type; moreover, there were directional differences in cumulative cortisol from straighter to curlier hair types which depended on racial group. In addition to demonstrating the impact of relatively novel control factors like hair sample weight, outdoor exposure, and hair type, the present study illustrates the importance of disentangling hair type and race to understand variability in cumulative hair cortisol. These influences should be included in future studies that measure hair cortisol.

Nonpharmacological pain management in vaccination. Perception of paediatricians, patients and guardians

INTRODUCTION

The use of nonpharmacological measures to reduce pain during vaccination has been studied extensively in infants, but there are fewer studies on its effectiveness in older children and on the parental perception of pain in children.

METHODS

We conducted a multicentre, quasi-experimental interventional study with a control group.

PATIENTS

infants aged 2-11 months and children aged 4 years that attended routine vaccination appointments.

SETTING

Primary care. Intervention during vaccination: infants were breastfed and 4-year-old children blew a party horn.

CONTROL

vaccination performed following routine practice.

MEASUREMENT

NIPS (Neonatal Infant Pain Scale) and duration of crying in infants, Wong-Baker FACES pain rating scale in older children and parents.

RESULTS

The study included 125 children (intervention: 60; control: 65). There was a significant decrease in perceived pain in the intervention groups: NIPS score in infants, 3.8 ± 1.1 compared to 5.2 ± 0.7 (P < .001); Wong-Baker FACES score at 4 years of 3.3 ± 1.7 compared to 4.2 ± 1.6 (P = .042). These same differences in support of the intervention were reflected in the parental assessments (3.4 ± 1.3 vs 4.5 ± 1.5; P < .001). The correlation between child and parent scores was strongly positive: 0.7 (95% CI, 0.59-0.78). However, the duration of crying was longer in the intervention group.

CONCLUSION

The use of distraction techniques reduces pain in children and the pain perceived by parents in their children, thus increasing their satisfaction with the procedure.

To aspirate or not to aspirate? Considerations for the COVID-19 vaccines

Syringe aspiration when vaccinating intramuscularly was not recommended before the pandemic due to the lack of conclusive evidence that it provides any benefit. However, in vivo evidence suggests that intravenous injection of mRNA vaccine can potentially lead to myocarditis, while introducing adenoviral vector to bloodstream can possibly result in thrombocytopenia and coagulopathy. These rare reactions were recorded in humans following the administration of the COVID-19 vaccines. Although the syringe aspiration may increase the level of pain at the injection site, it represents a simple technique to decrease the risk of vaccine introduction into the vascular system and potentially decrease the risk of severe reactions to mRNA and adenoviral vaccines. We are of the opinion that this cannot be disregarded if one considers that the COVID-19 vaccines will continue to be administrated globally in the form of initial and booster doses. Therefore, the aspiration when giving mRNA and adenoviral vaccines appears to be fully in line with the precautionary principle.

Analgesic and adjuvant properties of exercise with vaccinations in healthy young population

Introduction: Exercise holds the potential to be beneficial if used during vaccination processes by 1)exercise-induced analgesia to reduce pain associated with vaccination, 2)immune-enhancing effects, improving antibody responses to the vaccine, and 3)reducing local and systemic adverse reactions to the vaccine. This study examines whether analgesic responses could be enhanced locally in the exercising limb to further benefit the use of exercise during influenza vaccination processes to minimize vaccine-related pain and improve antibody response to inactivated influenza vaccines.Methods: 57 participants (22.6 ± 3.2 years, 33 females) randomized into a control (n = 19) or one of two exercise groups: pre-vaccine arm (n = 19) or pre-vaccine leg (n = 19). Intervention groups performed exercise (15 minutes), prior to administration of the vaccine. Vaccine-related pain and pressure pain threshold (PPT) were measured at baseline and post-vaccination for all groups. Blood samples were taken on the day of vaccination and one month later to measure serum antibody titers to influenza.Results: No significant difference in vaccine-related pain or change in PPT was found with exercise, however, there was a trend in higher reports of vaccine-related pain in females compared to males(p = .06). Significantly higher fold increase (p = .02) of the B/Brisbane/60/2008 strain was found in the exercise group compared to the control group.Conclusion: The current study failed to observe an analgesic effect of exercise to improve vaccine-related pain in young adults. However, immune-enhancing effects in one of four strains suggest potential adjuvant effects of exercise. Importantly, the sex difference in pain sensitivity suggests the need for separate analysis, especially when examining pain perception.Australian New Zealand Clinical Trial Registry (ACTRN:12617000374369).

The effect of intramuscular injection technique on injection associated pain; a systematic review and meta-analysis

AIM

To review the effect of different intramuscular injection (IMI) techniques on injection associated pain, in adults.

METHODS

The review protocol was registered on PROSPERO (CRD42019136097). MEDLINE, EMBASE, British Nursing Index and CINAHL were searched up to June 2020. Included studies were appraised and a meta-analysis, where appropriate, was conducted with a random effects model and test for heterogeneity. Standardised mean difference (SMD) with a 95% confidence interval in reported injection pain (intervention cf. control) was reported.

RESULTS

29 studies were included in the systematic review and 20 studies in the meta-analysis. 13 IMI techniques were identified. 10 studies applied local pressure to the injection site. Of these, applying manual pressure (4 studies, SMD = -0.85[-1.36,-0.33]) and Helfer (rhythmic) tapping (3 studies, SMD = -2.95[-5.51,-0.39]) to the injection site reduced injection pain, whereas the use of a plastic device to apply local pressure to the skin (ShotBlocker) did not significantly reduce pain (2 studies, SMD = -0.51[-1.58,0.56]). Acupressure techniques which mostly involved applying sustained pressure followed by intermittent pressure (tapping) to acupressure points local to the injection site reduced pain (4 studies: SMD = -1.62[-2.80,-0.44]), as did injections to the ventrogluteal site compared to the dorsogluteal site (2 studies, SMD = -0.43[-0.81,-0.06]). There was insufficient evidence on the benefits of the 'Z track technique' (2 studies, SMD = -0.20[-0.41,0.01]) and the cold needle technique (2 studies, SMD = -0.73[-1.83,0.37]) on injection pain. The effect of changing the needle after drawing up the injectate on injection pain was conflicting and warming the injectate did not reduce pain. Limitations included considerable heterogeneity, poor reporting of randomisation, and possible bias in outcome measures from unblinding of assessors or participants.

CONCLUSIONS

Manual pressure or rhythmic tapping over the injection site and applying local pressure around the injection site reduced IMI pain. However, there was very high unexplained heterogeneity between studies and risk of significant bias within small studies.

The feasibility, acceptability and preliminary efficacy of parent-targeted interventions in vaccination pain management of infants: a pilot randomized control trial (RCT)

Aim: To evaluate the feasibility, acceptability and preliminary efficacy of parent interventions for improving the use of pain management strategies during vaccination of infants, a two-armed pilot randomized control trial (RCT) was conducted. Materials & methods: 151 parents were randomized in two groups: Group 1) 'Be Sweet to Babies' videos and a tip sheet (n = 76); Group 2) As per Group 1 plus a motivational interviewing informed Affirmative Statements and Questions (AS&Q) (n = 75). Results & conclusion: Feasibility was evaluated by success of the recruitment (151 people in a week), rates of completed consent forms (85%), and surveys (59%). Over 94% satisfaction with interventions, processes and 88% intention to recommend the strategies to others determined the acceptability. Preliminary efficacy was evident by over 95% use of pain management strategies following the interventions. Clinical trial registration number: NCT03968432.

Comparing the Effects of Massage Therapy and Aromatherapy on Knee Pain, Morning Stiffness, Daily Life Function, and Quality of Life in Patients with Knee Osteoarthritis

BACKGROUND

Knee osteoarthritis is the most common articular disease, and non-medical treatment of this disease has attracted the attention of researchers. The purpose of this study was to compare the effects of aromatherapy and massage therapy on knee pain, morning stiffness, daily life function, and quality of life in patients with knee osteoarthritis.

METHODS

This is a clinical trial. In this study, 93 patients referred to the Imam Ali Hospital (Physical Therapy Clinic) who entered the study were randomly divided into three groups including massage therapy (n = 31), aromatherapy (n = 31), and the control (n = 31). The data gathering tools were a demographic characteristics questionnaire and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The questionnaire was completed before intervention and at the 5th and 10th sessions after intervention in all three groups. Data were analyzed by SPSS software version 20, and Chi-square, Fisher's exact test, repeated measures test, one-way ANOVA test, and Tukey's post hoc test were used for analysis.

RESULTS

The study shows that mean score subscale Symptoms and dryness in the 5th session and 10th session of intervention in the aromatherapy group is significantly higher than in the control group (p < 0.05). The massage therapy group had the highest pain score at the beginning of the intervention, but at the end of the 10th session of intervention had the least pain score. Mean score subscale Performance of daily life in the 5th session and 10th session of intervention in the aromatherapy group is significantly higher than in the control group (p < 0.05). Mean score in the subscale Performance, exercise, and recreational activities significantly differs between the aroma therapy and massage therapy groups compared with the control group in all times of interventions (p < 0.05), and in the mean score in the subscale Quality of life, there is no significant difference between the groups in all times of interventions (p > 0.05).

CONCLUSION

The use of both massage therapy and aromatherapy is recommended for patients with knee osteoarthritis. Interventions should be prolonged for at least 6 months in patients so their effects appear on the patient.

The effectiveness of the BuzzyⓇ device to reduce or prevent pain in children undergoing needle-related procedures: The results from a prospective, open-label, randomised, non-inferiority study

BACKGROUND

Pain from needle-related procedures in children can alter pain perception, increase pain sensitivity, and generate inappropriate pain responses. Currently pain management includes the use of lidocaine-containing patches, which is complicated to manage in a busy medical setting such as a vaccination centre. We assessed the Buzzy^Ⓡ device, which combines vibration and cold, to manage pain in children undergoing a needle-related procedure, compared to the standard lidocaine patch.

DESIGN

Prospective, open-label, non-inferiority trial.

SETTING

The vaccination centres of three university hospitals in France.

PARTICIPANTS

French speaking children aged 4-15 requiring a needle-related procedure (vaccination or venepuncture) were eligible. Principal exclusion criteria were allergy or sensitivity to the lidocaine patch.

METHODS

Children were randomly allocated (1:1) to use either the Buzzy^Ⓡ device or the lidocaine patch during the needle-related procedure. The lidocaine patch was applied to the puncture site for the hour prior to the intervention. The Buzzy^Ⓡ device was applied to the puncture site for 30 s and then moved 5 cm along the limb during the procedure. The refrigerated wings were detached if they bothered the child. The child assessed their pain using the validated Revised Faces Pain Scale. The revised faces pain scale comprised six facial expressions from 0, normal "no pain" to 10, a screaming face "severe pain" (2 points/face). The primary endpoint was the average pain score recorded by the child. The study aimed to test the non-inferiority of Buzzy^Ⓡ.

RESULTS

Overall 219 participants were randomised. The primary outcome was assessed in 215 children: 108 in the BUZZY group (43% asked for the refrigerated wings were de to be detatched before the end of the procedure) and 107 in the PATCH group. The baseline characteristics were similar between the study groups with an average age of 9 (range: 4.08-15.81). The average needle-related pain was 2.04 in the BUZZY group and 1.42 in the PATCH group. The average difference between the children's assessments in the groups was 0.62, thus faling to demonstrate non-inferiority.

CONCLUSIONS

Our study failed to show that the Buzzy^Ⓡ device was not inferior to the lidocaine patch in managing pain in children undergoing needle-related procedures. Tweetable abstract: Pain management in children undergoing a needle-related procedure vaccination: which efficacy for Buzzy^Ⓡ device as an alternative to lidocaine patch? A prospective, randomised study.

Implementing a clinical protocol using breastfeeding to mitigate vaccination pain in infants

BACKGROUND

Although an effective public health intervention and a routine pediatric practice, vaccines are a common source of iatrogenic pain in childhood. Techniques, such as exam table restraint may cause infants to struggle and heighten distress, but studies demonstrate that breastfeeding and lap holding are effective strategies to reduce injection pain during vaccination.

LOCAL PROBLEM

Adoption of pain-relieving techniques into clinical practice is often underutilized. In a pediatric clinical practice in southern Connecticut, there were no guidelines for providing pain mitigation strategies, including breastfeeding, during infant vaccination.

METHODS AND INTERVENTIONS

The Plan-Do-Study-Act (PDSA) cycle was used for the improvement process. A clinical protocol introduced breastfeeding as a pain-relieving strategy during vaccination; lap holding was a second option. All clinical staff were educated on the infant pain experience, and nurses were further trained on vaccine administration techniques during breastfeeding.

RESULTS

A total number of 354 infants were seen for vaccination during the 12-week project: 168 were breastfed infants, of which 53% were breastfed during vaccination; 234 were placed on the parent/caregiver's lap during vaccination; and only 13 infants were restrained on the exam table. There was no documentation of position for 18 infants.

CONCLUSIONS

A clinical protocol was an effective tool to guide nurses on pain-relieving options, such as breastfeeding and lap holding, during vaccine administration. Positive experiences during vaccination administration have the potential for short-term and long-term benefits including, compliance with routine care and adherence to vaccination schedules.

A More Comfortable Method of Skin Prick Testing in Children Ages 0-2 to Decrease Symptoms of Pain

BACKGROUND

Skin prick testing (SPT) is the best initial diagnostic method for individuals of all ages who have potential allergies.

AIM

We aimed to investigate if recent breastfeeding has any effect on reducing the pain of children before SPT.

DESIGN

Prospective, randomized, single-blinded study.

SETTINGS

Academic hospital specialized in pediatrics.

PARTICIPANTS/SUBJECTS

Sixty-four out of seventy-five children requiring SPT within ages 0-2 were included.

METHODS

All participants in this study were breastfed children, and that group assignment randomized them to the control group (n = 32) if children breastfed 30-90 min. prior to arriving for SPT, and study group of children (n = 32) who were also breastfed 30-90 minutes prior to arriving for SPT who were then breastfed again just prior to the beginning of the SPT. The FLACC pain scale was used to test the sensitivity of all children for pain before, during, and 15 minutes after the SPT. The effect of breastfeeding on the pain score and the duration of crying were compared among groups.

RESULTS

Both groups were similar according to age, gender, and other socio-demographic characteristics (p > .05). The percentage of children that cried during SPT was significantly higher in the control group than the study group (p = .002). The FLACC pain scale values were significantly lower in the study group (p < .001).

CONCLUSION

Recent breastfeeding before SPT is correlated with less crying by possibly reducing the perceived pain of children ages 0-2.

Comparison of Two Anticoagulants for Pain Associated with Platelet-Rich Plasma Injections

BACKGROUND AND AIM

Platelet-rich plasma (PRP) has long been used in skin rejuvenation and hair loss treatment. Some patients require multiple intradermal injections into the face and scalp, and the way in which these patients process and experience pain differs, depending on the patient. Minimizing pain and discomfort during nonsurgical procedures is essential for patient satisfaction. In our experience, the use of acid citrate dextrose-A (ACD-A) as an anticoagulant caused more patient discomfort than did sodium citrate (Na-citrate) among patients who underwent facial rejuvenation with PRP. The aim of the present study was to evaluate patient-related discomfort in PRP sessions using two different anticoagulants.

MATERIALS AND METHODS

This clinical trial included 10 patients who received facial PRP injections for facial rejuvenation and 10 patients who received PRP injections in their scalps for hair loss. On the application area, half the surface was treated with Na-citrate PRP injections, and the other half was treated with the same amount of ACD-A PRP injections. Neither the doctors who applied the treatment nor the patients were given information about which anticoagulant was used in each area. Immediately after the procedure, the patients were asked to score their pain on each side of the application area on a scale of 1-10 using a visual analog scale (VAS).

RESULTS

PRP injections using Na-citrate as an anticoagulant caused less discomfort on both the face and scalp as compared with that of ACD-A. The outcome was statistically significant.

CONCLUSION

Anticoagulants used in PRP preparation affected patients' pain perceptions during the injections. The sensation of pain with PRP prepared with Na-citrate as an anticoagulant was lower than that of PRP prepared with ACD-A. Further studies are required to evaluate the correlation between anticoagulants used for PRP preparation and pain feelings during injections.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Parent-Targeted Education Regarding Infant Pain Management Delivered During the Perinatal Period: A Scoping Review

All infants experience pain in early life from procedures. Parents recognize pain as a prevalent issue, reporting a strong desire for more information on infant pain. The aim of this study was to explore and map the current evidence of parent-targeted educational interventions about infant pain, delivered throughout the perinatal period. Records were identified in PubMed, CINAHL, EMBASE, and ERIC databases and hand searching recent publications in 3 relevant journals. Records in English that described or evaluated educational interventions on infant pain management aimed at parents during the perinatal period were eligible for review and those not related to pain or aimed at healthcare providers were excluded. Evaluation was completed following the Methodology for JBI Scoping Reviews and standardized critical appraisal instruments from the Joanna Briggs Institute. Initial search yielded 6946 records, with 9 included in analysis. Six studies were quantitative, 2 qualitative, and 1 mixed methods. Included interventions contained information about parent-led pain management strategies for infants in the neonatal intensive care unit (n = 4), full term (n = 4), or both (n = 1). Despite being an area of high concern for parents of newborns, few studies addressed parent-targeted education regarding infant pain. Future research examining the impact and efficacy of these interventions addressing parental and neonatal outcomes is warranted.

Nonpharmacologic Management of Pain During Common Needle Puncture Procedures in Infants: Current Research Evidence and Practical Considerations: An Update

Infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available that may be used for these painful procedures, including swaddling/containment, pacifier/non-nutritive sucking, rocking/holding, breastfeeding and breastmilk, skin-to-skin care, sweet tasting solutions, music therapy, sensorial saturation, and parental presence. Adoption these interventions into routine clinical practice is feasible and should be a standard of care in quality health care for infants. This review summarizes the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions.

The how's and what's of vaccine reactogenicity

Reactogenicity represents the physical manifestation of the inflammatory response to vaccination, and can include injection-site pain, redness, swelling or induration at the injection site, as well as systemic symptoms, such as fever, myalgia, or headache. The experience of symptoms following vaccination can lead to needle fear, long-term negative attitudes and non-compliant behaviours, which undermine the public health impact of vaccination. This review presents current knowledge on the potential causes of reactogenicity, and how host characteristics, vaccine administration and composition factors can influence the development and perception of reactogenicity. The intent is to provide an overview of reactogenicity after vaccination to help the vaccine community, including healthcare professionals, in maintaining confidence in vaccines by promoting vaccination, setting expectations for vaccinees about what might occur after vaccination and reducing anxiety by managing the vaccination setting.

Development of an Intervention to Reduce Pain and Prevent Syncope Related to Adolescent Vaccination

INTRODUCTION

There is a lack of research into the perspectives of patients, parents, and clinicians regarding strategies for vaccine-related pain and syncope prevention that may improve the adolescent vaccination experience and encourage future vaccination.

OBJECTIVE

To develop an intervention on the basis of preference for strategies to reduce pain and prevent syncope associated with adolescent vaccination.

METHODS

We conducted focus groups and interviews with 8 recently vaccinated Kaiser Permanente Northwest (KPNW) members aged 11 to 17 years and their parents to explore perceptions of pain and syncope after vaccination as well as receptivity to potential interventions. Additionally, we interviewed 7 clinical staff who routinely vaccinate children. We conducted content analysis to identify promising interventions and conducted a data synthesis workshop to select a final intervention for piloting.

RESULTS

All participants expressed willingness to use previsit education, breathing exercises, social support or distraction, and water consumption. Patients and parents expressed a need for verbal education and messaging about potential vaccine-related outcomes, and clinicians noted a need to identify patients who are anxious before a vaccination visit. Most participants suggested a "comfort menu" intervention, to include comfort and distraction items that medical staff offer adolescents before and during vaccination.

CONCLUSION

Patients, parents, and clinicians acknowledged the value of interventions to reduce pain and syncope after adolescent vaccination. Stakeholders identified a comfort menu as the intervention to be piloted at 2 KPNW pediatric clinics. Further research is needed to test the effectiveness of the "Vaccination Comfort Menu" intervention in improving vaccination experiences and continued receipt of vaccinations.

Needle size for vaccination procedures in children and adolescents

BACKGROUND

This is an update of a Cochrane Review first published in 2015. The conclusions have not changed.Hypodermic needles of different sizes (gauges and lengths) can be used for vaccination procedures. The gauge (G) refers to the outside diameter of the needle tubing. The higher the gauge number, the smaller the diameter of the needle (e.g. a 23 G needle is 0.6 mm in diameter, whereas a 25 G needle is 0.5 mm in diameter). Many vaccines are recommended for injection into muscle (intramuscularly), although some are delivered subcutaneously (under the skin) and intradermally (into skin). Choosing an appropriate length and gauge of a needle may be important to ensure that a vaccine is delivered to the appropriate site and produces the maximum immune response while causing the least possible harm. Guidelines conflict regarding the sizes of needles that should be used for vaccinating children and adolescents.

OBJECTIVES

To assess the effects of using needles of different sizes for administering vaccines to children and adolescents on vaccine immunogenicity (the ability of the vaccine to elicit an immune response), procedural pain, and other reactogenicity events (adverse events following vaccine administration).

SEARCH METHODS

We updated our searches of CENTRAL, MEDLINE, Embase, and CINAHL to October 2017. We also searched proceedings of vaccine conferences and two trials registers.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of using hypodermic needles of any gauge or length to administer any type of vaccine to people aged from birth to 24 years.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted trial data and assessed the risk of bias. We contacted trial authors for additional information. We rated the quality of evidence using the GRADE system.

MAIN RESULTS

We included five trials involving 1350 participants in the original review. The updated review identified no new trials. The evidence from two small trials (one trial including infants and one including adolescents) was insufficient to allow any definitive statements to be made about the effects of the needles evaluated in the trials on vaccine immunogenicity and reactogenicity.The remaining three trials (1135 participants) contributed data to comparisons between 25 G 25 mm, 23 G 25 mm, and 25 G 16 mm needles. These trials included infants predominantly aged from two to six months undergoing intramuscular vaccination in the anterolateral thigh using the World Health Organization (WHO) injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants). The vaccines administered were combination vaccines containing diphtheria, tetanus, and whole-cell pertussis antigens (DTwP). In some trials, the vaccines also contained Haemophilus influenzae type b (DTwP-Hib) and hepatitis B (DTwP-Hib-Hep B) antigen components.Primary outcomesIncidence of vaccine-preventable diseases: No trials reported this outcome.Procedural pain and crying: Using a wider gauge 23 G 25 mm needle may slightly reduce procedural pain (low-quality evidence) and probably leads to a slight reduction in the duration of crying time immediately after vaccination (moderate-quality evidence) compared with a narrower gauge 25 G 25 mm needle (one trial, 320 participants). The effects are probably not large enough to be clinically relevant.Secondary outcomesImmune response: There is probably little or no difference in immune response, defined in terms of the proportion of seroprotected infants, between use of 25 G 25 mm, 23 G 25 mm, or 25 G 16 mm needles to administer a series of three doses of a DTwP-Hib vaccine at ages two, three, and four months (moderate-quality evidence, one trial, numbers of participants in analyses range from 309 to 402. The immune response to the pertussis antigen was not measured).Severe and non-severe local reactions: 25 mm needles (either 25 G or 23 G) probably lead to fewer severe and non-severe local reactions after DTwP-Hib vaccination compared with 25 G 16 mm needles (moderate-quality evidence, one trial, 447 to 458 participants in analyses). We estimate that one fewer infant will experience a severe local reaction (extensive redness and swelling) after the first vaccine dose for every 25 infants vaccinated with the longer rather than the shorter needle (number needed to treat for an additional beneficial outcome (NNTB) with a 25 G 25 mm needle: 25 (95% confidence interval (CI) 15 to 100); NNTB with a 23 G 25 mm needle: 25 (95% CI 17 to 100)). We estimate that one fewer infant will experience a non-severe local reaction (any redness, swelling, tenderness, or hardness (composite outcome)) at 24 hours after the first vaccine dose for every 5 or 6 infants vaccinated with a 25 mm rather than a 16 mm needle (NNTB with a 25 G 25 mm needle: 5 (95% CI 4 to 10); NNTB with a 23 G 25 mm needle: 6 (95% CI 4 to 13)). The results are similar after the second and third vaccine doses.Using a narrow gauge 25 G 25 mm needle may produce a small reduction in the incidence of local reactions after each dose of a DTwP vaccine compared with a wider gauge 23 G 25 mm needle, but the effect estimates are imprecise (low-quality evidence, two trials, 100 to 459 participants in analyses).Systemic reactions: The comparative effects of 23 G 25 mm, 25 G 25 mm, and 25 G 16 mm needles on the incidence of postvaccination fever and other systemic events such as drowsiness, loss of appetite, and vomiting are uncertain due to the very low quality of the evidence.

AUTHORS' CONCLUSIONS

Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in low- and middle-income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

How are children who are delayed in the Childhood Vaccination Programme vaccinated: A nationwide register-based cohort study of Danish children aged 15-24 months and semi-structured interviews with vaccination providers

Aims: Delay of childhood vaccinations is common and influences efforts to reduce targeted diseases. In Denmark, the diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (DTaP-IPV-Hib) vaccine is recommended at ages 3, 5 and 12 months and the first measles-mumps-rubella vaccine (MMR-1) at 15 months. Following guidelines, children delayed at age 15 months should receive MMR-1 and DTaP-IPV-Hib-3 simultaneously, unless DTaP-IPV-Hib-2 was received less than 6 months ago, when MMR-1 alone is recommended. We studied compliance with these guidelines and the reasons for non-compliance with a focus on vaccination providers. Methods: We used a nationwide register-based cohort study of children born in Denmark between January 2000 and June 2013, who were lacking MMR-1 and DTaP-IPV-Hib-3 at age 15 months and were followed to 24 months. We also performed semi-structured telephone interviews with vaccination providers. Results: The study consisted of 156,921 children (18% of the children born in the period). Among the 40,060 children who had received DTaP-IPV-Hib-2 less than 6 months ago, 37,892 (95%) received MMR-1 alone. Among the 88,469 children who had received DTaP-IPV-Hib-2 more than 6 months ago, 6334 (7%) received DTaP-IPV-Hib-3 and MMR-1 simultaneously. The interviews indicated that some vaccination providers are reluctant to give multiple vaccinations at the same visit and some have a preference of following the usual sequence in the programme. Conclusions: Vaccination providers generally complied with the recommended minimum 6 months' interval between DTaP-IPV-Hib-2 and DTaP-IPV-Hib-3. Conversely, there was a low compliance with the recommendation to administer DTaP-IPV-Hib-3 and MMR-1 simultaneously. More efforts are needed to ensure timely vaccination.

Evaluating the impact of multilevel evidence-based implementation strategies to enhance provider recommendation on human papillomavirus vaccination rates among an empaneled primary care patient population: a study protocol for a stepped-wedge cluster randomized trial

Background

Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates.

Methods

Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates.

Discussion

Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes.

Trial registration

ClinicalTrials.gov, NCT03501992, registered April 18, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0778-x) contains supplementary material, which is available to authorized users.

Intramuscular injection CLIMAT pathway: a clinical practice guideline

The intramuscular (IM) injection has been part of nursing practice since the 1960s. Over the past 60 years, the practice of aspiration during IM injection has been controversial and understudied. In 2016, a study by Thomas et al identified that blood aspiration does occur during injection. This article introduces a clinical practice guideline for safe and effective aspiration during IM injection, as a follow-up to the findings of that study. The proposed guideline acknowledges the correct practice of aspiration and identifies considerations that may make aspiration unnecessary. These practices and considerations are presented to the reader using a visual clinical pathway and a narrative clinical practice guideline.

The effect of exercise on vaccine-related pain, anxiety and fear during HPV vaccinations in adolescents

INTRODUCTION

With increased school-based vaccinations for improved coverage rates and practicality, the World Health Organization (WHO) recently endorsed research to identify possible interventions to reduce vaccine-related pain in mass clinical and school-based settings. In particular, the lack of research in adolescents indicate a particular need in this population. Acute exercise has analgesic effects and has been used as a behavioural adjuvant to vaccination. Here, we examine the effect of exercise on vaccine-related pain, anxiety and fear in adolescents, during a school-based program for HPV vaccinations.

METHODS

116 students (Female: 61, Male: 55) aged 11-13 years were randomly allocated to either an Exercise (n = 60) or Control (n = 56) group. All participants completed demographic and Trait-anxiety questionnaires prior to receiving the vaccine according to usual care. The Exercise group also performed upper body exercise for 15 min prior to receiving the vaccine. Immediately after the vaccine administration, all participants reported on pain, anxiety and fear at the time of receiving the vaccine.

RESULTS

Female adolescents in the Exercise group reported significantly less pain (3.64; 95% CI, 2.98-4.30) than Controls (4.58; 95% CI, 3.96-5.19; p = 0.04). Further, females reported greater pain and anxiety than males in the Control group but not the Exercise group.

CONCLUSION

This study supports the use of exercise prior to vaccine administration, especially in female adolescents who are particularly vulnerable to negative experiences during vaccination procedures. Furthermore, the ease of application, as well as the benefit of exercise, provides support for the use of simple exercise prior to vaccination in mass vaccination settings. Clinical trial registry: ANZCTR, ACTRN12614001185651.

Effects of Thermomechanical Stimulation during Vaccination on Anxiety, Pain, and Satisfaction in Pediatric Patients: A Randomized Controlled Trial

PURPOSE

Vaccination can be a significant source of pain for pediatric patients, which could result in fear of medical procedures and future reluctance to seek medical care. It is important for nurses to provide pain prevention during these procedures. This study sought to measure the impact of an intervention combining cold and vibration on pain scores during routine pediatric immunization.

DESIGN AND METHODS

A prospective, open-label, randomized controlled trial to examine the effectiveness of the Buzzy device (thermomechanical stimulation) compared to no intervention (control group) in reducing child-reported pain during routine immunization. The Wong Baker Faces scale was used to collect child, parent, and observer reported anxiety and pain. Parents reported satisfaction with the procedure and overall office visit.

RESULTS

Fifty children between the ages of 3 and 18 were included in the present analysis. Mean child-reported pain scores were significantly lower in the group receiving thermomechanical stimulation compared to control (3.56 vs 5.92, p=0.015). Buzzy did not impact child-reported anxiety or how much pain the child expected. Parent-reported satisfaction did not vary significantly between groups, but was strongly associated with parent-reported pain scores.

CONCLUSIONS

Thermomechanical stimulation with the Buzzy device significantly reduced pain during pediatric immunization over a wide range of ages compared to control, but did not impact pre-procedure anxiety.

PRACTICE IMPLICATIONS

The Buzzy device is an easy to implement intervention to reduce pediatric pain during vaccination. It may have the greatest impact in younger children but could be offered during all immunizations.

Understanding Non-Completion of the Human Papillomavirus Vaccine Series: Parent-Reported Reasons for Why Adolescents Might Not Receive Additional Doses, United States, 2012

Completion rates of the human papillomavirus (HPV) vaccine series among U.S. adolescents are below public health targets. We explored parent-reported reasons for their children's non-completion of the HPV vaccine series using a nationally representative online survey of parents of children aged 9-17 years, fielded in October 2012. Among the 1,653 parents who responded, the proportion reporting that their child would definitely continue with the HPV vaccine series among those who had started the series ranged from 28% to 54%. The most common reason cited by parents for non-completion of the series was their child's fear of needles, followed by lack of awareness about additional doses and safety concerns. These findings demonstrate the need to encourage adoption of strategies addressing needle fears, utilize reminders for parents about subsequent doses, and emphasize recent HPV vaccine safety data in discussions with parents.

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.

If Euhydric and Isotonic Do Not Work, What Are Acceptable pH and Osmolality for Parenteral Drug Dosage Forms?

Parenteral products should aim toward being isotonic and euhydric (physiological pH). Yet, due to other considerations, this goal is often not reasonable or doable. There are no clear allowable ranges related to pH and osmolality, and thus, the objective of this review was to provide a better understanding of acceptable formulation pH, buffer strength, and osmolality taking into account the administration route (i.e., intramuscular, intravenous, subcutaneous) and administration technique (i.e., bolus, push, infusion). This evaluation was based on 3 different approaches: conventional, experimental, and parametric. The conventional way of defining formulation limits was based on standard pH and osmolality ranges. Experimental determination of titratable acidity or in vitro hemolysis testing provided additional drug product information. Finally, the parametric approach was based on the calculation of theoretical values such as (1) the maximal volume of injection which cannot shift the blood's pH or its molarity out of the physiological range and (b) a dilution ratio at the injection site and by verifying that threshold values are not exceeded. The combination of all 3 approaches can support the definition of acceptable pH, buffer strength, and osmolality of formulations and thus may reduce the risk of failure during preclinical and clinical development.

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.

ABM Clinical Protocol #23: Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant, Revised 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa

BACKGROUND

The Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa.

METHODS

A mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions.

RESULTS

The sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators' care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs.

CONCLUSIONS

We found high acceptance by caregivers and vaccinators of three injections. Caregivers' poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants' pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI's expansion in resource-limited countries.

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.

Pain management in the acute care setting: Update and debates

Pain management in the paediatric acute care setting is underutilised and can be improved. An awareness of the analgesic options available and their limitations is an important starting point. This article describes the evolving understanding of relevant pharmacogenomics and safety data of the various analgesic agents with a focus on agents available in Australia and New Zealand. It highlights the concerns with the use of codeine in children and discusses alternative oral opioids. Key features of oral, parenteral, inhaled and intranasal analgesic agents are discussed, as well as evidence supported use of sweet tasting solutions and non-pharmacological interventions. One of the biggest changes in acute care pain management has been the advent of intranasal fentanyl providing reliable potent analgesia without the need for intravenous access. The article will also address the issue of multimodal analgesia where a single agent is insufficient.

Why are children still crying? Going beyond "evidence" in guideline development to improve pain care for children: the HELPinKIDS experience

The failure to translate research evidence into day-to-day clinical practices is identified as a significant reason for suboptimal quality care across the health system, including procedural pain management in children. Clinical practice guidelines (CPGs) have been developed to assist in this process by synthesizing and interpreting research evidence for end users. Numerous CPGs have been developed for procedural pain management in children, yet gaps persist in the adoption of best practices. This article reviews the experience and approach of 1 guideline development group, the Help ELiminate Pain in KIDS Team (HELPinKIDS), in incorporating implementation considerations and knowledge translation (KT) strategies within the process of guideline development for the HELPinKIDS CPG about childhood vaccination pain management to facilitate greater uptake of the CPG. Specific areas that will be addressed include partnerships with stakeholders, rigor of guideline development, issues of implementation, and editorial independence. The work of HELPinKIDS was guided by a KT map, which identified, at a high level, the target audiences, key messages, tools, and strategies that could be used to communicate, disseminate, and implement the CPG into diverse settings. Examples of impact at both the individual and systems levels from HELPinKIDS KT activities are also presented.

Reducing pain at the time of vaccination: WHO position paper, September 2015-Recommendations

This article presents the World Health Organization's (WHO) recommendations for pain mitigation at the time of vaccination from the WHO position paper on reducing pain at the time of vaccination: WHO position paper-September 2015, recently published in the Weekly Epidemiological Record [1]. This position paper summarizes the evidence and integrates information pertaining to the reduction of pain, distress and fear during immunization across all age groups. In accordance with its mandate to provide guidance to Member States on health policy matters, WHO issues a series of regularly updated position papers on vaccines and combinations of vaccines against diseases that have an international public health impact, and on vaccination-related policy questions particularly concerning the use of vaccines in large-scale immunization programmes. They summarize essential background information and conclude with the current WHO position. This position paper addresses a cross-cutting issue which is relevant for all injectable vaccines and reflects the recommendations of WHO's Strategic Advisory Group of Experts (SAGE) on immunization. These recommendations were discussed by SAGE at its April 2015 meeting. The evidence presented at the meetings can be accessed at http://www.who.int/immunization/sage/previous/en/index.html.

Far From "Just a Poke": Common Painful Needle Procedures and the Development of Needle Fear

BACKGROUND

Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress.

OBJECTIVE

The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established.

RESULTS

First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue.

DISCUSSION

Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.