Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary)

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.

Review of outpatient procedural sedation clinics in a tertiary paediatric hospital in South Australia

AIM

Procedures, such as immunisation and venepuncture, can be distressing for paediatric patients, especially those with needle phobia and neurodevelopmental disorders. Procedural sedation helps provide access to equitable health care in this population. The aim of this study was to evaluate the pilot outpatient procedural sedation clinics at the Women's and Children's Hospital and the impact on patient care and outcomes.

METHODS

A prospective review was undertaken between July 2021 and May 2022 on all patients who attended the procedural sedation clinics at the Women's and Children's Hospital. These clinics were the COVID Specialist Immunisation Sedation Clinic (SISC) and Paediatric Sedation Clinic (PSC).

RESULTS

There were 182 visits in a total of 110 children with a 92% primary procedure success rate. Sixty-three per cent of patients had neurodevelopmental disorders with autism spectrum disorder being most common. There was a significant reduction in anxiety scores pre- and post-sedation and a reduction in anxiety scores if patients were to return without the use of sedation.

CONCLUSIONS

Outpatient procedural sedation is beneficial for a specific cohort of the paediatric population. This can also have a significant positive impact on patient care and potentially, long-term outcomes.

Determination of pain experienced by children during intravenous bolus treatments and its causes

OBJECTIVE

The present study aimed to determine the pain experienced by children during intravenous bolus treatment and to identify what causes it.

METHOD

In the first stage of the study, the first 40 observations were performed by two researchers. The study was continued by a single observer after the Kappa test was performed. In this study, 101 drug treatments were administered by intravenous bolus in patients aged between 1 month and 6 years. The pain experienced during treatment was assessed using pain scales according to the age group the patient was in.

RESULTS

Pain was observed in 63.4% (n = 64) of the treatments. There was a significant relationship between the type of medication administered and pain experienced during drug administration. There was also a significant correlation between the age of the children and their pain experiences. Given the location of the catheter, there was no significant difference among the children who experienced pain during intravenous treatment.

CONCLUSION

Intravenous drug therapy may cause pain in children. To minimize such pain, it is recommended to determine the drugs that cause pain during intravenous treatment and to develop application protocols to minimize pain caused by these drugs.

Reflections From School Communities in Underserved Populations on Childhood COVID-19 Vaccination

OBJECTIVES

Outbreaks in vaccine-preventable diseases among children have increased, primarily among under- or unvaccinated subgroups. The influence and interaction of a child's school community on parental health care decisions, such as vaccination, has not been explored. Our study examined childhood coronavirus disease 2019 (COVID-19) vaccine hesitancy within the context of school communities.

METHODS

This study combines data from 4 independent research studies funded by the National Institutes of Health Rapid Acceleration of Diagnostics Underserved Populations Return to School Initiative. We examined focus group data to better understand the apprehension surrounding parental and child COVID-19 vaccination among underserved school populations.

RESULTS

Across all study sites, 7 main themes emerged with regard to COVID-19-related vaccination concerns for children: (1) potential side effects, (2) vaccine development, (3) misinformation (subthemes: content of vaccine and negative intent of the vaccine), (4) vaccine effectiveness, (5) timing of vaccine administration/availability for children, (6) fear of needles, and (7) mistrust.

CONCLUSIONS

School settings offered unique access to youth and family perspectives in underserved communities. Our studies highlighted several factors contributing to COVID-19 vaccine hesitancy in school communities, which align with existing literature on vaccine hesitancy. These concerns centered primarily on potential harm of vaccines, as well as misinformation, mistrust, and timing of vaccines. Related recommendations for increasing vaccination rates are provided. Developing specific strategies that address parent and child concerns will be critical to reducing health inequities related to COVID-19 vaccination.

A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention to Reduce Distress and Pain Associated with Vaccine Injections in Young Children

Children remember their memories of pain long after the painful experience is over. Those memories predict higher levels of future pain intensity. Young children's memories can be reframed to be less distressing. Parents and the way they reminisce about past events with their children play a key role in the formation of pain memories. A novel parent-led memory-reframing intervention changed children's memories of post-surgical pain to be less distressing. The intervention efficacy in the context of vaccine injections is unclear. This registered randomized controlled trial (NCT05217563) aimed to fill this gap. Seventy-four children aged 4.49 years (SD = 1.05) and scheduled to obtain two COVID-19 vaccine injections and one of their parents were randomized to receive: (1) standard care; (2) standard care and memory-reframing information; and (3) standard care and memory-reframing information with verbal instructions. Children reported their pain after vaccine injections. One week after the first vaccination, children reported memory of pain. Parents reported their use of memory-reframing strategies and intervention feasibility and acceptability. The intervention did not result in significant differences in children's recalled or future pain. Parents rated the intervention as acceptable and feasible.

Stories to Take the Edge Off Pain During Immunization for Preschoolers: A Randomized Controlled Trial

IMPORTANCE

Fear and distress during immunization may lead to long-term preprocedural anxiety and nonadherence to immunization schedules. Pictorial stories provide a way of educating the parent and child about the procedure.

OBJECTIVE

To determine the efficacy of pictorial stories in reducing pain perception among children and anxiety among mothers during immunization.

DESIGN

Three-arm randomized controlled trial Setting: Immunization clinic of a tertiary care hospital in South India.

PARTICIPANTS

Fifty children ages 5 to 6 yr, who reported to the hospital for measles, mumps, and rubella and typhoid conjugate virus vaccines. Inclusion criteria were that the child was accompanied by the mother and maternal knowledge of either Tamil or English. Exclusion criteria were child hospitalization in the past year or neonatal intensive care unit admission in the neonatal period.

INTERVENTION

Pictorial story regarding immunization before the procedure that contained information related to immunization, coping strategies, and distraction techniques.

OUTCOMES AND MEASURES

Pain perception was evaluated using the Sound, Eye, Motor Scale; the Observation Scale of Behavioral Distress; and the Wong-Baker FACES Pain Rating Scale (FACES). Maternal anxiety was measured using the General Anxiety-Visual Analog Scale.

RESULTS

Of 50 children recruited, 17 were in the control group, 15 were in the placebo group, and 18 were in the intervention group. Children in the intervention group reported lower pain scores on the FACES (p = .04) compared with the placebo and control groups.

CONCLUSIONS AND RELEVANCE

A pictorial story is a simple and cost-effective intervention to reduce pain perception among children. What This Article Adds: Pictorial stories may be a feasible, simple, and cost-effective intervention to reduce pain perception during immunization.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Willingness to receive a vaccine is influenced by adverse events following immunisation experienced by others

An adverse event following immunization (AEFI) can have consequences for an individual's future decision making and may contribute to vaccine hesitancy. AEFIs vary in severity and can be experienced directly (by an individual themselves) or indirectly (through witnessed or recounted events). We sought to measure the prevalence of specific AEFIs and understand which AEFIs have the greatest associations with reduced willingness to receive a vaccine and how injection anxiety may moderate the relationship. We conducted a cross-sectional online survey with both qualitative and quantitative elements in a sample of adults aged 18 years and over in Australia. Nineteen percent of the 1050 respondents reported experiencing an AEFI that they found stressful. Those who experienced an AEFI reported significantly higher levels of injection anxiety than those who did not. Within the group who reported experiencing an AEFI, respondents were significantly less likely to be willing to receive a COVID-19 vaccine if they reported: indirect exposure to an uncommon/rare AEFI compared with other AEFIs (aOR:0.39; 95% CI: 0.18-0.87); indirect exposure to a scientifically unsupported AEFI compared with other AEFIs (aOR:0.18; 95% CI: 0.05-0.57). Direct exposure to an AEFI was not associated with willingness to receive a COVID-19 vaccine. For those who reported experiencing an AEFI, the odds of willingness to receive a COVID-19 vaccine decreased significantly with an increase in injection anxiety (aOR:0.94; 95% CI: 0.9-0.98). Our results suggest that more is needed to mitigate the consequences of AEFIs on vaccine willingness. Empathically acknowledging at a community level, the experience of both real and perceived AEFIs and incorporating accounts of positive vaccination experiences in vaccine hesitancy interventions may be useful.

Non-Pharmacological Management for Vaccine-Related Pain in Children in the Healthcare Setting: A Scoping Review

Purpose

To examine how research was conducted on non-pharmacological management in children with vaccine-related pain in the healthcare setting, so as to provide reference for the relief of vaccine-related pain in children.

Methods

This study conducted a scoping review guided by the methodological framework of Arksey and O’Malley. MEDLINE, Cochrane Library, EMBASE, CINAHL, PubMed databases were searched in detail, and search strategy included the keyword “vaccine”, the keyword “pain”, and the keyword “children”. Two researchers conducted literature screening and data extraction independently, and any disagreements were resolved through team consultation.

Results

This study retrieved 1017 literatures, of which 22 were finally included, including 18 randomized controlled studies, 3 quasi-experimental studies and 1 cohort study. Non-pharmacological management measures were summarized in the study, mainly involving taste, tactile, olfactory, visual, exercise, and postural interventions and injection technique. All the above non-pharmacological management were effective in mitigating vaccine-related pain in children. The study population in the included literatures was mainly neonates and infants. Regarding the analgesic effects of taste intervention, breastfeeding was better than sweeteners, and sweeteners were better than sterile water or non-nutritive sucking. However, there was a lack of comparative studies on the analgesic effects of other non-pharmacological management.

Conclusion

There are many non-pharmacological management measures with varying analgesic effects. Diversified non-pharmacological management measures can provide more analgesic choices for children. For reducing vaccine-related pain in newborns and infants, breastfeeding is recommended first, then sweeteners, and then non-nutritious sucking. In addition to the taste intervention, the analgesic effects of other non-pharmacological management measures need further comparative studies. Moreover, medical staff can use a combination of non-pharmacological analgesic measures to maximize the analgesic effect, and medical staff should also fully consider the analgesia willingness of children and parents.

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.

Use of virtual reality in the reduction of pain after the administration of vaccines in children in primary care centers: a randomized clinical trial (Preprint)

Background

Pain and anxiety caused by vaccination and other medical procedures in childhood can result in discomfort for both patients and their parents. Virtual reality (VR) is a technology that is capable of entertaining and distracting the user. Among its many applications, we find the improvement of pain management and the reduction of anxiety in patients undergoing medical interventions.

Objective

We aim to publish the protocol of a clinical trial for the reduction of pain and anxiety after the administration of 2 vaccines in children aged 3 to 6 years.

Methods

We will conduct a randomized, parallel, controlled clinical trial with 2 assigned groups. The intervention group will wear VR goggles during the administration of 2 vaccines, while the control group will receive standard care from a primary care center for the procedure. Randomization will be carried out by using the RandomizedR computer system—a randomization tool of the R Studio program. This trial will be an open or unblinded trial; both the subjects and the investigators will know the assigned treatment groups. Due to the nature of the VR intervention, it will be impossible to blind the patients, caregivers, or observers. However, a blind third-party assessment will be carried out. The study population will include children aged 3 to 6 years who are included in the patient registry and cared for in a primary care center of the region of Central Catalonia. They will receive the following vaccines during the Well-Child checkup: the triple viral+varicella vaccine at 3 years of age and the hepatitis A+diphtheria-tetanus-pertussis vaccine at 6 years of age.

Results

The study is scheduled to begin in January 2022 and is scheduled to end in January 2023, which is when the statistical analysis will begin. As of March 2022, a total of 23 children have been recruited, of which 13 have used VR during the vaccination process. In addition, all of the guardians have found that VR helps to reduce pain during vaccination.

Conclusions

VR can be a useful tool in pediatric procedures that generate pain and anxiety.

International Registered Report Identifier (IRRID)

PRR1-10.2196/35910

Community Pharmacists' Knowledge and Attitudes Towards Pediatric Pain Management in Nigeria

PURPOSE

Community pharmacists (CPs) frequently attend to pediatric patients with pain but limited data exist regarding their knowledge of and attitude to effective management of pediatric pain in Nigeria. Thus, this study aimed to evaluate the knowledge of and attitude to pediatric pain management among CPs in Nigeria.

PATIENTS AND METHODS

A validated and pilot-tested questionnaire, the Community Pharmacists Survey on Pediatric Pain, was administered to 517 eligible participants at the 38th Annual National Conference of the Association of Community Pharmacists of Nigeria. Independent samples t-test and one-way analysis of variance were used for inferential statistical analyses.

RESULTS

CPs with additional higher academic qualifications and clinically related additional academic degrees had significantly higher mean knowledge scores relative to first degree only holder counterpart (t= 4.33, p< 0.05, Eta2=0.05) and those without clinically related second degrees (t= 6.34, p< 0.05, Eta2=0.27). Pain knowledge among the study cohort also varied significantly by age group, years of practicing community pharmacy, ownership structure of premises, geographical location of practice and previous exposure to pain management training (F(4370)=2.858, p=0.025, Eta2=0.03; F(3371)=3.985, p=0.008, Eta2=0.03; F(2372)=3.643, p=0.027, Eta2=0.02; F(5369)=4.497, p=0.01, Eta2=0.06; F(2372)=3.587, p=0.029, Eta2=0.02), respectively.

CONCLUSION

Community pharmacists' knowledge of and attitude to pediatric pain management in Nigeria appeared sub-optimal, and requires regular targeted educational intervention to fill the identified gaps, improve service delivery and patient outcomes.

Predictive Factors for Anxiety during Blood Sampling and Insertion of Peripheral Intravenous Catheters in Paediatric Patients in Spain

INTRODUCTION

Invasive procedures for diagnosis purposes such as venepuncture and peripheral venous catheter insertion are painful procedures that cause great stress for paediatric patients. The objective of this study is to find out the factors that have an impact on the level of anxiety experienced by children undertaken these procedures.

DESIGN AND METHODS

Prospective study, 359 children between 2 and 15 years old were included, treated in a tertiary reference hospital in the region of Navarra (Spain). The impact of the variables recorded was analysed using a regressive analysis, the Wong-Baker and FLACC scales were used to measure the level of pain and the PACBIS scale to measure the level of stress and anxiety.

RESULTS

The average age of the participants was 7.93 years (SD: 4.04), with 51.8% (n = 186) boys and 48.2% (n = 173) girls. The mean value of pain recorded was 4.43 (SD:3.10). 45.7% (n = 123) of the venepuncture techniques was associated with minimum level of anxiety, including 11.1% of intravenous catheterization. Variables determining the anxiety has been detected such as age, sex, level of pain, parental conduct and time spent on the procedure.

CONCLUSIONS

Paediatric patients experience high levels of anxiety when undergoing painful procedures which are conditioned by multifactorial reasons. The increase in stress is directly related to the older age (>6 years old) of the patient, and statistically significant by the female gender, the longer duration of the technique and the parental block.

PRACTICE IMPLICATIONS

Healthcare professionals should work on some of the variables and apply measures aimed to mitigate anxiety levels. For example, reducing the duration of the procedure, training parents, and distracting techniques.

Effect of a School-Based Educational Intervention About the Human Papillomavirus Vaccine on Psychosocial Outcomes Among Adolescents: Analysis of Secondary Outcomes of a Cluster Randomized Trial

IMPORTANCE

Delivery of vaccination to adolescents via a school-based program provides an opportunity to promote their involvement in health decision-making, service provision, and self-efficacy (belief in one's ability to perform a certain behavior).

OBJECTIVE

To examine the effect of a human papillomavirus (HPV) vaccination education and logistical intervention on adolescent psychosocial outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this cluster randomized trial and process and qualitative evaluation, adolescents aged 12 to 13 years (first year of high school) were recruited at high schools in Western Australia (WA) and South Australia (SA) in 2013 and 2014. Statistical analysis was performed from January 2016 to December 2020.

INTERVENTIONS

The complex intervention consisted of an adolescent intervention to promote knowledge and psychosocial outcomes, shared decisional support tool, and logistical strategies.

MAIN OUTCOMES AND MEASURES

Prespecified secondary outcomes were assessed. The HPV Adolescent Vaccination Intervention Questionnaire (HAVIQ) was used to measure changes in adolescent knowledge (6-item subscale), fear and anxiety (6-item subscale), self-efficacy (5-item subscale), and decision-making (8-item subscale). The hypothesis was that the intervention would improve adolescent involvement in vaccine decision-making (measured before dose 1 only), improve vaccine-related self-efficacy, and reduce vaccine-related fear and anxiety (measured before doses 1, 2, and 3). Mean (SD) scores for each subscale were compared between intervention and control students. In the process evaluation, focus groups were conducted. Analyses of the HAVIQ data were conducted from 2016 to 2020. Qualitative analyses of the focus groups were undertaken from 2017 to 2020.

RESULTS

The trial included 40 schools (21 intervention and 19 control) across sectors with 6967 adolescents (mean [SD] age, 13.70 [0.45] years). There were 3805 students (1689 girls and 2116 boys) in the intervention group and 3162 students (1471 girls and 1691 boys) in the control group. The overall response rate for the HAVIQ was 55%. In WA, where parental consent was required, the response rate was 35% (1676 of 4751 students); in SA, where parental consent was not required, it was 97% (2166 of 2216 students). The mean (SD) score for decision-making in the intervention group before dose 1 was 3.50 (0.42) of 5 points and 3.40 (0.40) in the control group, a small but significant difference of 0.11 point (95% CI, 0.06 to 0.16 point; P < .001). There was a small difference in favor of the intervention group in reduced vaccination-related anxiety (pre-dose 1 difference, -0.11 point [95% CI, -0.19 to -0.02 point]; pre-dose 2 difference, -0.18 point [95% CI, -0.26 to -0.10 point]; pre-dose 3 difference, -0.18 [95% CI, -0.24 to -0.11]) and increased vaccination self-efficacy (pre-dose 1 difference, 4.0 points; [95% CI, 1.0 to 7.0 points]; pre-dose 2 difference, 4.0 points [95% CI, 2.0 to 6.0 points]; pre-dose 3 difference, 3.0 points [95% CI, 1.0 to 5.0 points]). Focus group data from 111 adolescents in 6 intervention and 5 control schools revealed more confidence and less anxiety with each vaccine dose.

CONCLUSIONS AND RELEVANCE

In this cluster randomized trial, there was a small difference in adolescent decisional involvement and vaccine-related confidence and reduced vaccination-related fear and anxiety that was maintained throughout the vaccine course in the intervention vs control groups. Guidelines for vaccination at school should incorporate advice regarding how this outcome can be achieved.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12614000404628.

Using Vibrating and Cold Device for Pain Relieves in Children: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Needle procedures are the most common source of pain, anxiety, and fear among children. A combination of a cooling ice-pack and/or a vibrating motor for pain management in children has been evaluated in trials, but their overall effects await a synthesis of the available evidence.

METHOD

Comprehensive search was conducted using Cochrane, PubMed, EMBASE, PsycINFO, CINAHL and Airiti. We calculated pooled risk ratios (RR), mean difference (MD) and 95% CI using RevMan 5.3. A meta-regression was conducted to investigate the effects of mean age on MD of pain.

RESULTS

A total of 1479 children from 16 publications were included. Compared with the control group, using cold-vibrating device significantly decreased pain level above the age of 2 (MD -3.03, 95% CI: -3.38, -2.68), as well as lower anxiety level among parents (MD -1.3, 95% CI: -1.9, -0.7). Meta-regression demonstrated a significant negative correlation of pain score with age. For children at 8.5 years, cold-vibration reduced the pain score by 0.13 averagely for every increment in year compared with controls (MD -0.13; 95% CI: -0.25, -0.01). No adverse events were reported in included studies.

DISCUSSION

The cold-vibrating device reduced pain levels significantly among children without adverse effects. Variation of factors might contribute to the heterogeneity of our study, such as age, different needle procedures, psychological strategies…etc.

CONCLUSIONS

Cool-vibration treatment reduced pain levels in children who underwent needle procedures and the treatment appears more effective in older children. The device is promising in clinical setting due to its non-invasiveness and ease of usage.

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).

Use of Lidocaine Cream for Pain Management During Immunizations of Infants at an Urban Health Clinic

BACKGROUND

Immunizations are a common source of pain and anxiety within the pediatric population. Implementation of lidocaine 4% cream, which has a short onset of action, as a standard of care for immunization practices may be feasible.

OBJECTIVE

The objective of this study was to assess the efficacy of lidocaine 4% cream as pain management during immunizations and to evaluate satisfaction of caregivers and nursing staff.

METHODS

This study was a prospective, randomized, placebo-controlled trial in an urban clinic, which included patients who were ≤ 14 months old accompanied by a caregiver who witnessed the patient receiving an immunization within the previous 7 months. Patients were randomized to receive either lidocaine 4% cream or placebo cream prior to vaccination. Time to cry and duration of cry were recorded. Caregivers completed surveys evaluating attitudes toward pain associated with immunizations as well as their satisfaction with the immunization process through Likert Scale ratings. Nurses completed a questionnaire assessing efficacy and feasibility of lidocaine 4% cream for pain management.

RESULTS

A total of 44 patients were included in the analysis in order to achieve 80% power with a p-value < 0.05. Mean duration of cry in patients receiving lidocaine 4% cream was 48.6 seconds in comparison to 65.9 seconds in patients receiving placebo (95%CI, -33.97 seconds to -0.48 seconds; p < 0.05).

CONCLUSIONS

Lidocaine 4% cream decreased total duration of cry following vaccinations in comparison to placebo with both caregivers and nurses willing to utilize lidocaine 4% cream in a clinic setting if available.

Factors associated with parents' experiences using a knowledge translation tool for vaccination pain management: a qualitative study

Background

Vaccination is a common painful procedure for children. Parents’ concern regarding vaccination pain is a significant driver of vaccine hesitancy. Despite the wealth of evidence-based practices available for managing vaccination pain, parents lack knowledge of, and access to, these strategies. Knowledge translation (KT) tools can communicate evidence-based information to parents, however little is known about what factors influence parents’ use of these tools. A two-page, electronic KT tool on psychological, physical, and pharmacological vaccination pain management strategies for children, was shared with parents as part of a larger mixed methods study, using explanatory sequential design, exploring factors related to uptake of this KT tool. The aim of this qualitative study was to understand what influenced parents’ perceptions of the relevance of the KT tool, as well as their decision as to whether to use the tool.

Methods

A qualitative descriptive design was used. A total of 20 parents of children aged 0–17 years (n = 19 mothers) reviewed the KT tool ahead of their child’s upcoming vaccination and participated in a semi-structured interview at follow-up. Interviews were recorded, transcribed verbatim, and analyzed with reflexive thematic analysis using an inductive approach.

Results

The analysis generated three interrelated themes which described factors related to parents’ use of the KT tool: (1) Relevance to parents’ needs and circumstances surrounding their child’s vaccination; (2) Alignment with parents’ personal values around, and experiences with, vaccination pain management (e.g., the importance of managing pain); and (3) Support from the clinical environment for implementing evidence-based strategies (e.g., physical clinical environment and quality of interactions with the health care provider).

Conclusions

Several factors were identified as central to parents’ use of the KT tool, including the information itself and the clinical environment. When the tool was perceived as relevant, aligned with parents’ values, and was supported by health care providers, parents were more inclined to use the KT tool to manage their children’s vaccination pain. Future research could explore other factors related to promoting engagement and uptake when creating parent-directed KT tools for a range of health-related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06326-2.

The effect of hypnosis on pain relief due to injection of dental infiltration anesthesia

Background and objective

Dental patients often experience the fear of pain induced by injectable anesthesia. This study aimed to investigate the impact of hypnosis on relieving the pain of injected dental infiltration anesthesia.

Materials and methods

This single‐blind clinical trial was conducted on 32 healthy volunteers to assess the pain perception in mucosal injection. The visual analog scale was applied for the measurement of one‐sided pain intensity in the maxilla without hypnosis. When hypnosis was implemented, the same procedure was performed on the other side of the maxilla reversely within one session.

Results

Hypnosis implementation significantly decreased the intensity of the perceived pain before anesthesia injection (p = 0.05).

Conclusion

Hypnosis before the injection of dental infiltration anesthesia could decrease the pain intensity caused by the injection. Therefore, hypnosis therapy is recommended as an effective approach to pain control for anesthesia injection.

Prevalence and predictors of vaccine hesitancy in an urbanized agglomeration of New Delhi, India

Background

The immunization program has been an important part of Indian public health policy for three decades; yet only 62% of children are being fully immunized. Vaccine hesitancy is a major contributor to the immunization gap that needs to be addressed.

Methods

A cross-sectional descriptive study of prevalence and predictors of vaccine hesitancy was conducted in 350 households having at least one child in the age group of 13–24 months. Statistical analysis was done using chi-square test and logistic regression.

Results

The prevalence of vaccine hesitancy was 28.9%. Fear of needles, concern about pain during vaccination, lack of family support, and apprehension regarding side effects were ascertained as reasons for vaccine hesitancy. The type of family, time taken to reach the health facility and antenatal care received by the mother were significant predictors of vaccine hesitancy.

Conclusion

The prevalence of vaccine hesitancy was found to be high. In 2019, the World Health Organization earmarked vaccine hesitancy as one of the major roadblocks to better global health. A better understanding of the subject can help public health agencies enhance vaccination coverage, not just in children but also as a tool to protect entire populations in this age of re-emerging epidemics.

Cold Vibration (Buzzy) Versus Anesthetic Patch (EMLA) for Pain Prevention During Cannulation in Children: A Randomized Trial

INTRODUCTION

The purpose of this study was to assess differences in observed pain-related behaviors during cannulation between a device combining cold and vibration (Buzzy) and the standard care (EMLA patch).

METHODS

Patients 18 months to 6 years old, requiring venous access in a pediatric emergency department, received either the Buzzy device or the EMLA patch. Predefined week randomization ensured equal allocation to the 2 intervention groups. Pain during cannulation was measured using the Children's Hospital of Eastern Ontario Pain Scale. Parent and nurse reports, cannulation success, and venous access times were also assessed.

RESULTS

In total, 607 included patients were randomized into the Buzzy group (n = 302) or the EMLA group (n = 305). Observed pain-related behaviors scores, parent-assessed pain scores, and nurse-reported pain ratings were higher with Buzzy.

CONCLUSIONS

Pain relief by a combination of cold and vibration during cannulation is not as effective as the standard-care method in children 18 months to 6 years old.

Children's Perspectives on Outpatient Physician Visits: Capturing a Missing Voice in Patient-Centered Care

Actively involving children in their healthcare is a core value of patient-centered care. This is the first study to directly obtain children's detailed perspectives on positive and negative aspects of outpatient physician visits in a primary care setting (e.g., checkups) and their preferred level of participation. Individual interviews were conducted with 167 children (female n = 82, male n = 85; ages 7-10, Mage = 8.07 years, SD = 0.82). Open-ended questions were used so that children's responses were not confined to researchers' assumptions, followed by close-ended questions to meet specific objectives. Quantitative content analysis, correlations, logistic regression, and Cochran's Q were used to explore the data. Children were highly fearful of needle procedures (61%), blood draws (73%), pain (45%), and the unknown (21%). Children indicated that they liked receiving rewards (32%) and improving their health (16%). Children who were more fearful during physician visits wanted more preparatory information (ExpB = 1.05, Waldx2(1) = 9.11, p = 0.003, McFadden's R2 2 = 0.07) and more participation during the visit (ExpB = 1.04, Waldx2(1) = 5.88, p = 0.015, McFadden's R2 2 = 0.03). Our results can inform efforts to promote positive physician visit experiences for children, reduce procedural distress, and foster children's ability to take an active role in managing their health.

Distraction in the Emergency department using Virtual reality for INtravenous procedures in Children to Improve comfort (DEVINCI): a pilot pragmatic randomized controlled trial

OBJECTIVES

Intravenous (IV) procedures cause pain and distress in the pediatric emergency department (ED). We studied the feasibility and acceptability of virtual reality distraction for patient comfort during intravenous procedures.

METHODS

Children were randomized to a control (standard care) or intervention group (standard care + virtual reality). Thresholds for feasibility and acceptability (primary outcomes) were determined through a priori established criteria. The level of procedural pain (principal clinical outcome) and distress, as well as memory of pain at 24 h were collected and reported as medians (Q1, Q3) for each group.

RESULTS

63 patients were enrolled, with a high rate of recruitment (78.8%) and game completion (90.3%). Patients, parents and, healthcare providers reported high satisfaction levels. There were no serious adverse events. Five of the 30 patients (16.7%) exposed to virtual reality reported mild side effects. Self-reported procedural pain (verbal numerical rating scale: 3 (1, 6)/10 vs 3 (1, 5.5)/10, p = 0.75) was similar between groups. Further exploratory clinical measures were reported for the intervention and control groups, respectively: self-rated distress during the procedure (Child Fear Scale: 1 (0, 2)/4 vs 2 (0, 3)/4); distress evaluated by proxy during the procedure (Procedure Behavior Check List: 8 (8, 9)/40 vs 10 (8, 15)/40); memory of pain at 24 h (VNRS: 2 (1, 3)/10 vs 4 (2, 6.5)/10).

CONCLUSION

The addition of virtual reality to standard care is feasible and acceptable for pain and distress management during IV procedures in the pediatric ED. Occasional mild, self-resolving side effects were observed in the intervention group. Self-reported pain during the procedure was similar between groups. CLINICALTRIALS.

GOV IDENTIFIER

NCT03750578.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Dynamics on the field: a focused study on the culture and context of pediatric pain management at four Ghanaian hospitals

Background

As part of efforts to develop and implement a short course educational program on pediatric pain management, the current study sought to understand the culture and contextual factors that influence children’s pain management in order to improve the practice in pediatric care settings.

Methods

Guided by Bourdieu’s theory of practice, a focused ethnographic study was conducted from October, 2018 to February, 2019. The study was contextualized at four Ghanaian hospitals among purposefully sampled nurses, physicians, hospitalized children and their families. During the 20-week study period, three ethnographers spent 144 h conducting participant-observation sessions. Formal and informal interviews were held with participants in addition to review of hospital records.

Results

Analysis of the field data resulted in four themes. “Children’s pain expression and response of caregivers” described the disposition (habitus) of both children and caregivers to act in particular ways due to children’s incomplete health status (bodily capital) which caused them pain and also resulted in discomforting procedures. “Pharmacological pain management practices and attitudes” elucidated the use of analgesics as the mainstay disposition (habitus) in children’s pain management due to high level of respect (symbolic capital) given to such interventions on the pediatric units (field). “Managing pain without drugs” illustrated healthcare providers and family caregivers’ disposition (habitus) of using diverse nonpharmacological methods in managing children’s pain. “Communication and interaction between pain actors” depicted how children’s access to care givers (social capital) can serve as a powerful tool in influencing pediatric pain assessment and management disposition (habitus) on the pediatric units (field).

Conclusions

The habitus of pediatric pain actors toward pain assessment and management practices are influenced by various forms of capital (social, cultural, symbolic, bodily and economic) operating at different levels on the pediatric care field. Quality improvement programs that seek to enhance pediatric pain management should use the insights obtained in this study to guide the development, implementation and evaluation stages.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12887-020-02399-w.

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.

Routine Childhood Vaccines Given From 1 through 18 Years of Age

In addition to the vaccines due in the first year of life, the US Advisory Committee on Immunization Practices recommends that children continue to receive vaccines regularly against a variety of infectious diseases. Starting at 12 to 15 months of life, these include the two-dose measles-mumps-rubella vaccine series and the two-dose varicella vaccine series. Also in the second year of life, infants should begin the two-dose hepatitis A vaccine series and complete the Haemophilus influenzae type B vaccine series as well as the pneumococcal conjugate vaccine series. Before 19 months of life, infants should receive the third dose of the poliovirus vaccine and the fourth dose of diphtheria-tetanus-acellular pertussis (DTaP) vaccine. The final doses of poliovirus and tetanus-diphtheria-acellular pertussis vaccines are both due at 4 to 6 years of life. Before each influenza season, every child should receive the influenza vaccine. Those less than 9 years of age who previously received less than two doses need two doses a month apart. At 11 to 12 years of life, all should get two doses of the human papillomavirus vaccine, the adolescent/adult version of the tetanus-diphtheria-acellular pertussis vaccine, and begin a two-dose series of meningococcal ACWY vaccine. Each of these vaccines is due when the vaccine works to protect against both an immediate risk as well as to provide long-term protection. Each vaccine-preventable disease varies in terms of the nature of exposure, the form of the morbidity, the risk of mortality, and potential to prevent or ameliorate its harm.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures

Common medical procedures to assess and treat patients can cause significant pain and distress. Clinicians should have a basic approach for minimizing pain and distress in children, particularly for frequently used diagnostic and therapeutic procedures. This statement focuses on infants (excluding care provided in the NICU), children, and youth who are undergoing common, minor but painful medical procedures. Simple, evidence-based strategies for managing pain and distress are reviewed, with guidance for integrating them into clinical practice as an essential part of health care. Health professionals are encouraged to use minimally invasive approaches and, when painful procedures are unavoidable, to combine simple pain and distress-minimizing strategies to improve the patient, parent, and health care provider experience. Health administrators are encouraged to create institutional policies, improve education and access to guidelines, create child- and youth-friendly environments, ensure availability of appropriate staff, equipment and pharmacological agents, and perform quality audits to ensure pain management is optimal.

La gestion de la douleur et de l’anxiété chez les enfants lors de brèves interventions diagnostiques et thérapeutiques

Les interventions médicales courantes utilisées pour évaluer et traiter les patients peuvent causer une douleur et une anxiété marquées. Les cliniciens devraient adopter une approche de base pour limiter la douleur et l’anxiété chez les enfants, notamment à l’égard des interventions diagnostiques et thérapeutiques fréquentes. Le présent document de principes est axé sur les nourrissons, les enfants et les adolescents qui subissent des interventions médicales courantes mineures, mais douloureuses. Il n’aborde pas les soins prodigués à l’unité de soins intensifs néonatale. Les auteurs examinent des stratégies simples et fondées sur des données probantes pour gérer la douleur et l’anxiété et donnent des conseils pour en faire un volet essentiel de la pratique clinique. Les professionnels de la santé sont invités à utiliser des façons de procéder peu invasives et, lorsque les interventions douloureuses sont inévitables, à combiner des stratégies simples de réduction de la douleur et de l’anxiété pour améliorer l’expérience du patient, du parent et du professionnel de la santé. Les administrateurs de la santé sont encouragés à créer des politiques pour leurs établissements, à améliorer la formation et l’accès aux lignes directrices, à créer des environnements propices aux enfants et aux adolescents, à s’assurer de la disponibilité du personnel, de l’équipement et des agents pharmacologiques appropriés et à effectuer des contrôles de qualité pour garantir une gestion de la douleur optimale.

Active surveillance of adverse events following immunization (AEFI): a prospective 3-year vaccine safety study

BACKGROUND

Vaccines used in national immunization programs are considered safe and effective but immunization safety has become as important as the efficacy of vaccination programs. The objective of the study was to detect adverse events following immunization (AEFIs) to all vaccines administered to a pediatric population in India.

METHODS

The prospective active vaccine safety surveillance study enrolled eligible children in the age group 0-5 years receiving vaccination from the immunization center at JSS Hospital, Mysuru. Study participants were monitored at the site for 30 min following vaccination and a telephonic survey was made after 8 days to identify all AEFIs. Causality assessment of the AEFIs were done using a new algorithm developed by the safety and vigilance department of the World Health Organization.

RESULTS

The incidence of reported AEFIs was 13.7%. The most frequently reported AEFI was fever (n = 3095, 93.2%) with an incidence of 109.7 per 1000 doses of vaccine administered, followed by persistent crying (n = 69, 2.4 per 1000 doses of vaccine) and diarrhea (n = 57, 2.0 per 1000 doses of vaccine). The majorly implicated vaccine for AEFIs was Pentavac® followed by BCG. Consistent causal association to immunization was observed in 93.4% of cases.

CONCLUSIONS

A high incidence rate of AEFI was observed in our study population when compared with previous published studies. AEFI surveillance studies help to detect changes in the frequency of adverse events, which may be an alert to consider vaccine quality or identify a specific risk among the local population.

Reducing Pain and Fear in Children During Venipuncture: A Randomized Controlled Study

BACKGROUND

Venous blood sampling is a common procedure in the hospital setting and cause significant pain and stress for children.

AIM

This study was conducted to determine and compare the effects of balloon inflation, ball squeezing, and coughing methods on levels of pain and fear during venipuncture in children aged 7-12 years.

DESIGN

Experimental, randomized controlled study.

SETTING

The study was conducted at a state hospital in Turkey between March and July 2017.

PARTICIPANTS/SUBJECTS

The study population comprised children 7-12 years of age who were subjected to venous blood sampling in the phlebotomy unit of a state hospital. The study sample included 120 children for a confidence interval of 95% and statistical power of 80%.

METHODS

The children were assigned to one of four groups (balloon inflation, ball squeezing, coughing, and control groups), each including 30 participants. The children's pain and fear were rated before and after the procedure by the children themselves, their parents, and a researcher using the Wong-Baker FACES Pain Rating Scale and Children's Fear Scale, respectively.

RESULTS

Mean scores for pain and fear after the procedure were lower in all intervention groups compared with the control group (p = .001). There was no statistical difference in pain or fear scores between the intervention groups; however, the children in the coughing group had the lowest scores for both pain and fear.

CONCLUSION

Balloon inflation, ball squeezing, and coughing were all effective in reducing pain and fear associated with venipuncture in children aged 7-12 years. These are simple, rapid, and cost-effective methods that nurses can implement during venipuncture with minimal equipment and preparation.

Procedural pain reduction strategies in paediatric nuclear medicine

BACKGROUND

In paediatric nuclear medicine, the majority of the scans require intravenous (IV) access to deliver the radiotracers. Children and parents often cite procedural pain as the most distressing part of their child's hospitalization. In our department, various pain management strategies including physical and psychological distraction methods and pharmacological intervention have been implemented to reduce procedural pain.

OBJECTIVE

The purpose of this study was to evaluate and compare different pain reduction strategies used in our paediatric nuclear medicine department.

MATERIALS AND METHODS

The charts of 196 children (114 female) were reviewed retrospectively (median age: 8 months; interquartile range [IQR]: 33.1). Children were categorized into five groups: (1) Maxilene (topical liposomal lidocaine; n=50), (2) Pain Ease (vapocoolant; n=69), (3) oral sucrose (n=48), (4) Maxilene and Pain Ease combined (n=10), and (5) no pharmacological/adjuvant intervention (n=19). Physical and psychological distraction were used in all patients. Therefore, Group 5 only received physical and psychological strategies. Physical methods included supportive positioning, deep breathing, temperature considerations, massage pressure or vibration and neonatal development strategies (e.g., non-nutritive sucking, facilitated tucking, swaddling, rocking). Psychological strategies included education, distraction with movies, books or storytelling, and relaxation techniques. The pain perceived by the children after the IV access was compared in these five groups. Two types of pain assessment were used in this study: self-reporting pain scale and behavioural observational pain rating scale. Pain was reported on a scale of 1 to 10. The average pain score was also compared between patients who had one or two attempts for IV access and those who had more than two attempts.

RESULTS

The average pain score was 2.8 (mean±standard error [SE]=0.4) in Maxilene, 2.1 (SE=0.3) in Pain Ease, 2.7 (SE=0.3) in sucrose, 1.6 (SE=0.5) in combined Maxilene and Pain Ease and 3.4 (SE=0.6) in "no pharmacology/adjuvant" groups. There was no statistically significant difference between the four pharmacology groups of Maxilene, Pain Ease, sucrose and no pharmacology/adjuvant intervention group. However, the pain score was significantly reduced in patients who received both Maxilene and Pain Ease combined compared with the patients who didn't have any pharmacological/adjuvant intervention (P=0.041). The average pain was 2.2 (SE=0.1) with one attempt at IV access, 3.0 (SE=0.5) with two attempts and 5.1 (SE=0.9) with three attempts.

CONCLUSION

A combination of two pharmacological/adjuvant interventions may be more effective in reducing procedural pain compared with a single intervention. A comprehensive pain management program should consider all available interventions - pharmacological, adjuvant, physical and psychological. Further randomized clinical trials are needed to evaluate if a combination of two or more methods of pharmacological and adjuvant interventions are more effective to reduce procedural pain compared with only one method.

Immunization-Associated Pain: Taking Research to the Bedside

BACKGROUND

Immunization-associated pain is the number one cause of pain in pediatric settings. Untreated pain has many short- and long-term detrimental effects. The purpose of this project was to implement a nonpharmaceutical immunization-associated-pain prevention program.

METHOD

This project was implemented at a pediatric primary care clinic. Staff were educated about immunization-associated pain and techniques for decreasing/preventing pain. Families were educated about pain control, and the practitioner and parent/child picked interventions to decrease pain. Preimplementation and postimplementation data were collected using previously validated pain and satisfaction scales.

RESULTS

Pain prevention interventions decreased pain for children between 2 months and 7 years of age by 4.7 points on a Faces, Legs, Activity, Cry, Consolability (i.e., FLACC) scale. For children 7 years and older, pain during immunization decreased on average by 1.76 points on the visual analog scale.

CONCLUSION

Non-pharmaceutical interventions are effective in decreasing immunization-associated pain.

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.

The Use of the Buzzy, Jet Lidokaine, Bubble-blowing and Aromatherapy for Reducing Pediatric Pain, Stress and Fear Associated with Phlebotomy

PURPOSE

This study aimed to investigate the effects of the Buzzy, Jet lidokaine, bubble-blowing and inhalation aromatherapy with lavender essence on pain, stress and fear in children undergoing phlebotomy.

DESIGNS AND METHODS

This study was a prospective, randomized controlled trial. The sample was comprised of children aged 5 to 10 years requiring blood tests. Children were assigned to five subgroups through randomization performed using a computer program: the Buzzy group (n = 39), Jet lidokaine group (n = 39), bubble-blowing group (n = 39), inhalation aromatherapy with lavender essence group (n = 39) and control group (n = 39). The children's levels of pain were evaluated and reported by the parents, observers and the children, who self-reported using the Oucher Pain Scale. The children's fear levels were assessed using the Children's Fear Scale, and salivary cortisol analysis was conducted to evaluate stress levels.

RESULTS

A significant difference was found between the intervention and control groups in terms of levels of pain during and after phlebotomy in favor of the Buzzy group (p < 0.05). There was a significant difference between the fear scores of the children in the intervention and control groups before phlebotomy (p < 0.05). This difference was found to be caused by the bubble-blowing method. There was a significant difference between intervention and control groups fear levels in favor of the Buzzy group during phlebotomy (p < 0.05).

PRACTICE IMPLICATIONS

It is recommended that the Buzzy and bubble-blowing be used during phlebotomy in children to reduce the severity of their pain.

Children's Pain and Distress at a Public Influenza Vaccination Clinic: A Parent Survey and Public Observation Study

Immunizations are a necessary but distressing and painful procedure that most infants and children regularly undergo. Each year, a tertiary pediatric hospital in Canada holds an influenza vaccination clinic for all staff and their families. Evidence-based interventions to reduce pain and distress in babies and children are used. Despite this, infants and children continue to be distressed throughout the vaccination procedure. The objectives of this study were to: (1) measure the prevalence of distress among infants and children before, during, and after vaccine administration at the clinic, and (2) evaluate parents' perception of their child(ren)'s distress before, during, and after vaccine administration and the effectiveness of pain management interventions used during the clinic. A cross-sectional design of naturalistic observation and parent surveys was used and data was analyzed using descriptive statistics. A total of 283 children between 6 months and 18 years were vaccinated at the clinic, with 52% observed to be distressed before, during, or after the procedure. There were 115 parents of 206 children that completed the survey; 47% of these parents perceived that their children were distressed before, during, or after vaccination, and 42% perceived that the pain treatments used for their child(ren) were very effective. The results of this study will continue to inform interventions for needle-related pain and distress management, as well as improvements for future public vaccination clinics.

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.

Immunizations under sedation at a paediatric hospital in Melbourne, Australia from 2012-2016

BACKGROUND

Sedation for immunizations is of particular importance in a subset of paediatric patients with anxiety disorders, needle phobia, developmental or behavioural disorders. The Royal Children's Hospital (RCH) Melbourne offers a unique immunization under sedation service for these patients. We aimed to evaluate the number and types of patients using inpatient sedation for immunizations, distraction and sedation techniques used, and outcomes of these procedures.

METHODS

A medical record review was conducted on all patients who had immunization under sedation between January 2012 to December 2016 in the RCH Day Medical Unit (DMU).

RESULTS

A total of 139 children and adolescents had 213 vaccination encounters. More than half of the vaccination encounters involved multiple vaccines. A total of 400 vaccines were administered. One third of patients (32.3%) had multiple DMU admissions for vaccinations. The median age of patients was 13 years. There were only 10 (4.7%) failed attempts at vaccination; all due to patient non-compliance with prescribed sedation. The majority of patients (58.9%) had a diagnosis of needle phobia. Sedation was most commonly adequately achieved with inhaled nitrous oxide (54.7% sole agent). Midazolam was often used as an adjunct therapy (42.8%). Local anaesthetic cream or play therapy, were used in only 5.9% and 3.9% of patients respectively, although this may reflect poor documentation rather than actual practice.

CONCLUSIONS

For a subset of paediatric patients for which standard immunization procedures have failed, distraction techniques and conscious sedation enable immunizations to be given safely and effectively. Future research will develop protocols to streamline immunization procedures under sedation.

Feasibility of a pilot intervention to reduce pain and syncope during adolescent vaccination

PURPOSE

Vaccines recommended for adolescents are considered safe and effective, however administration may occasionally result in acute pain at the injection site or syncope (fainting). These adverse effects pose a risk to patient safety and are potential barriers to adherence to future vaccinations. We assessed a novel intervention designed to help prevent acute pain and syncope associated with adolescent vaccinations.

METHODS

We conducted a 3-month pilot study to assess the feasibility and acceptability of a vaccination comfort menu within two Kaiser Permanente Northwest pediatric clinics. The menu offered a variety of comfort items (e.g., cold packs, squeeze balls) that children could select prior to their vaccination. We surveyed parents of recently vaccinated adolescents and interviewed providers to assess the implementation and effectiveness of the intervention.

RESULTS

Response rate for the parent survey was 33% (378/1136). Only 20% of the parents reported that their provider offered the comfort menu during the vaccination visit. Approximately 50% of the adolescents who were offered the menu selected a comfort item and most of these participants reported that the item was very (35%) or somewhat (38%) helpful in improving their vaccination experience. Per provider interviews, common barriers to implementing the intervention included lack of time and convenience, and the brevity of the pilot period.

CONCLUSIONS

The comfort menu may improve the vaccination experience of youth and increase the likelihood of adherence with future vaccinations. However, only 20% of the parents reported that their provider offered the menu during the vaccination visit. Additional research is needed to determine the feasibility of implementing this intervention on a larger scale, as well as assessing whether the intervention has a significant impact on reducing adverse events.

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 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.

Parent Attitudes Toward Pain Management for Childhood Immunizations

OBJECTIVES

Evidence-based pain-limiting strategies for pediatric immunizations remain underutilized, with barriers identified to date mostly pertaining to health care providers and systems of care. The present study sought to quantify and investigate parent attitudes toward pain management as another potential barrier to the routine use of pain-mitigating strategies during immunizations.

MATERIALS AND METHODS

Questionnaires measuring parent attitudes, willingness to pay, and perceived barriers for using pain management for immunizations were completed by 259 parent/guardians of children ages 0 to 5 years attending appointments at an urban primary care clinic in the Midwestern United States.

RESULTS

Parent attitudes toward pain management for immunization were relatively normally distributed and varied from strongly positive to negative, with 33% of parents disagreeing that they were concerned about the pain their child may experience and 50% agreeing that there are no lasting negative effects from immunization pain. Negative parent attitudes were associated with willingness to spend less in money or time for pain management and with greater perceived significance of cost, time, and other barriers for using pain-mitigating strategies.

DISCUSSION

Some parents perceive limited value in trying to reduce pain during immunizations such that they may be hesitant to invest much time or effort in interventions. Greater success of translating evidence-based pain management into practice therefore may require accounting for differences in parent attitudes by tailoring educational efforts and pain management options accordingly.