Reducing Pain of Pediatric Immunizations

• The pain associated with immunizations can create anxiety and distress for the children receiving the immunizations, their parents, and healthcare providers. Dread evoked by painful immunization procedures may create feelings of persistent tension in future clinical encounters, thereby interfering with optimal delivery of healthcare.
• The injection process can be divided into 2 periods: before the injection and during the injection.
• Before the injection, preparation of a child older than 2 years reduces anxiety and subsequent pain. Children younger than 4 years should be prepared shortly before the injection itself.
• Intramuscular immunizations should be administered in the vastus lateralis (anterolateral thigh) for infants and toddlers younger than 18 months and in the deltoid (upper arm) for children older than 36 months. The ventrogluteal area may be the most appropriate site for all age groups.
• Despite the common belief that the shortest needle with the thinnest gauge would produce the least trauma and pain, this does not seem to be the case. Several studies suggest that longer needles, which are more likely to penetrate muscle than shorter ones, cause less pain, fewer adverse effects, and less local reaction.
• During the injection, parental attitudes affect the child's pain behaviors. Excessive parental reassurance, criticism, or apology tends to increase distress, whereas humor and distraction may reduce distress.
• The child's age, temperament, and interests and parent's personal style will aid in selecting effective distraction techniques. These may include storytelling, reading to the child, deep breathing, and blowing.
• During injection to children younger than 6 months, sucrose solution should be routinely given directly into the mouth or on a pacifier. This decreases evidence of distress and is relatively inexpensive.
• Because of the high cost and time needed for administration, routine local anesthetic administration is not indicated, but selective use is recommended for children who are especially fearful, who have had previous negative experiences, or who will require multiple procedures in the future.
• Pressure at the immunization site decreases pain, whether applied with a device or finger, and this strategy is noninvasive, inexpensive, and without adverse effects. Properties of the injectate itself can exacerbate pain, but there has been little research in this area.
• Parents often prefer that multiple injections be given simultaneously, rather than sequentially, if there are sufficient personnel.

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Dr Marwah