Reducing Child Immunisation Pain
Introduction
Immunisations are the most effective way to provide individuals and the population with protection against diseases. To provide this protection, the immunisation schedule in New Zealand recommends immunisation protection against ten diseases which translates into eleven injections by four years of age (Ministry of Health, 2011). Therefore immunisations are one of the most common health related procedures for children in a primary health setting. Despite the proven benefit of immunisations, the pain related to these injections causes great anxiety and distress for the child and parent (Schecter et al., 2007). This paper discusses the use of distraction techniques and topical anaesthetics during children’s immunisations, to determine which is more effective in alleviating pain.
Clinical Issue
Parents are often anxious about exposing their child to a possibly painful and upsetting procedure. Because immunisation in New Zealand depends upon the decision from the caregiver it is important nurses make an effort to reduce pain during immunisation visits as the majority of children have a negative association with needles (Ives & Melrose, 2010). This is typically from a previous negative immunisation experience as all children have a pain memory to anticipate painful procedures (Schecter et al., 2007). Nurses need to be aware of effective techniques so they can improve the experience for both the caregiver and child (Pillitteri, 2013).
Distraction
Distraction is a component of cognitive and behavioural mechanisms that has been developed to decrease pain experienced during immunisations (Demore & Cohen, 2005). Distraction has been found to be effective in decreasing children’s pain responses during immunisations and is one of the most commonly used non-pharmacologic approaches in paediatric pain management (Cramer-Berness, 2007). A possible explanation for the purpose of distraction is the gate control theory, a scientific model which explains pain transmission, suggests the central nervous system controls the pain experience, thus cognitive attention might affect the processing of pain (Schecter et al., 2007). A variety of distraction techniques have been evaluated to reduce immunisation pain.
The following researchers have examined movies (Cohen, Blount, Cohen, Schaen & Zaff, 2006), interactive robots (Pringle et al., 2001), kaleidoscopes (Vessey, Carlson & McGill, 1994), bubble blowing (Sparks, 2001), short stories (Mason, Johnson & Woolley, 1999) and music (Fowler & Lander, 1987). Regardless of the variability in interventions, the majority of study results demonstrate the effectiveness of distraction for reducing pain. Distraction is particularly common because it can be used in any setting, whether in the clinic or community. For example adult non-procedural talk requires no equipment and is always available for the family member or nurse to use. Gonzalez, Routh and Armstrong (1993) conducted a study to determine the effects of non-procedural talk and reassurance. Along with other studies, Blount (1992) supported that mothers who use non-procedural talk to their children exhibited less distress than those who used reassurance. This study also shows the importance of involving parents in the immunisation process by incorporating parent lead distraction and allowing parents to hold/rock their child during the immunisation. If parents are trained around distraction then the child will recognise their parent’s positive reinforcement and believe the immunisation is a procedure they should not be afraid of (McMurty, McGrath & Chambers, 2006).
Distraction strategies that involve equipment, many have been proven effective. Cohen, Blount and Panopoulos (1997) examined cartoon movies as a distractor. Results showed children exposed to the movie displayed less distress than those in the control environment. However in another study by Cohen (2002) where children were also exposed to an animated movie, results showed children were less distressed prior to and after the injection but not during the actual immunisation. Therefore this study suggested distraction was more beneficial in the recovery time after the injection. The selection of the distractor stimuli must be carefully selected, giving consideration to the age and cognitive maturity of the patient. Other factors to consider are the child’s natural coping tendencies, patient preferences, temperament and other individual characteristics (Schecter et al., 2007).
Topical anaesthetics
Another potential intervention for decreasing child immunisation pain is the use of topical anaesthetics. Currently they are not routinely used due to the lack of clinician knowledge regarding their effectiveness and inconvenience, as they require thirty to sixty minutes for results to be effective (Taddio et al., 2007). However, parents have successfully demonstrated they can and are willing to apply topical anaesthetics to their child prior to the immunisation (Taddio, Nulman, Goldbach, Ipp & Koren, 1994). Parents also report they are willing to pay to reduce immunisation pain (Taddio et al., 2007). The most popular topical anaesthetic and most studied for child immunisations is EMLA cream. This cream contains lidocaine and prilocaine which numbs the surface area of the skin, hence reducing pain as the needle penetrates the skin (Schecter et al., 2007). A study evaluating children 4 to 6 years, examined the effects of EMLA cream for intramuscular and subcutaneous immunisations compared to a placebo cream (Cassidy et al., 2001). The study showed EMLA was successful in reducing pain during the immunisation and during the recovery time. Results report 43% of children in the placebo group showed significant pain, compared with 17% in the EMLA group.
Vapocoolant and ethyl chloride sprays are another form of topical anaesthetic which numb the skin and may prevent the transmission of pain sensation (Cohen & Holubkov, 1997). These have been used to provide immediate onset but have a short duration (30seconds). Their advantage over EMLA is they are available at a lower cost for the clinic and require twenty seconds to reach effectiveness. Although one study found vapocoolant to be equally effective as EMLA for immunisation pain (Cohen & Holubkov, 1997), other studies have demonstrated they are no better than a placebo (Cohen et al., 2009).
Implications for practice
Distraction is effective as it takes the child’s attention away from the immunisation, therefore the amount of pain experienced is reduced as the child’s focus is shifted to something else. Distraction strategies are easy to use, provided the medical centre have equipment available or are brought with the child. The disadvantage of distraction may be it will add time to the procedure, as it may take time to engage the child in the distracter (DeMore & Cohen, 2005). However in other circumstances it may make the procedure shorter to perform due to less distress from the child and distraction resulting in a faster recovery time, as demonstrated in Cohen’s (2002) study. Distraction may also add cost for the clinic, associated with purchasing items to use as distracters. As Cassidy (2002) found, one option may be to use televisions to play movies, but the cost of this may be prohibited for some clinics. For some clinics it may be easier to have a selection of distractors on hand such as toys, stories, or bubbles which the family member can select to present to their child.
Topical anaesthetics are difficult to use in practice considering the time required for optimal effects is one hour. This is inconvenient for staff and parents, as parents would need to come into the clinic in advance so the cream has time to take effect. EMLA appears to be effective in reducing the sensation of pain at the skin but its research is limited for whether it will ease the discomfort for more superficial procedures such as intramuscular immunisations (Cohen et al., 2006).
Vapocoolant and ethyl chloride have immediate effects and are time and cost effective but their efficacy remains uncertain (Cohen et al., 2009). One reason they may not be effective is because the cold sensation from the sprays may be perceived as painful. Children younger than three years in particular do not have the cognitive development to comprehend the purpose of a cold sensation in reducing pain, so it may cause them to focus on the procedure and cause distress (Cohen et al., 2009).
Recommendations
Given its ease and cost effectiveness, distraction should be a key intervention for nurses managing pain in immunisations. For distraction to be effective it has been proven the appropriate distractor must be selected (Schecter et al., 2007). For nurses the best way to address this would be to involve the parents in the selection of the distractor. Parents know their child best so will have an accurate judgment as to what distraction their child will engage in (Cramer-Berness, 2007). From research it appears beneficial to recommend parents utilize the distraction, as involving the parent in the delivery of the injection may decrease child pain and will improve the parent’s perception of the immunisation (Gonzales, Routh & Armstrong, 1993). Another suggestion is to allow parents to engage in relaxing techniques like holding and rocking as this has been shown to decrease pain in children (Blount, 1992). Combining relaxing and distraction techniques from the parent or nurse may be an effective and economical way to alleviate pain.
Given the lack of availability of a fast acting topical anaesthetic with a proven effectiveness, the use of topical anaesthetics cannot be recommended for daily use (Schecter et al., 2007). For nurses to address the issue of time efficacy relating to EMLA, it would be beneficial for the parents to apply this cream to their child before they are due for their immunisation. Parents have expressed they are willing to do this (Taddio et al., 1994) so nurses should discuss this option with the parent. Vapocoolant sprays may be used more routinely by the nurse as they have a quicker onset of action, but the nurse should assess whether this is appropriate for their patient as research reports these sprays could cause more distress (Cohen et al., 2009). Therefore it would be more effective for nurses to use this product on older children who have the ability to understand the purpose of the cold feeling.
Conclusion
Immunisations are one of the most common recurring health procedures in childhood that cause pain and distress, therefore nurses must be aware of what techniques are effective to make this procedure less painful. A variety of topical anaesthetics are available such as EMLA. This has been effective but its efficacy for intramuscular immunisations is limited and requires a one hour preparation. Alternatives such as vapocoolant sprays are more effective in time but are limited by their short duration. Distraction is an easy alternative for nurses working in clinics. Literature supports its efficacy and can be optimised by choosing the appropriate distractor and involving the parents in the immunisation.
References
Blount, R. L. (1992). Training children to cope and parents to coach them during routine immunizations: Effects on child, parent, and staff behaviours. Behaviour Therapy, 23(4), 689–705.
Cassidy, K. L., Reid, G. J., McGrath, P. J., Smith, D. J., Brown, T. L., & Finley, G. A. (2001). A randomized double-blind, placebo-controlled trial of the emla patch for the reduction of pain associated with intramuscular injection in four to six-year-old children. Acta Paediatrica,90(11), 1329-1336.
Cohen, L. L. (2002). Reducing infant immunization distress through distraction. Health Psychology, 21(2), 207-211.
Cohen, L.L., Bernard, R.S., McClellan, C.B., Piazza-Waggoner, C., Taylor, B.K., & MacLaren, J.E (2006). Topical Anesthesia Versus Distraction for Infants' Immunization Distress: Evaluation With 6-month follow-up. Children's Health Care, 35(2), 103-121.
Cohen, L. L., Blount, R. L., & Panopoulos, G. (1997). Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations. Journal of Pediatric Psychology, 22(3), 355-370.
Cohen, R. E., & Holubkov, R. (1997). Vapocoolant spray is equally effective as emla cream in reducing immunization pain in school-aged children. Pediatrics, 100(6), 1-6.
Cohen, L. L., McLaren, J. E., DeMore, M., Fortson, B., Friedman, A., Lim, C. S., & Gangaram, B. (2009). A randomized controlled trial of vapocoolant for pediatric immunization distress relief. The Clinical Journal of Pain, 25(6), 490-494.
Cramer-Berness, L. J. (2007). Developing effective distractions for infant immunizations: The progress and challenges. Children's Health Care, 36(3), 203-217.
DeMore, M., & Cohen, L. L. (2005). Distraction for pediatric immunization pain: A critical review. Journal of Clinical psychology in Medical Settings ,12(4), 281-291.
Fowler, K. S., & Lander, J. R. (1987). Management of injection pain in children. Pain, 30(2), 169-175.
Gonzalez, J. C., Routh, D. K., & Armstrong, F. D. (1993). Effects of maternal distraction versus reassurance on children's reactions to injections. Journal of Pediatric Psychology,18(5), 593-604.
Ives, M., & Melrose, S. (2010). Immunizing children who fear and resist needles: Is it a problem for nurses?. Nursing Forum, 45(1), 29-39. doi: 10.1111/j.1744-6198.2009.00161.x.
Mason, S., Johnson, M. H., & Woolley, C. (1999). A comparison of distractors for controlling distress in young children during medical procedures. Journal of Clinical psychology in Medical Settings, 6(3), 239-248.
McMurty, C. M., McGrath, P. J., & Chambers, C. T. (2006). Reassurance can hurt: Parental behavior and painful medical procedures. Journal of Pediatrics,148(4), 560-561.
Ministry of Health. (2011). Immunisation Handbook 2011. Wellington, New Zealand: Ministry of Health.
Pillitteri, A. (2013). Maternal and child health nursing: Care of the childbearing and childrearing family. (7th ed.). Philadelphia: Lippincott Williams and Wilkins.
Pringle, B., Hilley, L., Gelfand, K., Dahlquist, L. M., Switkin, M., Diver, T., Sulc, W., & Eskenazi, A. (2001). Decreasing child distress during needle sticks and maintaining treatment gains over time Journal of Clinical Psychology in Medical Settings, 8(2), 119-130.
Schecter, N. L., Zempsky, W. T., Cohen, L. L., McGrath, P. J., McMurty, M., & Bright, N. S. (2007). Pain reduction during pediatric immunizations: Evidence-based review and recommendations. Pediatrics,119, 1184-1198. doi: 10.1542/peds.2006-1107
Schneider, Z., & Whitehead, D. (2013). Identifying research ideas, questions, statements and hypotheses. In Z. Scheider, D. Whitehead, G. LoBiondo-Wood & J. Haber (Eds.), Nursing and midwifery research methods and appraisal for evidence-based practice (4th ed.) (pp.63-64). Sydney, Australia: Mosby.
Sparks, L. (2001). Taking the "ouch" out of injections for children. using distraction to decrease pain. The American Journal of Maternal/Child Nursing,26(2), 72-78.
Taddio, A., Manley, J., Potash, L., Ipp, M., Sgro, M., & Shah, V. (2007). Routine immunization practices: Use of topical anesthetics and oral analgesics. Pediatrics, 120(3), 637-643.
Taddio, A., Nulman, I., Goldbach, M., Ipp, M., & Koren, G. (1994). Use of lidocaine-prilocaine cream for vaccination pain in infants. Journal of Pediatrics,124(4), 643-648.
Vessey, J. A., Carlson, K. L., & McGill, J. (1994). Use of distraction with children during an acute pain experience. Nursing Research, 43(6), 369-372.
