Patient Care During Vaccine Administration
Patients should be prepared for vaccination with consideration for their age and stage of development. Parents/ guardians and patients should be encouraged to take an active role before, during and after the administration of vaccines. Be There for Your Child During Shots is a handout for parents. It is located at http://www.eziz.org/assets/docs/ IMM-686ES.pdf.
Vaccine safety concerns and the need for multiple injections have increased anxiety associated with immunizations for patients, parents and health-care personnel. Health-care providers need to display confidence and establish an environment that promotes a sense of security and trust. Everyone involved should work to provide immunizations in the safest and least stressful way possible. Simple strategies that can be used by both parents and providers to make receiving vaccines easier include:
Displaying a positive attitude through facial expressions, body language, and comments
Using a soft and calm tone of voice
Making eye contact, even with small children
Explaining why vaccines are needed (e.g., “this medicine will protect you from getting sick” or “this shot is a shield to protect your body against infection”)
Being honest and explaining what to expect (e.g., do not say that “the injection won’t hurt”)
Positioning & Comforting Restraint
When determining patient positioning and restraint, consider the patient’s comfort, safety, age, activity level, and the site of administration. Parent participation has been shown to increase the child’s comfort. When vaccines are being administered to infants and small children, the parent/guardian should be encouraged to hold the child during administration. The parent/guardian should be instructed on how to help the child stay still so the vaccine can be administered safely. If the parent is uncomfortable, another person may assist or the patient may be positioned safely. Comforting Restraint for Immunizations at http://www. eziz.org/assets/docs/IMM-720ES.pdf outlines positioning techniques.
While definitive guidelines for positioning patients during vaccination have not been established, some recommendations have been suggested. Research supports the belief that children are less fearful and experience less pain when receiving an injection if they are sitting up rather than lying down. The exact mechanism behind this phenomenon is unknown; it may be that the child’s anxiety level is reduced, which in turn reduces the child’s perception of pain. Parents should be instructed to hold infants and children in a position comfortable for the child and parent, in which one or more limbs are exposed for injections.
All providers who administer vaccines to older children, adolescents, and adults should be aware of the potential for syncope (fainting) after vaccination and the related risk of injury caused by falls. Clinicians should: (1) make sure the person who is being vaccinated is always seated or lying down; (2) be aware of symptoms that precede fainting (e.g. weakness, dizziness, pallor); and (3) provide supportive care and take appropriate measures to prevent injuries if such symptoms occur. The Advisory Committee on Immunization Practices (ACIP) also recommends that providers consider observing the patient (with patient seated or lying down) for 15 minutes after vaccination.
Procedural Pain Management
Concern and anxiety about injections are common for all ages. Fear of injections and needlestick pain are often cited as reasons why children and adults, including health-care personnel, refuse vaccines. Immunizations are the most common source of iatrogenic pain and are administered repeatedly to children throughout infancy, childhood and adolescence.
If not addressed, this pain can have long term effects such as pre-procedural anxiety, fear of needles and avoidance of healthcare behaviors through the lifetime. It has been estimated that up to 25% of adults have a fear of needles, with most fears developing in childhood. Decreasing pain associated with immunizations during childhood may help to prevent this distress and future healthcare avoidance behaviors.
Pain is a subjective phenomenon influenced by multiple factors, including an individual’s age, anxiety level, previous healthcare experiences, and culture. Although pain from immunizations is, to some extent, unavoidable, there are some things that parents and healthcare providers can do to help when children and adults need vaccines. Evidence-based strategies to ease the pain associated with the injection process include:
Breastfeeding
Breastfeeding has been demonstrated as a soothing measure for infants up to 12 months of age receiving injections. Several aspects of breastfeeding are thought to decrease pain, including holding the child, skin-to-skin contact, sweet-tasting milk and the act of sucking. Potential adverse events such as gagging or spitting up were not reported. Breastfeeding should occur before, during and after the administration of vaccines. Allow adequate time for the infant to latch onto the nipple properly. Bottle feeding with breast milk or formula should not be considered a substitute for breastfeeding for pain management.
Sweet tasting solutions
Sweet tasting liquids are an analgesic for infants up to 12 months of age. Sweetened liquids are recommended for infants who are not breastfed during vaccination. Several studies have demonstrated a reduction in crying after injections when young children (12 months or younger) ingest a small amount (a few drops to half a teaspoon) of a sugary solution prior to administration of the vaccine. Coughing and/or gagging may occur but infrequently (less than 5% of patients). Parents should be counseled that sweet tasting liquids should only be used for the management of pain associated with a procedure such as an injection.
Injection technique
Aspiration prior to injection and slowly injecting medication are practices that have not been evaluated scientifically. Aspiration was originally recommended for safety reasons and injecting medication slowly was thought to decrease pain from sudden distension of muscle tissue. Although aspiration is advocated by some experts, and most nurses are taught to aspirate before injection, there is no evidence that this procedure is necessary. The ACIP’s General Recommendations on Immunization document states that aspiration is not required before administering a vaccine.
There are no reports of any person being injured because of failure to aspirate. In addition, the veins and arteries within reach of a needle in the anatomic areas recommended for vaccination are too small to allow an intravenous push of vaccine without blowing out the vessel. A 2007 study from Canada compared infants’ pain response using slow injection, aspiration, and slow withdrawal with another group using rapid injection, no aspiration, and rapid withdrawal. Based on behavioral and visual pain scales, the group that received the vaccine rapidly without aspiration experienced less pain. No adverse events were reported with either injection technique.
Order of injections
Frequently children and adults receive 2 or more injections at an immunization encounter. Some vaccines are associated with more pain than others. Because procedure pain can increase with each injection, the order the vaccines are administered may effect the overall pain response. Some vaccines cause a painful or stinging sensation when the injecting the vaccine; examples include measles, mumps and rubella (MMR) and human papillomavirus (HPV) vaccines. Injecting the most painful vaccine (e.g., MMR, PCV13, or HPV) last when multiple injections are being administered can decrease the pain associated with the injections.
Tactile Stimulation
Rubbing or stroking the skin near the injection site prior to and during the injection process with moderate intensity may decrease pain in older children (4 years and older) and adults. The mechanism for this is thought to be that the sensation of touch competes with the feeling of pain from the injection, and thereby results in less pain.
Distraction
Psychological interventions such as distraction in children have been demonstrated to be effective at reducing stress and the perception of pain during the injection process. Distraction is defined as using tactics which are intended to take the patient’s attention away from the procedure. Distraction can be led by the provider, child or parent. Certain types of parental behaviors (e.g., nonprocedural talk, suggestions on how to cope, humor) have been related to decreases in children’s distress and pain, whereas others (e.g., reassurances, apologies) have been related to increases in children’s distress and pain. Parents should be encouraged to use distraction methods and instructed in appropriate distraction techniques. Distraction can be accomplished through a variety of techniques (e.g., playing music, books, pretending to blow away the pain, deep breathing techniques).
Topical anesthetics
Topical analgesia may be applied to decrease pain at the injection site. These products (e.g., 5% lidocaine-prilocaine emulsion) should be used only for the ages recommended and as directed by the product manufacturer. Parents should be educated in the appropriate use of topical analgesics including the exact site(s) the medication should be applied. These analgesics often need to be applied before (20 to 60 minutes depending on the product) vaccine administration to be effective.
Following are other techniques used by some providers. There is insufficient evidence to recommend these techniques to relieve the pain associated with vaccine administration.
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