Immunizations have been instrumentalin reducing and eliminating a number of infectious diseases and their harmful effects. Rightly so, they are considered a crowning achievement of modern medicine.
The World Health Organization estimates that over 12 billion immunizations are administered each year (~5% are for children). Specific vaccination schedules vary by region: Canadian children may receive up to one dozen separate injections before their 2nd birthday and two dozen by school age. Unfortunately, these numerous immunizations are accompanied by an equally frequent adverse event: pain.

Pain is complex and has both sensory and emotional components. In fact, negative emotions such as fear can increase the amount of pain a person experiences. The reality is that for many children and their parents, immunizations are far from “just a little poke” and instead are both painful and distressing. There are short- and long-term consequences of unmanaged pain from needle procedures like immunizations. In
the short term, children show increased distress during the procedure and longer procedure times.
Long-term consequences include increased behavioral distress at future procedures and avoidance of future immunizations and medical care due to needle fears

So what can we do? Fortunately, many effective, simple and cost-free strategies exist to reduce immunization pain. The biggest problem is making sure parents and health care providers know about them. This is where the Help Eliminate Pain in Kids Team (HELPinKIDS Team) comes in. Headed by
one of the authors, Anna Taddio, this team is dedicated to getting the word out about reducing the pain from immunization injections. The Team includes individuals from across Canada involved in immunization and pediatrics, such as physicians, nurses, pharmacists, psychologists, policy-makers, researchers and parents.

“3Ps” Pain Management
The HELPinKIDS Team summarized all the research performed around the world about immunization pain and developed a guideline that outlines practical, low-cost solutions. The guideline is organized around the “3P” approach to pain management: pharmacologic (medication), physical and psychological. Pain management tends to work best when these strategies are combined.

1st P: Pharmacalogical Pain Management
Talk About the Procedure: Children should be prepared in an age-appropriate way before the procedure; children who are quite young should only be told a little in advance. Older children can be told more ahead of time so they can practice coping techniques. You should answer your child’s questions honestly. Don’t tell her that it won’t hurt as this doesn’t make her feel less pain and it may not be true.

Use Topical Anesthetics: Topical anesthetics are numbing substances that are put on the skin and can be used on children of all ages. Common examples include EMLA® cream or patch (AstraZeneca)
and LMX® cream (Ferndale Labs). They are available at most pharmacies. They need to be applied
20-60 minutes in advance, so require some planning. Ask your health care provider about where
to apply them on your child’s skin. You may have to apply them in two separate body areas if more than
one area is used for immunization. If you are using a cream, then it needs to be covered with a dressing
(like a bandage) so it doesn’t get accidentally wiped off.

Although some people believe giving oral analgesics such as ibuprofen (Motrin®, Advil®) or acetaminophen (Tempra®, Tylenol®) beforehand may help with injection pain, there is no evidence that it
actually does. Giving children oral analgesics prior to immunizations is not recommended. They are only recommended for afterward, if the child develops side effects like fever or ongoing pain, and is uncomfortable.

2nd P: Physical Pain Management
Positioning of Infants and Children: Children should not lie down on their back (supine) during immunizations, as this increases pain and distress. Hold your infant or child in a position that is comfortable, such as a “bear hug,” or have your child sit upright. Do not hold your child too tightly, as this can increase distress.

Deep Breathing: It may seem strange to highlight the importance of breathing, but the reality is that when stressed, many of us do not breathe properly. The use of slow, deep breathing (diaphragmatic breathing) can reduce both pain and distress. Toys or props (e.g., pinwheels, bubbles) to facilitate deep breathing and blowing may add an element of distraction. Children 3 years and older should be taught to use slow,
deep breaths and parents can act as coaches during immunizations to help them remember to use this
strategy. When teaching children to deep breathe, it can be helpful for them to imagine that their belly or
tummy is filling up with a balloon when they take a deep breath in (their stomach should actually push out when breathing in), and then they let the air out of the balloon when they breathe out.

3rd P: Psychological Pain Management
Distraction: Use distraction and humor, and encourage your child to use these coping strategies. Distraction is defined as talking about or doing things to keep your child’s mind off the pain and can be used for all ages.

Parents or health care professionals can lead distraction or children who are old enough (≥3 years) can do so themselves. The particular distraction strategy should be age-appropriate. For example, for a child under 3 years old, sing, blow bubbles, or use a rattle. School-aged children can talk about something else (movies, family pet), count, watch a video, or listen to music.

Younger children may need coaching to stay distracted. Older children can listen to music or read a book. Don’t say things that will make your child focus his/her attention on the procedure (e.g., “It’s almost over,” “Don’t worry” and “I’m sorry you have to go through this”).

Specially for Infants
Breastfeeding: Did you know that breastfeeding your baby during injections can reduce your baby’s pain? Breastfeeding has a number of components that can help, including the sweet-tasting milk, the act of sucking and beingheld closely in skin-to-skin contact with mom. Pretty powerful stuff! We recommend mothers start to breastfeed their infants just before the injection, continue during, and for also for several minutes after the injection. Some people might want to use formula or bottled breast milk, but they are not the same as breastfeeding and we do not know how effective they are when it comes to pain reduction.

Sweet-tasting solutions: If amother is not able to breastfeed, then the next best thing is to offer a sweet-tasting solution, such as sugar water. Sugar water is easy to prepare: right before the procedure, mix one packet/cube of sugar with two teaspoons (10 mL) of water in a cup. Use a cup, syringe or pacifier to put the sweet solution into your baby’s mouth 1-2 minutes before the injection and discard the rest.

Role of Health Professionals
Take time to talk to your health care providers. Tell them your plans for how you will manage your child’s pain and distress and encourage them to support your efforts by performing injections quickly. For children who are over 4 years old, ask providers to rub the skin close to the injection site before and during the injection. Research shows that pressing or rubbing near where the immunization is injected helps reduce pain. The principle behind this practice is that it provides “white noise” and the touch sensation competes
with the pain sensation for your brain’s attention. (Have you ever found it helpful to rub your toe after you stub it on a table?)

Research shows that both parents and health care providers are more satisfied with immunizations when children’s pain is managed (not surprisingly)!

The strategies reviewed are effective, easy, and low in cost or free. Pay attention to what seems most helpful for your child. After the procedure, ask your child how much pain she experienced (or judge for yourself for an infant).Use this information to plan for the next time.

Although we focused on strategies to manage immunizations, the same techniques work for other
needle procedures (blood tests) and also for adults! In fact, worries about needles are not only a problem
in childhood, but also about 1 in 10 adults is afraid of needles.

For further information, please visit the Canadian Medical Association Journal that published the guideline and brochures for parents and health care providers ( A video about the guideline can be found here: www.

Working together, we can help take the Ouch! out of immunizations.

The development of the HELPinKIDS guideline was supported by a knowledge synthesis grant (KRS-91783) from the Canadian Institutes of Health Research. The HELPinKIDS Clinical Practice Guideline was based on three systematic reviews appearing in Clinical Therapeutics (2009, Issue 31, Supplement 2).

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From issue: 27/07-08