Nursing Research on the Green
Nicholle Frahm-Ward, RN, MSN
- Background: Vaccinations are a vital component of childhood preventive care, protecting thousands of children from life threatening illness. Unfortunately, they are also the most frequent painful procedure done in a pediatric clinic (Wallace et al., 2010). By age two the Centers for Disease Control and Prevention (CDC) recommends that children be vaccinated against fourteen preventable diseases. Currently, if combination vaccines are not used, this means that before age two a child could receive twenty or more intramuscular (IM) or subcutaneous (SQ) injections.
- Significance: “The pain linked with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them” (Schechter et al., p. 1184). This anxiety of needles can cause routine care to be delayed or avoided due to the anxiety that immunizations cause (Cassidy et al., 2001). It is imperative that those who are administering vaccines along with the caregivers of these children have a clear understanding of the best methods to decrease the child’s perception of pain while receiving routine vaccinations.
- Purpose/objective: The purpose of this project was to translate the results of the three recent systemic/integrative reviews into an understandable evidenced-based teaching sheet for caregivers and nurses concerning best practices to reduce pain perceptions when a pre-school aged child receives an intramuscular or subcutaneous immunization.
- Methods/project: An initial search was performed to locate literature related to the most effective psychological and physical interventions to decrease pain perception in preschoolers during routine immunizations. The Cochrane Database, Medline, Centers for Disease Control (CDC) and the American Academy of Pediatrics Journal (AAP) web sites were searched.. Key words such as immunization and pain, injection and pain, children and immunization, children and injection, pediatric immunization and pain, preschool and injection and pain, vapocoolant and injection, childhood and immunization and pain, distress and injection, and Shot Blocker were used in the literature search. Peer-reviewed articles only were incorporated. Current relevant literature (within the past 5 years) was utilized. Studies that included only infants, adults, or older children were not selected. All studies located were quantitative. No current qualitative studies were found to be relevant to the topic under consideration. In the course of searching for articles, two current systematic reviews were found, along with one “evidence-based review.” Since systematic reviews serve as a form of the highest level of evidence (Polit & Beck, 2008) and since the findings of these reviews are often not disseminated widely, a decision was made to focus upon developing an evidenced-based guideline derived from the findings of these reviews.
- Results: There are specific interventions that can be used to reduce perceived pain in children receiving injections. Evidence-based interventions that are specific to pre-school children are provided below. The interventions include: • cognitive and behavioral distraction (Uman, Chambers, McGrath, & Kisely, 2006) • combined cognitive and behavioral interventions (Uman et al., 2006) • developmentally appropriate preparation for all children greater than age two (Schechter et al. 2007) • a calm and matter of fact parental demeanor without excessive reassurance (Schechter et al. 2007) • use of local anesthetic in overly anxious children (Schechter et al. 2007) • children sitting in an upright position (Taddio et al. 2009) • stroking the skin near the injection site prior to and during injection (Taddio et al. 2009) • the order of vaccine injections when 2 injections are administered successively (most painful injection last) (Taddio et al. 2009) • rapid injection without aspiration for intramuscular injection (Taddio et al. 2009)
- Clinical Implications: It is clear that evidenced- based interventions exist and could be more widely utilized.
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