Among the range of factors that may influence a parent’s decision to vaccinate their child, pain is a common modifiable factor.1 Pain was the most commonly (44%) cited vaccine-related concern in a survey of parents with young children,2 and other findings have linked insufficient pain management during immunizations with an increased fear of needles and later health care avoidance.1
Numerous interventions have demonstrated effectiveness in reducing vaccine pain immunization with little need for preplanning (Table). These strategies include deep breathing, cold-compress therapy, sucrose and breastfeeding for younger children, use of tactile stimulation, and injecting the most painful vaccine last.3 Other techniques require more planning, such as use of topical anesthetics and psychologic interventions.3
Table. Evidence-Based Strategies for Reducing Pain in Childhood Immunizations3
|Breastfeeding or oral sucralose solutions in infants|
|Breathing techniques: deep breathing or blowing during vaccination|
|Psychological distraction: clinician- or child-led distraction|
|Tactile stimulation: rub or stroke the skin near the injection site with moderate intensity before and during vaccination|
● Inject the most painful vaccine first
● Use a rapid injection technique without aspiration
● Avoid placing the child in the supine position
To identify factors that influence the use of vaccine pain prevention strategies during childhood immunization, researchers conducted a national survey of nurse practitioners (NPs). Respondents consisted primarily of pediatric NPs (82%) and NPs who work in primary care settings (72%).1
Nearly all respondents viewed the use of pain control methods during immunization as somewhat (60%) or completely important (36%).1 However, these strategies were underused with 21% of participants indicating that they do not use such techniques even though 50% reported that patients and families had inquired about such measures.
The survey responses further indicated that time (22.4%), availability (17.5%), lack of knowledge (17%), staff support (14.1%), cost (12.1%), lack of resources (7.4%), safety concerns (4.7%), and environmental factors (3.4%) were barriers to the use of pain control measures during immunization.1
The study authors recommended a focus on education to help reduce many of these barriers and recently launched a toolkit developed by the National Association of Pediatric Nurse Practitioners’ (NAPNAP) Immunization Special Interest Group to help meet this need. The toolkit includes health care provider education on how to utilize different techniques, why they work, and how to pick age-appropriate interventions. This module provides continuing education credit and includes educational materials to be posted around the office as well as a sample supply list for pain prevention interventions.
To learn more about these findings and implications for clinicians, we interviewed lead author Christina Cwynar, DNP, CPNP-PC, PMHNP-BC, assistant professor in the Primary Care Pediatric Nurse Practitioner program in the Department of Women, Children, and Family Nursing at Rush University College of Nursing in Chicago. She is also a nurse practitioner at C.S. Mott Children’s Hospital in Ann Arbor, Michigan.
Q: What were your thoughts about your findings? Were you surprised by the barriers identified or providers’ responses about the importance of pain control measures, for example?
Dr Cwynar: The results of this survey were not surprising to me and back our hypothesis. I do believe that there was some bias in the responses, as it is very likely that clinicians who found the topic either interesting or important participated in the survey — possibly highlighting that providers who responded believe that pain prevention interventions are more important than what the wider clinician pool believes.
This survey also primarily looked at NPs’ beliefs, perceived barriers, and practices. Ideally, we need to assess these things across the continuum of care from the medical assistant to the bedside nurse to the physician to get a true understanding of what barriers exist.