Distraction Techniques

Positive techniques to distract from pain should be considered when immunizing children with special needs in primary care. Providing a trustworthy and honest relationship is more likely to minimize anxiety in children with special needs.21,27 Distraction techniques used in practice when immunizing children include streaming movies on hand-held devices, blowing bubbles or pinwheels, deep breathing, or music therapy.28 Squeezing a squishy object, such as a small soft ball, reduces pain in children during painful procedures.28 Because topical anesthetic creams need to be applied 1 hour prior to immunization, other pain-relieving strategies are preferred in the literature.

Implementing new, innovative technologies into immunization practices may also reduce distress in children with special needs. Rossi et al found social assistive robots (SAR) used during vaccination procedures reduced pain and distress. The robot captures the child’s attention and redirects attention towards interesting objects.29

Thermomechanical stimulation devices, which use cold therapy and vibration, help reduce vaccination pain but have not been found to decrease children’s anxiety about the procedure.30

Continue Reading

Children with special needs benefit from being held in their parent’s lap as this position offers comfort and secureness for the child while reducing anxiety, either facing or looking away from the procedure site.19 The goal of comforting restraints is to offer the least amount of force possible while keeping the child with special needs safe during immunizations. Restraining with use of excessive force may cause high levels of distress in children with special needs.31 Children with special needs feel an increased loss of control with prolonged restraint time. Comforting restraining time should be minimal.32

Neurodiversity Movement

The neurodiversity movement is a relatively new concept for health care providers to understand when meeting holistic needs, including immunization for children with special needs. Advocates view autism as a combination of an individual’s natural variation and disability.33 Common neurodiverse diagnoses include autism, attention-deficit/hyperactivity disorder (ADHD), and dyslexia.34 The main goals of the neurodiversity movement are achieving equal rights and respect for the individual, providing resources for support and educational opportunities, accommodating autistic differences, and providing a more decisive role for autistic voices in policy development.35,36 Central to the neurodiversity movement is the idea of using identity-first (eg, autistic person or autistic) vs person-first (person with autism) language.35,36 Pediatric providers must continue to follow the neurodiversity movement to provide the highest quality of care, including immunization administration, to children with special needs.34


Caring for children with special needs is a rewarding but challenging part of pediatric practices. A priority for any provider is to meet the holistic health care needs of children, including providing routine immunizations. Children with physical disabilities, neurologic and neurodevelopmental disorders, and autism are at higher risk for vaccine-preventable illnesses and face significant health disparities. Physical and psychosocial barriers exist when immunizing children with special needs and are vital considerations in practice. Health care providers should provide the most current, evidence-based immunization recommendations to children with special needs to promote optimal health outcomes. Offering an honest and trusting relationship with children with special needs is rewarding for patients and their families as well as clinicians.

Alison W. Bray, MSN, APRN, CPNP-PC, is a pediatric nurse practitioner in Rockwall, Texas, and a Doctor in Nursing Practice candidate at Baylor University Louise Herrington School of Nursing in Dallas, Texas. Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, is a clinical professor at the Baylor University Louise Herrington School of Nursing, and immediate past president of the National Association of Pediatric Nurse Practitioners (NAPNAP).


1. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needsPediatrics. 1998;102(1 Pt 1):137-140. doi:10.1542/peds.102.1.137

2. Autism and developmental disabilities monitoring (ADDM) network. Centers for Disease Control and Prevention. Updated March 31, 2022. Accessed April 20, 2022. https://www.cdc.gov/ncbddd/autism/addm.html

3. Young N, Crankshaw K. Disability rates highest among American Indian and Alaska Native children and children living in poverty. United States Census Bureau. Published March 25, 2021. Accessed April 13, 2022. https://www.census.gov/library/stories/2021/03/united-states-childhood-disability-rate-up-in-2019-from-2008

4. Koppaka R. Ten great public health achievements: United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(19):619-623.

5. Top ten threats to global health in 2019. World Health Organization. Accessed April 1, 2022. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

6. Stone CA Jr, Rukasin CRF, Beachkofsky TM, Phillips EJ. Immune-mediated adverse reactions to vaccinesBr J Clin Pharmacol. 2019;85(12):2694-2706. doi:10.1111/bcp.14112

7. Xu G, Snetselaar LG, Jing J, Liu B, Strathearn L, Bao W. Association of food allergy and other allergic conditions with autism spectrum disorder in childrenJAMA Netw Open. 2018;1(2):e180279. doi:10.1001/jamanetworkopen.2018.0279

8. Oduwole EO, Pienaar ED, Mahomed H, Wiysonge CS. Current tools available for investigating vaccine hesitancy: a scoping review protocolBMJ Open. 2019;9(12):e033245. doi:10.1136/bmjopen-2019-033245

9. Langkamp DL, Dusseau A, Brown MF. Vaccine hesitancy and low immunization rates in children with Down syndromeJ Pediatr. 2020;223:64-67.e2. doi:10.1016/j.jpeds.2020.03.025

10. Ryan J, Malinga T. Interventions for vaccine hesitancyCurr Opin Immunol. 2021;71:89-91. doi:10.1016/j.coi.2021.05.003

11. Vielot NA, Islam JY, Sanusi B, et al. Overcoming barriers to adolescent vaccination: perspectives from vaccine providers in North CarolinaWomen Health. 2020;60(10):1129-1140. doi:10.1080/03630242.2020.1802639

12. Magistà S, Albanesi M, Chaoul N, et al. Safety of measles, mumps, and rubella vaccine in egg allergy: in vivo and in vitro managementClin Mol Allergy. 2020;18(1):21. doi:10.1186/s12948-020-00136-3

13. Pfizer-BioNTech COVID-19 vaccine (also known as Comirnaty): overview and safety. Centers for Disease Control and Prevention. Accessed April 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html

14. Moderna COVID-19 vaccine (also know as Spikevax): overview and safety. Centers for Disease Control and Prevention. Accessed April 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Moderna.html

15. Parisi CAS, Kelly KJ, Ansotegui IJ, et al. Update on latex allergy: new insights into an old problemWorld Allergy Organ J. 2021;14(8):100569. doi:10.1016/j.waojou.2021.100569

16. Nucera E, Aruanno A, Rizzi A, Centrone M. Latex allergy: current status and future perspectivesJ Asthma Allergy. 2020;13:385-398. doi:10.2147/JAA.S242058

17. Prevalence of allergies and asthma. American Academy of Allergy, Asthma & Immunology. Accessed April 20, 2022. http://www.aaaai.org/Tools-for-the-Public/Conditions-Library/Allergies/prevalence-of-allergies-and-asthma

18. Droste JH, Wieringa MH, Weyler JJ, Nelen VJ, Vermeire PA, Van Bever HP. Does the use of antibiotics in early childhood increase the risk of asthma and allergic disease? Clin Exp Allergy. 2000;30(11):1547-1553. doi:10.1046/j.1365-2222.2000.00939.x

19. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S. Managing pain and distress in children undergoing brief diagnostic and therapeutic proceduresPaediatr Child Health. 2019;24(8):509-535. doi:10.1093/pch/pxz026

20. Hampton T, Crunkhorn R, Lowe N, et al. The negative impact of wearing personal protective equipment on communication during coronavirus disease 2019J Laryngol Otol. 2020;134(7):577-581. doi:10.1017/S0022215120001437

21. Krmar RT. White-coat hypertension from a paediatric perspectiveActa Paediatr. 2019;108(1):44-49. doi:10.1111/apa.14416

22. O’Neill J, Newall F, Antolovich G, Lima S, Danchin M. The uptake of adolescent vaccinations through the School Immunisation Program in specialist schools in Victoria, AustraliaVaccine. 2019;37(2):272-279. doi:10.1016/j.vaccine.2018.11.034

23. Fombonne E, Goin-Kochel RP, O’Roak BJ, SPARK Consortium. Beliefs in vaccine as causes of autism among SPARK cohort caregiversVaccine. 2020;38(7):1794-1803. doi:10.1016/j.vaccine.2019.12.026

24. Gabis LV, Attia OL, Goldman M, et al. The myth of vaccination and autism spectrumEur J Paediatr Neurol. 2022;36:151-158. doi:10.1016/j.ejpn.2021.12.011

25. Goin-Kochel RP, Fombonne E, Mire SS, et al. Beliefs about causes of autism and vaccine hesitancy among parents of children with autism spectrum disorderVaccine. 2020;38(40):6327-6333. doi:10.1016/j.vaccine.2020.07.034

26. Bonsu NEM, Mire SS, Sahni LC, et al. Understanding vaccine hesitancy among parents of children with autism spectrum disorder and parents of children with non-autism developmental delaysJ Child Neurol. 2021;36(10):911-918. doi:10.1177/08830738211000505

27. Jurko A Jr, Minarik M, Jurko T, Tonhajzerova I. White coat hypertension in pediatricsItal J Pediatr. 2016;42:4. doi:10.1186/s13052-016-0213-3

28. Sirtin Tumakaka GY, Nurhaeni N, Wanda D. Squeezing a squishy object effectively controls pain in children during intravenous catheter insertionPediatr Rep. 2020;12(Suppl 1):8692. doi:10.4081/pr.2020.8692

29. Rossi S, Larafa M, Ruocco M. Emotional and behavioural distraction by a social robot for children anxiety reduction during vaccinationInt J Soc Robot. 2020;12(3):765-777. doi:10.1007/s12369-019-00616-w

30. Redfern RE, Chen JT, Sibrel S. Effects of thermomechanical stimulation during vaccination on anxiety, pain, and satisfaction in pediatric patients: a randomized controlled trial. J Pediatr Nurs. 2018;38:1-7. doi:10.1016/j.pedn.2017.09.009

31. Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guidelineCMAJ. 2010;182(18):E843-855. doi:10.1503/cmaj.101720

32. British Columbia. Preparing for a positive experience. Immunize BC. Published November 17, 2017. Accessed April 20, 2022. https://immunizebc.ca/preparing-positive-experience

33. den Houting J. Neurodiversity: an insider’s perspectiveAutism. 2019;23(2):271-273. doi:10.1177/1362361318820762

34. Embracing neurodiversity in our health systems. American Academy of Pediatrics. Accessed April 20, 2022. https://www.aap.org/en/news-room/aap-voices/embracing-neurodiversity-in-our-health-systems/

35. Stephens MM, Kavanaugh E. Improving immunization coverage in special populationsPrim Care. 2020;47(3):453-465. doi:10.1016/j.pop.2020.05.002

36. Hughes JA. Does the heterogeneity of autism undermine the neurodiversity paradigm? Bioethics. 2021;35(1):47-60. doi:10.1111/bioe.12780