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#205 Preventing Painful Pokes: Decreasing Immunization Pain in Kids

What are the best methods for decreasing immunization pain in young children?

The most consistent evidence is for breastfeeding (prevents more severe pain for 1 in 2 patients versus control), topical anesthetics (prevent clinically significant pain for 1 in 4 children versus placebo) and video distraction (reduces pain by ~2.4 points more than placebo on a 5-point pain scale)The evidence does not support pre-medicating with oral analgesics or reassurance/verbal distraction by parents for managing pain.

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  • Most recent systematic review/meta-analysis: 10 randomized controlled trials (RCTs), 1,066 infants aged 1-12 months, versus various controls. Statistically significant reduced:1 
    • Cry duration by 38 seconds. 
    • Composite pain scores Standard Mean Difference (SMD)=1.7 (“large” effect). 
      • Example:2 Severe pain on infant pain score, 16% versus 75% (control), Number Needed to Treat (NNT)=2. 
  • Other systematic reviews found similar.3,4 
Topical anesthetics (examples lidocaine/prilocaine cream): 
  • Two Systematic reviews:4,5 
    • “Distress” (13 RCTs, 1,424 children age <3 years):1 SMD=0.91(probable “large” effect).
      • Example:6 Children who cried after vaccination, 7% versus 22% (placebo), NNT=7. 
    • Pain (ages 4-11); three RCTs (n=269): No effect.4 But, if remove highest risk-of-bias study, SMD=0.47 (“moderate” effect). 
      • Example:7 Clinically significant pain, 17% versus 43% (placebo), NNT=4. 
    • On 100-point pain scale: Topicals 17 points better than placebo (two RCTs, n=253).7   
Sweet-tasting solutions: 
  • Most recent systematic review:8  
    • No significant difference in cry duration or composite pain scores (six RCTs, 520 children aged 1-4).
    • One RCT (n=472) found fewer children had severe pain scores: 36% versus 64%, NNT=4. 
  • Inconsistent effects also in other reviews.1,4  
Video distraction:  
  • Three systematic reviews (1-4 RCTS, 90-456 patients):9-11 
    • Five of 9 outcomes positive, with “moderate-large” effect,3,4 (SMD 0.49-0.84). 
      • Example:12 One RCT, pain scale out of 5 (lower worse): 4.3 video versus 1.9 control.
  • Pre-medicating with oral pain relievers and reassurance/verbal distraction by parents does not reduce pain.4,11,13 
  • Further information on injection technique to minimize pain and resources for parents available online.14  

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  • Adrienne J Lindblad BSP ACPR PharmD
  • Kristina Quan

1. Harrison D, Reszel J, Bueno M, et al. Cochrane Database System Rev. 2016; 10:CD011248.

2. Dilli D, Küçük IG, Dallar Y. J Pediatr. 2009; 154:385-90.

3. Benoit B, Martin-Misener R, Latimer M, et al. J Perineonatal Nurs. 2017 ;31(2):145-59.

4. Shah V, Taddio A, McMurtry CM, et al. Clin J Pain. 2015 Oct; 31(10 Suppl):S38-63.

5. Shah V, Taddio A, Rieder MJ, et al. Clin J Pain. 2009; 31 Suppl 2:S104-51.

6. Abuelkheir M, Alsourani D, Al-Eyadhy A, et al. J Int Med Res. 2014; 42:329-6.

7. Cassidy KL, Reid GJ, McGrath PJ, et al. Acta Paediatr. 2001; 90:1329-36.

8. Harrison D, Yamada J, Adams-Webber T, et al. Cochrane Database System Rev. 2015; 5:CD008408.

9. Pillai Riddell R, Taddio A, McMurtry CM, et al. Clin J Pain. 2015 Oct; 31(10 Suppl):S64-71.

10. Pillai Riddell R, Racine NM, Gennis HG, et al. Cochrane Database System Rev. 2015; 12:CD006275.

11. Birnie KA, Chambers CT, Taddio A, et al. Clin J Pain. 2015; 31:372-89.

12. Cohen LL, Blount RL, Panopoulos G. J Pediatr Psychol. 1997; 22:355-70.

13. Chambers CT, Taddio A, Uman LS, et al. Clin J Pain. 2009; 31:S77-103.

14. HELPinKids. Available at: Last Accessed: October 5, 2017.

Authors do not have any conflicts of interest to declare.