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#205 Preventing Painful Pokes: Decreasing Immunization Pain in Kids


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

BOTTOM LINE
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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EVIDENCE
Breastfeeding: 
  • 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.
Context: 
  • 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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Author(s):

  • 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: http://phm.utoronto.ca/helpinkids/resources.html. Last Accessed: October 5, 2017.

Authors do not have any conflicts of interest to declare.