Pediatrics Medical News about Child Immunization Pain Physical Medicine Injections

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Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials
Clinical Therapeutics, 10/15/09

Taddio A et al. – Pain during immunization can be decreased by: (1) injecting the least painful formulation of a vaccine; (2) having the child sit up (or holding an infant); (3) stroking the skin or applying pressure close to the injection site before and during injection; (4) injecting the least painful vaccine first when 2 vaccines are being administered sequentially during a single office visit; and (5) performing a rapid intramuscular injection without aspiration.

Methods

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched to identify randomized controlled trials (RCTs) and quasi–RCTs that determined the effect of physical interventions and injection techniques on pain during injection of vaccines in children 0 to 18 years of age, using validated child self–reported pain or assessments of child distress or pain made by others (parent, nurse, physician, observer).
Effects of: (1) different formulations of the same vaccine; (2) position of the child during injection; (3) intramuscular versus subcutaneous injection; (4) cooling of the skin at the injection site with ice before injection; (5) stroking the skin or applying pressure close to the injection site before and during injection; (6) order of vaccine injection when 2 vaccines were administered sequentially; (7) simultaneous versus sequential injection of 2 vaccines; (8) vaccine temperature; (9) aspiration before injection; (10) anatomic location of injection; (11) aspects of the needle (gauge, length, angle of insertion, speed of injection) were determined
All meta–analyses were performed using a fixed–effects model.

Results

19 RCTs involving 2814 infants and children (0–18 years of age) were included in the systematic review.
In 2 trials that used child self–reports of pain during administration of measles–mumps–rubella vaccine (total, 680 children with complete data), the Priorix vaccine caused less pain than the M–M–RII vaccine. In 3 trials (404 children), the number needed to treat (NNT) with Priorix to prevent 1 child from crying was 3.2.
In 4 trials (281 infants and children), sitting children up or having parents hold infants appeared to cause less pain than the supine position, but the difference was not statistically significant; however, significant heterogeneity was found among the studies, and a qualitative approach was used for data analysis. A benefit was observed for 3 of the 4 studies.
Stroking the skin close to the injection site before and during injection reduced pain in 1 trial.
One study (120 children) found that when diphtheria–polio–tetanus–acellular pertussis–Haemophilus influenzae type b (DPTaP–Hib; Pentacel) and pneumococcus (Prevnar) were injected sequentially during the same office visit, observer– and parent–reported pain scores were lower when DPTaP–Hib was injected first.
In 1 study (113 infants) comparing rapid intramuscular injection without aspiration and slow intramuscular injection with aspiration, the rapid injection without aspiration was associated with less pain.

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