Intervention to Reduce Pain, Anxiety of Immunization Feasible in Pediatric Practices

From Medscape Medical News
Laurie Barclay, MD

November 15, 2010 — Implementing an intervention to reduce the pain and anxiety associated with immunization delivery is feasible in pediatric practices, according to the results of a study reported online first November 15 and in the December print issue of Pediatrics.

"Many strategies have been developed to address the pain and anxiety associated with immunizations, but these often are underutilized by pediatric providers," write Neil L. Schechter, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "An educational outreach strategy known as 'academic detailing' has been effective in changing health provider practices."

This study aimed to assess the effect of a 1-hour teaching module on immunization pain reduction practices in 14 randomly selected pediatric offices at 1 and 6 months after training. Before and at 1 and 6 months after the intervention, parents were interviewed by telephone questionnaires regarding their children's recent immunization experiences. Clinicians completed a survey at baseline and at 6 months.

Thirteen practices in suburban Hartford, Connecticut, completed the study, yielding 839 telephone interviews and 92 clinician surveys. At 1 month after the intervention, there were significant improvements from baseline in parents' reports of receiving information (P = .04), using strategies to reduce pain (P < .01), learning something new (P < .01), using a ShotBlocker (Bionix [a plastic device that applies pressure at the injection site]; P < .01), using sucrose (P < .01), and having higher levels of satisfaction (P = .015). Except for satisfaction, all rates remained higher than baseline findings at 6 months (all P < .01).

Clinician surveys also documented significant increases at 6 months in the use of needles longer than 5/8 inches, sucrose, pinwheels, focused breathing, and ShotBlockers.

A 1-hour teaching session had measurable effects on the use of pain-reducing strategies at 1 and 6 months after the intervention," the study authors write. "This research supports the hypothesis that small-group teaching sessions at the site of care can be associated with changes in practice behaviors."

Limitations of this study include controversy regarding satisfaction with the clinical encounter as a multifactorial variable and the inability to determine why some interventions that were adopted initially by many practitioners remained popular while others did not.

"Importantly, no single strategy by itself has been shown to change practice behaviors uniformly, but a combination of approaches that are ongoing is far more likely to do so," the study authors conclude. "This strategy, along with others, should be considered as part of an overall plan to improve health care quality for children during their medical encounters in office settings. Finally, regarding immunizations and other procedures, children's comfort need not be sacrificed in the provision of good medical care; in fact, it should be considered an essential component of it."

The study was supported by the Mayday Fund and the Kohl Family Foundation. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 15, 2010.

Pain Management...

I guess I thought I would have more to say about it.  And everything I do have to say, can be looked up easily online.  When I started this, I was just very emotional about the way heart surgery was performed on infants until the 1980's.  This was my way of processing.  I guess the important thing now is that we never assume the doctors are doing everything they can for our children in terms of pain management.  Be sure to talk with the doctor, understand the procedure and the pain management options, and do what you feel is best for your child.  Thanks for reading.

Just one more thing about shots...

Look at this sad photo.  Don't you wish there was an easier way?

http://www.columbiamissourian.com/stories/2009/10/07/ap-poll-third-parents-oppose-swine-flu-vaccine/

H1N1

Have any of you had the H1N1 vaccine yet?  Or your kids?  How did it go?  I know someone who took her 2 grandsons and one spiked a fever of 101 afterward.  But, that's what your body is supposed to do.  Start fighting it and build antibodies.  I'm pretty convinced I'm getting it for the kids as soon as it's available.  My 3 year old will probably get the nasal spray.  She just got the Flumist for the routine vaccine and she was so happy to not need a shot.  My one year old won't be so lucky.  I would appreciate hearing any experiences you have had or your thoughts about the vaccine.  Has anyone had H1N1 or think you may have?  Thanks!

http://www.askdrsears.com/thevaccinebook/2009/09/flu-vaccine-update-for-20092010-season.asp

http://www.askdrsears.com/thevaccinebook/

So Many Shots!!

Shots...where to start.  I hate them!  Don't mind getting them myself, but I get so anxious when my kids have to get them.  Does anyone else feel this way or is it no big deal for most of you?  My daughter is so fearful of the doctor's office because of them.  She openly tells her doctor that she does not like him.  At my son's one year visit a couple weeks ago, he received four shots, two per leg.  Then his doctor tells me he'll need a booster for the flu shot in one month.  He is also recommending the H1N1 vaccine and I'm reading that it will also be a series of two shots for his age, and then by that time we'll be ready for his 15 month appt when more shots are due.  It just seems like so much.  Are there any children out there who aren't fearful of going to the doctors?

So I wanted to post some information about methods for lessening the pain during vaccines, a couple I have tried, and I'm curious what others have tried (especially if it's something that worked!!).

The first thing I tried was the sugar theory.  If you give an infant sugar just before or during the shot, it's less painful.  So, I went online and bought TootSweet Sucrose Solution (guaranteed bacteria and mold free) from Hawaii Medical.  The solution comes in 1oz cups with a vanilla scented pacifier to dip into the solution and then give to the infant to suck on during the vaccine.  My daughter seemed to cry just as much.  Still have 4 of the 1oz cups sitting here.  Of course I have read you can also breastfeed your infant during the shot, but I was never up for that.

Then there's EMLA cream that numbs the skin.  I tried this with my daughter too.  You need a prescription and the pediatrician was willing to give me one with no problem.  You need to put it on the skin one hour before the shot and keep it covered with something that won't rub it off.  I used a tagaderm bandage.  I have read some use plastic wrap.  First, my daughter cried when I put it on.  I'm not sure why.  I tried it on my own skin and it felt a little weird, but it didn't hurt.  But worse than that, because I put it on at home before I left for the appt, I never seemed to get the cream in just the right place and it seemed to stress out the nurse because it wasn't exactly where she wanted to give the shot.  I'm stressed enough about the whole thing, I don't need the nurse to be stressed too! The first time I used it the nurse didn't give the shot where I put the cream.  I think I tried it a couple more times and stopped.  Of course, if you don't mind waiting, you could have the nurse put it on and then wait an hour at the doctor's office before the shot is administered.

Recently I read that something as simple as the order the shots are given can reduce some of the pain.  No personal experience with this one, but here's the link.  http://www.medpagetoday.com/PrimaryCare/Vaccines/14040

The sense of smell is the most advanced sense that babies have at birth.  According to a Swiss study, by one month, a familiar odor can soothe your baby, so try holding her with a blanket that smells of breast milk or a familiar baby lotion during vaccines.

These are just a couple things I have tried or read about.  Of course, you could search the Web and find other ideas.  Are any of these much of a benefit to the baby or is it more for our own peace of mind?  If you have had success with other methods, I would love to hear about it, because the shots aren't going away anytime soon!

http://www.aimtoolkit.org/talk/order/Lessening_the_Pain_of_Vaccines.pdf

Why I'm Doing This

Most of us have heard of the pain of open heart surgery.  Maybe you have known someone who has been through it.  Maybe you have been through it yourself.  The pain you're thinking of is the pain experienced after the surgery.  Have you ever considered the pain you would endure if awake during the procedure with no pain management?  The initial incision, breaking of the sternum, prying open of the rib cage.  How would you respond if a doctor suggested that you go through the procedure in this way?  You would think he's crazy!?!

Did you know that until 1985-1987, infant heart surgery was performed like this?  No pain management, only a drug to paralyze the infant making it impossible to move a muscle or cry out in pain.  Some say the reason was because it was thought babies don't feel pain, but I find it impossible to imagine that anyone ever believed that.  http://www.math.missouri.edu/~rich/MGM/blog/chamberlain.html

According to one article I read, the parents of these infants were not made aware that the surgery was performed in this manner.  As a mom, I can't imagine consenting if I did know or if that was my only option in order to save my child's life, what it would be like to experience knowing that your child had to endure such an inhumane procedure.  If a person were to subject someone to this procedure outside of "surgery" it would be considered a heinous crime and that individual would likely spend the rest of their life in prison.  But since it occurred in an operating room, with doctors who the parents trusted to save their child's life, I guess it's okay.

From what I have read, heart surgery is no longer performed in this way.  I pray it isn't.  However, infants still do not fair well when it comes to managing the pain of many procedures.  A day after my son's delivery, my husband and I were still uncertain whether we wanted him to be circumcised.  We asked how the area would be numbed and the doctor told us he doesn't use anything.  "The procedure is so quick, it isn't worth the time to numb the area."  Isn't worth it to who?  This really angers me, hence my blog.  I would like to use this blog to share pain management techniques I come across and hope others will share as well.  Hope some of you find it helpful.  Thanks for reading!

Some interesting resources:

http://pediatrics.aappublications.org/cgi/content/abstract/100/4/626

http://www.ama-cmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf

http://pediatrics.aappublications.org/cgi/content/abstract/118/Supplement_2/S78