Research looks at new ways to ease pain of kids' shots

Children experience less pain with a vaccination if the skin is pretreated with an anesthetic and they are taught about what to expect. Being accompanied by a parent and being entertained with simple diversions also help, according to a study in the December Family Practice.

"This strategy could make vaccines more acceptable to children and may improve child-doctor relationships, and contribute to a decrease in child fear about health care," wrote the authors from the University of Nancy in France.

Physicians said this study made a lot of sense, and the research is part of a trend toward examining ways to reduce the pain children experience in the health care system. Several other projects are investigating whether the order in which shots are given affects the amount of hurt caused. The efforts also seek ways to reduce the injection pain experienced by newborns.

"It's a very important topic, which doesn't get a lot of attention," said Evelyn Reis, MD, an associate professor of pediatrics at Children's Hospital of Pittsburgh. "We now have many more shots to protect kids, which is great, but for a lot of kids, it's very difficult to get those shots."

Reducing pain associated with vaccinations is considered important. Although the sensation usually is brief, getting a shot is a frequent part of a child's experience in a doctor's office -- so much so that it can affect their willingness to receive care and their parents' willingness to bring them.

The Family Practice study "is a very worthwhile and very interesting paper," said Jonathan L. Temte, MD, PhD, associate professor of family medicine at the University of Wisconsin, Madison. "A child can associate a visit with a doctor as negative just based on that experience of getting immunizations and the needlestick. ... At this point in time, when we're seeing some resistance toward immunizations for all sorts of reasons, reducing some of that angst is welcome." Dr. Temte also is a member of the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

Many doctors who care for children said some version of the intervention most likely is carried out in most practices. Distraction is a frequent strategy. Anesthesia is less common, primarily because it can be costly and needs to be applied up to an hour in advance. Many physicians said they provide anesthetic cream on request or for a child who is receiving numerous shots in one visit. Distractions range from having the child play with soap bubbles, as in this study, to party blowers. The goal is to reduce the fear and anxiety that often precedes the actual needlestick and makes subsequent ones more difficult to give to an apprehensive child.

"The pain of vaccination is an extremely small part of the experience," said James Becker, MD, associate professor in family and community health at Marshall University in West Virginia. "The fear of pain is a larger part of the experience for children and drives the responses in the office."

But experts also cautioned that efforts to alleviate such brief discomfort not become so involved that they add to the economic and resource challenges involved in providing children with the full schedule of immunizations.

"Efficiency is critical," Dr. Temte said. "And some sort of balance needs to be established between getting children vaccinated and other concerns such as comfort."

Researchers also said it was necessary to tailor strategies to the child, particularly regarding age.

"This study is important, because a lot of these techniques have been looked at individually but not as a package," said Neil Schechter, MD, director of the division of pain medicine at Connecticut Children's Medical Center in Hartford and author of a literature review on the subject in the May 2007 Pediatrics. "But individualizing this package is critical."

For example, the Family Practice study included those ages 4 to 12, but a subgroup analysis found that the intervention did not make a statistical difference in the pain experienced by those ages 10 to 12. And research by Dr. Reis has suggested that pain in infants who receive multiple injections can be reduced with a combination of sucrose, sucking on a pacifier or bottle, and being held by a parent. It's unclear what the most appropriate strategies may be to reduce pain in children ages 1 to 4.