Good Practice in Postoperative and Procedural Pain Management ...

4.3.6 Immunization and intramuscular injectionImmunization schedules result in increasing numbersof intramuscular injections being administered toinfants and children. At 2 and 3 months, infants areoffered diphtheria, tetanus, pertussis, hemophilus(Hib), and polio immunization as one vaccination,with a separate meningococcal or pneumococcal vaccine.All 3 are given at 4 months. Children receive furtherimmunizations at 1 year and 15 months, again atpreschool, and finally at school leaving. Intramuscularadministration of asparaginase to children with leukemia,and long-acting penicillin therapy are other examples.The pain of these injections is widelyacknowledged and contributes to anxiety in patientsand their parents/carers, particularly regarding vaccinations.There is now evidence that such pain may bereduced by a number of strategies. Knowledge thatpractitioners have considered the use of these strategiesmay help parents in their decisions about immunization.It is important that treatable pain is not a barrierto the childhood immunization program.See also sections 4.0, 4.1, and 4.2 on the generalmanagement of procedural pain.Good practice pointIntramuscular injections should be avoided in childrenas part of routine care. If intramuscular injection isunavoidable, pharmacological and nonpharmacologicalstrategies should be employed to reduce pain.RecommendationsPsychological strategies such as distraction should beused for infants and children undergoing vaccination:Grade A (85,122–124).Consider additional procedure modifications such as vaccineformulation, order of vaccines (least painful first)needle size, depth of injection (25 mm 25 gauge needle),or the use of vapocoolant spay: Grade A (125–132).Swaddling, breast-feeding or pacifier, and sucrose shouldbe considered in infants undergoing vaccination: GradeA (7,78,133,134).EvidenceThere are two phases of immunization pain: the initialpain of the needle piercing the skin and injection of avolume of vaccine into the muscle or subcutaneous tissue,followed by a later phase of soreness and swelling atthe vaccination site because of subsequent inflammatoryreaction. Studies have generally investigated strategiesdesigned to deal with the former, presumably becausethis is perceived to be the most unpleasant component.Children typically dread needle-related pain; the use ofeither nonpharmacological or pharmacological painreduction strategies may reduce subsequent negativerecall (123). There is good evidence that nonpharmacologicalmethods, particularly distraction, can reduceimmunization pain (85,122,123,135). There is also evidenceof benefit from nonpharmacological strategies inneonates and young infants