Making injections less painful for children

Wednesday January 16 2019

The pain and fear around childhood vaccinations contributes to the development of needle phobias.

The pain and fear around childhood vaccinations contributes to the development of needle phobias. PHOTO | FILE | NATION MEDIA GROUP 

THE NEW YORK TIMES
By THE NEW YORK TIMES
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Paediatric pain specialists believe that reducing the pain associated with needles can lead to better healthcare.

The pain and fear around childhood vaccinations contributes to the development of needle phobias, which can make people reluctant to get flu shots and other potentially lifesaving vaccines, said Dr. Stefan Friedrichsdorf, the medical director of pain medicine and palliative care at Children’s Minnesota.

Thus, paediatric pain specialists hope that reducing or eliminating the pain associated with needles can potentially reduce what we now call vaccine hesitancy, encouraging parents to get those annual flu shots for themselves and their children, and generally taking away some of the fear that can get in the way of ideal health care.

“We now have noticed that since we started doing this, it’s a life changing event, children are less and less likely to be needle phobic,” Friedrichsdorf said. “We are trying to prove it’s lifesaving.” Through an initiative called the Comfort Promise at Children’s Minnesota, the entire hospital has committed to reducing or eliminating needle pain, along with other types of pain.

So how do you eliminate, or at least substantially reduce, the pain of vaccination or blood draws? Parents should make sure that their children’s pediatrician or hospital always offers the four elements of the Comfort Promise, Friedrichsdorf said.

Numb the skin

Topical anaesthesia, in the form of lidocaine cream, is available over the counter and safe even for infants, he said; it should be applied at least 30 minutes before the shot or the blood draw. At Children’s Minnesota, he said, it is offered to “every single child every single time,” which involves a great deal of planning and coordination. “It’s doable but it’s a lot of hard work,” he said.

Let infants breastfeed

Offer breastfeeding or a pacifier dipped in sugar water for infants under 12 months old when they are getting shots or blood draws. The effect, Friedrichsdorf said, is “spectacular.” A systematic review has shown that in infants, breastfeeding is more effective than topical anaesthetics, said Christine Chambers, a professor and children’s pain researcher at Dalhousie University in Halifax, Nova Scotia.

Don’t pin a child down

Children should never be held down, which is frightening in itself; instead, put the child in an upright position on a parent’s lap. “In our hospital, it’s illegal to hold children down,” Friedrichsdorf said. “Unfortunately, all over America people are adhering to the old idea of just pin them down.”

When I was in training, we routinely restrained children when they needed stitches or other minor — and painful — procedures by velcroing them into what we called “papoose boards.” Very rarely, a child will need to be held down for emergency lifesaving procedures, when there is no time to lose. But in the vast majority of cases, with pain control and distraction for the child, that kind of restraint should be unnecessary. “Papoose boards should be illegal, they don’t make any sense,” Friedrichsdorf said.

Provide distraction

Provide age-appropriate distraction with anything from a parent’s phone or iPad to blowing bubbles.

The kinds of statements that parents make about pain and needles can have a big impact on children, said Dr. Chambers. Research has shown, she said, that what parents may intend as reassuring statements about how it will be over soon, or it won’t hurt too much, are perceived as a signal of parent anxiety and can actually make children feel worse and increase their pain. Instead, parents should “use distracting statements, or give suggestions about how children can cope, like taking a deep breath,” she said.

If these measures are not enough for some procedures, Friedrichsdorf said, “the answer is nitrous gas” and, rarely, when necessary, forms of deeper sedation.

Chambers leads the “It Doesn’t Have to Hurt” initiative in Canada, which provides parents with evidence about children’s pain control so they can advocate for their children. An article she wrote in September in the journal Pain Reports summarises developments in the field of paediatric pain research.

She told a story of one mother who took her baby to the emergency department and asked if she could breastfeed while the baby was having a procedure done. The initial response was no; “there’s a lot of misconceptions, the baby will associate pain with feeding, or the baby will choke,” Chambers said. But the mother persisted and finally prevailed, and “eventually the resident said, go ahead, and then said, this was one of the best procedures I’ve ever done.”

Paediatric pain specialists speak with real passion about their ability to shield children from even the “routine” pain of shots and blood draws. But they acknowledge that change in medical practice can be slow, and that parents are their most important partners in advocacy. “Simply asking the question, ‘What can be done to manage my child’s pain,’ just bringing that possibility up,” often starts doctors and nurses thinking about better pain management, Chambers said.

And of course, children are not the only ones out there who are frightened. “We don’t talk about how many adults are afraid of needles or avoid getting needles,” Chambers said. “We’ve had many parents in our initiative say, these strategies have worked not only for my children but for me.”

So what gets in the way? Friedrichsdorf points out that veterinary medicine requires much more training in how to handle pain “before you can operate on a hamster” than is required of paediatricians and even of surgeons. And the logistics of providing this kind of pain management for routine shots and blood draws can be very daunting for institutions or busy practices: all those topical anaesthetics to be applied, all those distraction techniques to be taught and practiced.

An international initiative, ChildKind, certifies hospitals that meet standards for paediatric pain control, attempting to build in both standards and a strong incentive for the best evidence-based practices. And Minnesota is working with five other children’s hospitals in the United States and Canada to replicate its comfort promise initiative, while others are implementing these changes independently.

Parents can also take the initiative, learning about the evidence, bringing the information to their children’s health care providers, and partnering in everything from applying the topical cream to providing the distracting conversation or device or even bubbles, to holding doctors to a high standard for their children’s sake.

Friedrichsdorf said that after working in pain management for nearly 20 years, he recognises that his message gets through most effectively when parents demand good pain control for their children.

He added: “I hope parents never accept no as an answer.”

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