Published online May 1, 2007
PEDIATRICS Vol. 119 No. 5 May 2007, pp. e1184-e1198 (doi:10.1542/peds.2006-1107)
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SPECIAL ARTICLE

Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations

Neil L. Schechter, MDa,b,c, William T. Zempsky, MDb,c, Lindsey L. Cohen, PhDd, Patrick J. McGrath, PhDe,f, C. Meghan McMurtry, BAe,f and Nancy S. Bright, BSNa,c

a Pain Relief Program, Connecticut Children's Medical Center, Hartford, Connecticut
b Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
c Department of Pediatrics, St Francis Hospital and Medical Center, Hartford, Connecticut
d Department of Psychology, Georgia State University, Atlanta, Georgia
e Centre for Research in Pediatric Pain, IWK Health Centre, Halifax, Nova Scotia, Canada
f Department of Psychology, Dalhousie University, Halifax, Nova Scotia, Canada

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Key Words: immunizations • injection • clinical practice • pain control

Abbreviations: DPT—diphtheria-pertussis-tetanus • EMLA—eutectic mixture of local anesthetics • MMR—measles-mumps-rubella

Accepted Nov 15, 2006.