When it comes to the pain of vaccines, there are strategies that work.

A few weeks ago I blogged about the roots anti-vaccine sentiment and their correlation with different attitudes. While the paper (and much of my post) focused on the correlation between those that hold anti-vaccine views and the belief in conspiracy theories, the researchers also looked at forms of “disgust” which included the very idea of injections themselves. In that paper, the authors noted:

According to the model of attitude roots, (sub)clinical fears and phobias can underpin some antiscience beliefs. For example, some people have heightened disgust reactions to needles, hospitals and blood. People who experience these heightened disgust reactions might be tempted to develop a set of attitudes that gives them permission to avoid the triggers for their disgust; for example a rejection of techno-medical interventions, and a skepticism or hesitancy toward immunizations.

When looking across different countries, there was a positive but inconsistent correlation found. What this means (and check out the post for detail) is that for some individual, the fears of needles, blood and even the thought of painful vaccinations may contribute towards anti-vaccine sentiment. With that in mind, I want to focus my post today on a topic that may be easier to address than conspiracy beliefs: The pain of vaccinations.

Again, from the same paper:

According to the attitude roots model, one way to create change is to identify underlying motives for rejecting the science on immunization, and then to tailor interventions that are congenial to those underlying motivations (the so-called jiu jitsu approach; Hornsey & Fielding, 2017). From this perspective, the goal of science communication is to align with people’s underlying fears, ideologies and identities, thus reducing people’s motivation to reject the science. If the motivation to reject the science is reduced, then people should become more willing to embrace the evidence on its merits.

While I’m a strong supporter of vaccines, I recognize that they can be a hard sell, especially to parents with children that don’t tolerate the pain of vaccines well. Vaccination can be painful, and parents understandably don’t like seeing their children suffer, when that pain is potentially avoidable. Mild pain is the most common consequence of gaining protection from what may be fatal illnesses. It seems like a fair trade-off to me. But that’s not the case for everyone. Fear of needles and injections is not uncommon: It’s estimated that 10% of the population avoids vaccinations for this reason. The pain of vaccines can lead to anxiety, fear, and even nonadherence with vaccination schedules. Needle fear may begin in childhood, and can continue over the lifespan, and for some, may be a factor leading them to opt out of annual influenza campaigns – or even other forms of conventional health care.

In light of what’s known about the prevalence of needle fears, their potential effect on vaccination adherence, and the possible impact on public health because of unvaccinated individuals, it makes sense to do whatever we can to minimize the pain and discomfort of vaccines. But what works? There is good evidence to inform our strategies. And these strategies can be very effective.

Back in 2010 I blogged about a systematic review on vaccine pain completed by Anna Taddio, a pharmacist and professor at the University of Toronto. The review answered 14 clinical questions on vaccine pain, which can be summarized as:

  • Breastfeeding during the vaccination process offers analgesic effects
  • Sweet oral solutions (1 packet/cube in 2 tsp of water) provide analgesic effects in those <12 months of age
  • Slow injections and aspirations (drawing back) should be avoided
  • When giving multiple injections, give the most painful one last
  • Rubbing/stroking the skin may reduce pain if done before the vaccine, but not after
  • Topical anaesthetics work
  • Distractions haven’t been shown to be that effective
  • There’s no evidence for acetaminophen or ibuprofen in advance of vaccination

To update this evidence there’s a new summary prepared by the Alberta College of Family Physicians. ACFP prepare short, evidence-based summaries of key clinical topics. This review links to some excellent videos prepared by the University of Toronto and the Hospital for Sick Children, which are highly recommended for parents as well as health care professionals interested in reducing the pain of vaccinations. Here’s one of their videos:

What are the best methods for decreasing immunization pain?

First, their bottom line:

The most consistent evidence is for breastfeeding (prevents more severe pain for 1 in 2 patients versus control), topical anesthetics (prevent clinically significant pain for 1 in 4 children versus placebo) and video distraction (reduces pain by ~2.4 points more than placebo on a 5-point pain scale). The evidence does not support pre-medicating with oral analgesics orreassurance/verbal distraction by parents for managing pain.

The key findings are as follows:

  • Breastfeeding during vaccination has been evaluated in 10 RCTs in children aged 1-12 months, against different controls. It significantly reduced cry duration, and evaluations of “severe pain” (measured on an infant pain score) from 75% to 16%.
  • Topical anaesthetics such as lidocaine/prilocaine cream are also very effective. These products can be purchased at pharmacies or online. Two systematic reviews showed that these products reduce distress and pain significantly beyond placebo. For example the percentage of children that cried after vaccination decreased from 22% to 7% in one study.
  • Sweet-tasting solutions (as described above) have positive, but less consistent effects, possibly through a mild analgesia effect. They don’t appear to affect cry duration but may have some effect on pain.
  • Video distractions are relatively new, but make sense to evaluate given the ubiquity of phones we all carry now. They have been evaluated in several RCTs. They appear to have moderate to large effects.
  • Pre-medicating with pain relievers has no significant effect. Don’t give Tylenol or Advil before your child’s vaccination, thinking it will have an meaningful effect.

Improving vaccine acceptance

When people express concerns about vaccines, understanding and addressing the roots of these concerns may be more effective to increasing acceptance. Multiple strategies to reduce vaccine pain have been tested, and several are very effective. The right strategies in childhood may help avoid a lifetime of negative health-related behaviors and decisions.

Posted by Scott Gavura

Scott Gavura, BScPhm, MBA, RPh is committed to improving the way medications are used, and examining the profession of pharmacy through the lens of science-based medicine. He has a professional interest is improving the cost-effective use of drugs at the population level. Scott holds a Bachelor of Science in Pharmacy degree, and a Master of Business Administration degree from the University of Toronto, and has completed a Accredited Canadian Hospital Pharmacy Residency Program. His professional background includes pharmacy work in both community and hospital settings. He is a registered pharmacist in Ontario, Canada. Scott has no conflicts of interest to disclose. Disclaimer: All views expressed by Scott are his personal views alone, and do not represent the opinions of any current or former employers, or any organizations that he may be affiliated with. All information is provided for discussion purposes only, and should not be used as a replacement for consultation with a licensed and accredited health professional.