Effects of a skin refrigerant/anesthetic and age on the pain responses of infants receiving immunizations

Pharmacological interventions for reducing pain related to immunization or intramuscular injection in children: A mixed treatment comparison network meta-analysis of randomized controlled clinical trials

Various interventions were observed to reduce pain following vaccination in children. This study is a network meta-analysis comparing pharmacological interventions. Electronic databases were searched for appropriate randomized controlled clinical trials comparing active pharmacological agents to reduce pain following vaccination or intramuscular injection in neonates, infants, or children. Pain score was the primary outcome measure. Random effects model was used for generating pooled estimates. A total of 23 studies were included in the network meta-analysis. Topical eutectic mixture of local anesthetics (EMLA) significantly reduced pain scores. Crying time was also observed to be lower with vapocoolant spray and 25% sucrose and glucose solutions. Quality of the evidence was observed to be either low or very low. Topical EMLA significantly reduce pain following intramuscular injections particularly vaccination. However, due to low grade quality of the evidence, more studies are obligatory.

Randomized controlled trial of topical EMLA and vapocoolant spray for reducing pain during wDPT vaccination

BACKGROUND

Intramuscular vaccination is among the most common source of iatrogenic pain in infants. Vapocoolant sprays are rapid-acting alternative to topical anesthetics. They provide transient anesthesia via evaporation induced skin cooling, and reduce pain due to vaccine injection in children and adults. The objective was to compare the synergistic analgesic effect of eutectic mixture of local anesthetics (EMLA) with breastfeeding (EB group) and vapocoolant spay with breastfeeding (VB group) to that of only breastfeeding (BO group) during whole cell diptheria, pertussis and tetanus (wDPT) vaccination.

METHODS

A double blind randomized controlled trial was done to include infants up to 3 months of age who came for their first wDPT vaccination. The primary outcome variable was the duration of cry after vaccination. Secondary outcome variables were Modified Facial Coding Score, Neonatal Infant Pain Scale and latency of onset of cry.

RESULTS

Of the 201 eligible participants, 111 babies were excluded and remaining 90 babies were randomized into three groups of thirty each. The groups did not differ significantly in baseline characteristics. Median (interquartile range, IQR) of duration of cry was lesser [35.86 (21.07-107.75) seconds] in babies receiving EMLA cream with breast feeding (EB group) and in babies receiving vapocoolant spray with breast feeding (VB group) [32.58 (21.25-106.21) seconds] as compared to babies receiving only breast feeding (BO group) [67.5 (27.6-180) seconds] (P=0.147). Difference in median (IQR) of latency of cry was not statistically significant. Modified Facial Coding Score and Neonatal Infant Pain Scale at 1 minute and 3 minutes was significantly lower in the EB and VB group, as compared to the BO group (P<0.05).

CONCLUSION

Addition of topical EMLA application or vapocoolant spray to breastfeeding during wDPT vaccination does not reduce duration of cry in infants up to 3 months of age. However, they are able to show reduction in pain score and further studies are warranted to assess their efficacy as pain relief measures in infants and children.

Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-Analysis

BACKGROUND

This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan.

DESIGN/METHODS

Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI).

RESULTS

Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone.

CONCLUSIONS

Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants.

A systematic review of vapocoolants for reducing pain from venipuncture and venous cannulation in children and adults

BACKGROUND

Studies of vapocoolants for pain reduction from venipuncture have demonstrated conflicting results.

OBJECTIVE

Our aim was to systematically review the literature regarding the analgesic effectiveness of vapocoolants in children and adults.

METHODS

We searched MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register of Trials using key words: vapocoolant, pain, venipuncture, and cannulation. We included randomized or quasi-randomized studies comparing vapocoolants to placebo or no treatment. Two authors reviewed titles and abstracts and extracted data. Quality was assessed by consensus using the Cochrane risk of bias tool. The primary outcome was self-reported pain using a 100-mm visual analog scale, a 0- to 10-point numerical scale, or observational scale for preverbal children. Data were pooled using a random effects model.

RESULTS

Twelve studies including 1266 patients (509 children, 757 adults) were identified. No significant pain reduction was found in children receiving vapocoolants vs. placebo or no treatment (mean difference -10 mm; 95% confidence interval [CI] -26 to 6). In adults, less pain was reported when vapocoolants were compared with no treatment: -10 mm on a 100-mm scale (95% CI -17 to -4); but not when compared to placebo (-12 mm; 95% CI -26 to 2). Pain from application of vapocoolants was greater than placebo (8 mm; 95% CI 4 to 2).

CONCLUSIONS

Vapocoolants were ineffective in children and adults when compared to placebo, and effective in adults only when compared to no treatment. The magnitude of effect was low and was offset by increased pain from application. They cannot be recommended for routine use in children or adults.

Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections

OBJECTIVE

The aim of the study was to determine the efficacy of ShotBlocker (Bionix, Toledo, Ohio) in reducing pediatric pain with intramuscular (IM) injections.

METHODS

A prospective randomized controlled trial was conducted in children aged 2 months to 17 years who required an IM injection. Children were randomized to the no-intervention group or the ShotBlocker group. Demographic data and the number of IM injections were recorded. Perceived pain scores were obtained from nurses and caregivers using a 6-point Likert-type scale. Baker Wong Faces scale was used in children 36 months or older. Difficulty using the device was also rated by nurses on a 6-point scale.

RESULTS

One hundred sixty-five children were enrolled with 80 in the no-intervention arm and 85 in the ShotBlocker arm. The mean age of children was 45 months and 56% were male. Perceived pain scores by nurses were higher for the no-intervention group (2.6 vs 1.8, P < .001) as well as by caregivers (2.6 vs 2.1, P = .04). Children aged 36 months and older (n = 64) did not report a difference in pain scores (1.5 vs 1.3, P = .6); however, in a subgroup of children 72 months or older, pain scores trended higher in the no-intervention group (1.3 vs 0.5, P = .051). Nurse-perceived difficulty of ShotBlocker use was low 1.39 (+/-1.1).

CONCLUSIONS

Nurses and caregivers noted lower pain scores in children assigned to the ShotBlocker group. These differences were not as evident when children rated their own pain.

The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial

BACKGROUND

Established noninvasive pharmacologic means of alleviating pain and anxiety in children undergoing intravenous cannulation are time-consuming, and thus impractical for routine use in the emergency department. Vapocoolant sprays provide transient skin anesthesia within seconds of application. We compared the effect of a new vapocoolant spray to placebo on pain due to intravenous cannulation in children.

METHODS

In this double-blind randomized controlled trial, which we conducted between June 1 and Sept. 12, 2006, 80 children aged 6-12 years received either vapocoolant spray or placebo before cannulation. Children rated their pain using a 100-mm colour visual analogue scale. Secondary outcomes included success rate on first attempt at cannulation and pain ratings by the children's parents, nurses and child life specialists.

RESULTS

We found a modest but significant reduction in pain with the use of vapocoolant spray (mean difference 19 mm, 95% confidence interval [CI] 6-32 mm; p < 0.01). Cannulation on first attempt was more often successful with the use of vapocoolant spray (85.0%) than with placebo (62.5%) (mean difference 22.5%, 95% CI 3.2%-39.9%; p = 0.03). The number needed to treat to prevent 1 cannulation failure was 5 (95% CI 3-32). Parents (p = 0.04), nurses (p = 0.01) and child life specialists (p < 0.01) considered the children's pain to be reduced with the use of vapocoolant spray.

INTERPRETATION

The vapocoolant spray in our study quickly and effectively reduced pain due to intravenous cannulation in children and improved the success rate of cannulation. It is an important option to reduce childhood procedural pain in emergency situations, especially when time precludes traditional interventions. (http://ClinicalTrials.gov trial register no. NCT00130650.).

Pain reduction during pediatric immunizations: evidence-based review and recommendations

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.

Ethyl vinyl chloride vapocoolant spray fails to decrease pain associated with intravenous cannulation in children

The purpose of the study was to determine the effect of ethyl vinyl chloride vapocoolant spray on pain reported by children undergoing intravenous cannulation. A randomized, double-blinded, placebo-controlled trial was conducted on eligible children between the ages of 9 and 18 years seen in a pediatric emergency department and requiring intravenous cannulation. Informed consent was obtained, and children were randomized to receive ethyl vinyl chloride spray, isopropyl alcohol spray, or no spray (control group). Patient demographics and information pertaining to each intravenous cannulation were recorded. Children indicated the degree of pain associated with intravenous cannulation on a 100-mm visual analog scale (VAS) compared to a baseline pain score of "zero." Statistical analysis was performed by using Stata version 7. One hundred twenty-seven subjects were enrolled: 37 received ethyl vinyl chloride vapocoolant spray, 48 received isopropyl alcohol spray (placebo), and 42 received no pretreatment. Mean VAS scores for pain experienced during cannulation were 34, 33, and 31 mL for each group, respectively. Ethyl vinyl chloride vapocoolant spray failed to measurably reduce pain associated with intravenous cannulation when compared to those pretreated with isopropyl alcohol spray or receiving no intervention.

Topical vapocoolant quickly and effectively reduces vaccine-associated pain: results of a randomized, single-blinded, placebo-controlled study

BACKGROUND

Comprehensive international travel preparation often requires several vaccines. Up to 90% of adults have some fear of injections, mostly due to injection-related pain. Pediatric studies with routine vaccines have shown topical anesthetic EMLA cream (lidocaine and prilocaine, Astra Pharmaceuticals, Inc.) and the topical vapocoolant Fluori-Methane (dichlorodifluoromethane and trichlorodifluoromethane, Gebauer Co.) to be equally effective in reducing pain from vaccinations. EMLA cream is expensive and requires a 60-min application, while Fluori-Methane (FM) is immediate in onset of action and inexpensive. Skin anesthesia begins at 10 degrees C. Fluori-Methane can briefly cool the skin to 0 degrees C.

METHODS

We studied the effectiveness of topical vapocoolant on adult clients at our international travel clinic in a randomized, controlled trial of topical FM vs. cold (4 degrees C) saline placebo. Using a preset randomization table, participants served as their own controls, receiving placebo/control or active agent (participant blinded) in one arm (left or right), and a similar number of vaccines in the untreated arm. Vaccines were administered according to a set protocol per arm to minimize the risk of bias. Pain was measured using a modified McGill present pain intensity (PPI) pain index. Subjects rated their pain immediately and at 5 min on a six-level scale, noting treated and untreated arms separately. A questionnaire was completed on intervention preferences. Sample size was predetermined to achieve 90% statistical power estimating 25% efficacy (minimum n=172).

RESULTS

One hundred and eighty-five participants were enrolled; 93 FM and 92 cold saline placebo. FM-treated arms had a significant reduction in immediate pain compared to untreated arms (pain scale mean 2.2 vs. 3.1; p<.0001), and compared to placebo (mean 2.2 vs. 2.8; p<.01). Delayed pain at 5 min was not affected by FM or control (mean 1.9 vs. 2.0) compared to no intervention (pain scale 1.9). The intervention preference questionnaire indicated that participants did not find FM therapy uncomfortable. They would choose FM therapy in the future, over a cream, especially if a wait was involved.

CONCLUSION

The topical vapocoolant Fluori-Methane is an effective, quick, preferred, inexpensive agent for reducing vaccine-associated injection pain for international travel clients.

Reducing injection pain in children and adolescents with diabetes: a review of indwelling catheters

Most children and adolescents find the pain when injecting insulin quite minimal but still significantly more painful than a placebo injection. However, injection pain and needle phobia are major problems for a small number of patients, even after many years of diabetes. Needle diameter is of less importance for the experienced pain. The use of indwelling catheters (Insuflon, Unomedical, Lynge, Denmark) for introducing insulin injections at the onset of diabetes results in an evident relief of preinjection anxiety, injection problems, and the procedural pain of repeated injections. The average indwelling time is 3-5 d. Fixation problems and local redness at the insertion site are the most frequent side effects. However, the frequency is low and they can be dealt with effectively. Needles of 8-10 mm should be used for injecting to avoid penetration of the tubing of the catheter. Using indwelling catheters for up to 4-5 d does not affect the absorption of insulin, when the catheter is inserted in an area free from lipohypertrophies. The long-term (measured by hemoglobin A1c) and short-term metabolic control (measured by blood glucose profiles and serum-free insulin) is not altered. Using this type of injection aid may decrease the risk of future injection problems, such as needle phobia, in very select patients. In conclusion, indwelling catheters can safely be used from the onset of diabetes to lessen injection pain in children and adolescents, and may facilitate the use of intensive insulin therapy in this age group.

The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma

INTRODUCTION

The purpose of this study was to determine the effectiveness of nursing interventions in decreasing pain for children with minor musculoskeletal trauma and moderate pain and to examine patient satisfaction.

METHODS

Children were assigned to 1 of 3 intervention groups: (1) standard care (ice, elevation, and immobilization) only; (2) standard care and ibuprofen; or (3) standard care and distraction. Children were monitored for pain ratings for 60 minutes. Children who sustained minor musculoskeletal trauma within the past 24 hours and presented with pain ratings of 2 or greater using the 0-5 Wong/Baker faces scale were included. Two patient satisfaction questions were asked of parents upon their child's discharge from the emergency department.

RESULTS

A statistically significant decrease in pain for all patients (76) occurred at 30 minutes (F = 4.39, P <.05) and was maintained at 60 minutes. The distraction group demonstrated a statistically significant reduction in pain compared with the other groups at 30 minutes; this reduction was maintained at 60 minutes (F = 47.07, P <.05). Parents of only 6 children expressed dissatisfaction with overall pain management. Twelve percent of children who were not in the group receiving medication received analgesics while in the emergency department. At discharge, only 37% of children with fractures and/or sprains had received medications for pain.

DISCUSSION

Children with musculoskeletal trauma may be under-medicated. Distraction techniques can be an effective adjunct to analgesia for children with musculoskeletal pain in the emergency department and should be made available. Ibuprofen may not be an effective analgesic for children with these injuries; stronger analgesics may be required.

Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines

The growing abundance of highly immunogenic vaccines has arrived with a burden of pain, distress, and common adverse reactions that in turn may interfere with parental compliance and aggravate anti-vaccine sentiment. In a study of 150 children in each of 2 age-groups, we found that approximately 20% of the subjects suffered serious distress or worse. During the procedural phase, approximately 90% of the 15-to-18 month old children and 45% of the 4-to-6 year old children showed serious distress or worse. To address non-adherence with pediatric vaccine schedules, we must consider all of the possible issues that might prevent a parent from taking a child to a health care provider for vaccination. In that same study we identified useful predictors for both preparatory and procedural distress - predictors that might be used in identifying children who might benefit from preventive interventions. Vaccine providers might consider a variety of interventions. Attitude, empathy, instruction, and practice have all been shown to have a salutatory effect upon pain and anxiety with medical procedures in general and specifically with vaccinations. Distraction has also been found to be an effective method for distress and pain prevention in children. More formal methods of clinical hypnosis which combine a deep state of relaxation with focused imagery and suggestion have also been found to be effective in helping children and adolescents prepare for, cope with, and tolerate the pain and anxiety associated with medical procedures. So-called 'sugar nipples' delivering small amounts of sucrose orally at the time of a painful procedure in an infant has been not been shown to decrease vaccination pain and studies on refrigerant topical anesthetics are mixed. Studies have found a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) effective in providing adequate local anesthesia in children, but it suffers from problems in practical application. Studies with various injection techniques have not identified ready solutions, and although jet injection appears to provoke less anxiety and cause less immediate pain, studies also indicate a somewhat greater incidence of delayed local reactogenicity including soreness and edema. Other measures to prevent or rapidly treat other common adverse events have been shown effective and should be considered as well.

Taking the "ouch" out of injections for children. Using distraction to decrease pain

PURPOSE

This research compared the effect of two forms of distraction on injection pain in a convenience sample of preschool children.

DESIGN

A quasi-experimental study of 105 children (53 girls and 52 boys) ages 4 to 6 years needing DPT immunizations. Data were collected at three sites: two school-based immunization clinics and one public health center with a walk-in immunization program.

METHODS

Study children were randomly assigned to receive one of three treatments with their DTP injection: touch, bubble-blowing, or standard care. Prior to injection, a measure of medical fear was obtained (Child Medical Fear Scale) and pain was measured through use of the Oucher Scale.

DATA ANALYSIS

Planned comparisons within analysis of variance (ANOVA) tested the differences in pain scores by treatment. Factorial ANOVA was used to determine the influence of age or gender on treatment, and the effect of medical fear on pain was analyzed using correlational statistics and factorial ANOVA.

RESULTS

Both forms of distraction, touch and bubble-blowing, significantly reduced pain perception. There were no interaction effects of either age or gender. Fear was a significant covariate, but distraction was effective even when fear was not held constant.

CLINICAL IMPLICATIONS

Distraction appears to be an effective method for decreasing injection pain in young children. It is an easy, practical nursing intervention to help children cope with this common, painful experience.

Assessment of pain in the neonate

This article critically reviews the measures developed for assessing pain in the human neonate. Information was gathered with a computerized literature search of published articles and abstracts, a manual review of relevant conference proceedings, recently published journals, unpublished reports and manuscripts, and personal files. This identified 16 measures that were critically examined for their psychometric properties (reliability and validity) and clinical use. Special emphasis was placed on the feasibility of using neonatal pain assessment measures for clinical practice to address the research-practice gap. Although considerable progress has been made in the field of neonatal pain assessment, few measures have adequately established psychometric properties and clinical utility. Furthermore, most measures have been developed for research and not for the clinical setting. Issues regarding sensitivity, specificity, and the ability to detect clinically important changes have not been addressed. A sufficient number of infant pain measures have now been developed to assess acute pain. There is a paucity of measures to assess chronic pain in infants, and measures for infants who are low birth weight, critically ill, or ventilated. Future research should be aimed at strengthening the properties of existing measures, and at the development of measures for those infants with chronic pain or special needs.

Cold therapy and its effect on procedural pain in children

A quasi-experimental design was used to determine if cold therapy decreased the perceived pain associated with intramuscular injections in children. A convenience sample of 40 children aged 10 to 18 years was randomly assigned to the control or experimental group. The experimental group had an ice pack placed on the injection site for 15 min prior to injection, whereas the control group received injections according to hospital protocol. Ice was not shown to be significant in reducing procedural pain; however, distraction and parental support were effective.

A revised measure of acute pain in infants

Acute pain in infants is not assessed or managed optimally. The objectives of the study were (a) to adapt a behavioral pain assessment measure (Children's Hospital of Eastern Ontario Pain Scale, CHEOPS) for use with infants, and (b) to establish the reliability and validity of the measure in a study of infants undergoing immunization. Ninety-six healthy 4- to 6-month-old infants were randomized to receive either the local anesthetic cream Eutectic Mixture of Local Anesthetics (EMLA) (N = 49), or a placebo (N = 47) prior to immunization. The infant's behavioral response was videotaped immediately before and following the immunization. Postprocedural pain scores were assessed from the videotape and were significantly lower in infants who received EMLA (P = 0.01). Pain scores were also significantly correlated with visual analogue scale (VAS) scores assessed during vaccination. Five independent raters also independently rated ten infants to determine interrater reliability. Agreement between raters' scores was high (intraclass correlation coefficient, 0.95). Results from this study suggest that this measure has beginning construct and concurrent validity and interrater reliability when used in a research study. Further testing of the measure in the clinical setting is required.