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

Pain in Neonates: Perceptions and Current Practices

All newborns experience pain during routine care, which can have long-lasting negative effects. Despite the availability of effective methods to prevent and reduce pain, most infants will receive ineffective or no treatment. Optimal pain management includes the reduction of the number of procedures performed, routine pain assessment and the use of effective pain-reducing interventions, most notably breastfeeding, skin-to-skin contact and sweet-tasting solutions. Parents are an essential component of the comprehensive assessment and management of infant pain; however, a gap exists regarding the uptake of parent-led interventions and the engagement of families. Practice recommendations for infant pain care are discussed.

If we know better, why don't we do better? A rapid quality improvement project to increase utilization of comfort measures to reduce pain and distress in children in a COVID-19 mass vaccination clinic

INTRODUCTION

Many evidence-based tools exist to address pain and distress associated with injections; however, there remains a large gap between the knowledge of these tools and their utilization. Our hospital began a quality improvement (QI) project prior to COVID-19, with the goal of increasing the utilization of Comfort Promise measures during needle procedures. When COVID-19 vaccinations were approved, our mass vaccination clinics provided an opportunity to rapidly increase utilization across the institution. The primary aim was to increase the percentage of comfort measures (CM) offered with COVID-19 vaccinations.

METHODS

Through this QI project, nurses and other professionals implemented CMs during COVID mass vaccination clinics. Clinics occurred in 3 age-based waves. Waves served as Plan-Do-Study-Act (PDSA) cycles. Families completed post-vaccination surveys to determine what CMs were offered and intention for future use with vaccinations.

RESULTS

Uptake of CMs (PainEase, ShotBlockers, Comfort Positioning, Alternative Focus, Topical Lidocaine, and Breastfeeding/Sucrose) throughout the waves increased and generally remained stable. CMs also seemed to decrease pain/distress with vaccinations (70.5 to 88.7%), and children/caregivers intended to use some combination for future vaccinations (82.5 to 98.5%).

CONCLUSIONS

Fast-paced mass vaccination clinics provided an ideal opportunity to significantly increase utilization of CMs. Across age groups CMs yielded high satisfaction and interest in future utilization. Clinic nurses returned to their own sub-specialties and became change agents.

IMPLICATIONS

If all healthcare providers can work together to achieve consensus while incorporating comfort measures into daily practice, sustained change with incorporation of these evidence-based tools can be achieved. Future directions are discussed.

[Translating evidence: pain treatment in newborns, infants, and toddlers during needle-related procedures : German version]

INTRODUCTION

Treatment of pain in preterm, sick, and healthy newborns and infants and toddlers (up to 2 years of age) is consistently reported to be inadequate, and effective strategies are poorly implemented.

OBJECTIVES

To present existing evidence of effective pain treatment strategies during needle-related procedures and to highlight initiatives focused on translating evidence into practice.

METHODS

This Clinical Update focuses on the 2022 International Association for the Study of Pain Global Year for Translating Pain Knowledge to Practice in the specific population of newborns, infants, and toddlers. Best evidence is reviewed, and existing knowledge translation strategies and programs available to implement evidence into practice are presented.

RESULTS

Effective strategies for newborn and young infants during frequently occurring needle procedures include small volumes of sweet solutions, breastfeeding, or skin-to-skin care when feasible and culturally acceptable. In addition, strategies such as nonnutritive sucking, positioning, swaddling, gentle touch, facilitated tucking, and secure holding can be used. For toddlers, the evidence is less robust, and discerning between pain and distress is challenging. However, strategies recommended for needlerelated procedures include upright secure comfort holding by parents/caregivers, age-appropriate distraction, and topical anesthetics. Translation of effective pain management needs to involve the family, who need to be supported and empowered to comfort their child during painful procedures. Organizational, nationwide, and global initiatives aimed at improving implementation of effective pain treatments exist.

CONCLUSION

There is evidence of effective pain management strategies for newborns, infants, and toddlers, and a great deal of effort is being made to translate knowledge into action.

Efficacy of oral mefenamic acid versus paracetamol as a prophylactic analgesic for needle pain in children receiving vaccination: a three-arm, parallel, triple-blind, placebo-controlled MAP VaC randomized controlled trial

BACKGROUND

Needle pain due to routine vaccination is an important factor contributing to low vaccine adherence and immunization coverage. Prophylactic oral analgesics can address this important issue of needle pain related to vaccination. Paracetamol and mefenamic acid are commonly used nonsteroidal anti-inflammatory drugs for pain relief, but there is little published literature on whether the same can be used for needle pain related to vaccination.

OBJECTIVES

This study was planned to compare the efficacy of oral mefenamic acid and paracetamol over placebo as a prophylactic analgesic during vaccination and prophylactic antipyretic during the post-vaccination period.

DESIGNS

Three-arm, triple-blind, randomized controlled trial.

METHODS

This study was conducted at the outpatient department of a tertiary-level medical college in South India from January 2021 to June 2022. In this three-arm interventional trial, each arm had either a single dose of placebo or mefenamic acid (4 mg/kg/dose) or paracetamol (10 mg/kg/dose). These medicines were administered orally 30 min before vaccination to reduce needle pain.

MAIN OUTCOME AND MEASURES

Outcome was measured with the change of FLACC (Face, Leg, Activity, Cry, Consolability) scoring at the time of vaccination, subsequently at 15 and 30 min of vaccination in all three groups. Appearance of fever, grade of fever, and need for antipyretics 24 h after vaccination were also noted.

RESULTS

There was a significant difference in FLACC scores at the time of administration (p = 0.010) and at 15 min (p = 0.014) with mefenamic acid compared to placebo. Although the paracetamol group showed a difference when compared to the placebo, it was not significant at the time of administration (p = 0.401), at 15 min (p = 0.451), or 30 min (p = 0.892) post-vaccination. The appearance of fever, grade of fever, and use of antipyretic up to 24 h post-vaccination had no significant difference among any of the three groups.

CONCLUSION

Mefenamic acid was more potent than placebo for pre-vaccination pain prophylaxis in children. There was no difference in the appearance of fever and its grade among the three groups. The promising results from this trial warrant further large-scale studies to recommend a single oral dose of mefenamic acid to tackle needle pain related to vaccination in children to improve vaccine adherence and coverage.

TRIAL REGISTRATION

CTRI (Clinical trials registry-India) (CTRI/2021/01/030239). [Date of Commencement: 13 Jan 2021, Date of last recruitment: 30 June 2022 (now closed for new participants)].

Comparison of Sucrose vs. Swaddling in Pain Management during Birth Dose of Hepatitis B Vaccine: A Randomized Control Trial

OBJECTIVES

To evaluate the efficacy of pain management of 1 ml of 24% sucrose given orally compared to routine care given one minute before vaccination for reduction of pain.

METHODS

This double-blind randomized controlled trial included term neonates visiting Pediatric OPD for immunization. Neonates were randomly assigned into two groups (Group A- Sucrose, Group B- Swaddling). Commercially available sucrose solution (StayHappi solution 24%) was given in a dose of 1 ml to the neonates. Video recording of the neonate's facial expression was done during the procedure. Duration of cry, latency of onset of cry as well Modified Neonatal Facial Coding Score (MFCS) were the outcome variables.

RESULTS

The mean (SD) of birth weight and gestational age was 2729 (321.6) g and 38.24 (0.84) d, respectively. Analysis showed significant difference in total MFCS across the groups (P <0.001). Total MFCS was significantly lower in sucrose group [4.88 (1.07) vs. 7.17 (0.95)]. The duration of cry (in seconds) was also found to be significantly lower in sucrose group.

CONCLUSIONS

Administration of 1 ml 24% sucrose one minute prior to immunization is efficacious in pain management during injectable immunization.

The certified child life specialist: A novel resource in the pediatric primary care clinic for managing children's pain during routine immunizations

This study evaluated the effect of the Certified Child Life Specialist (CCLS) on pediatric pain and pain management during routine immunization administration in the pediatric primary care clinic. Children 4-12 years of age (n = 125) presenting for a well child physical examination at a rural primary care clinic were selected to receive standard nursing care or standard nursing care plus CCLS support during routine immunization administration. Patient reported pain was measured using the Faces Pain Scale-Revised (FPS-R), and patient behavioral responses were measured during immunization administration using the Children's Emotional Manifestation Scale (CEMS). The performance of psychosocial interventions and administration of topical pain-relieving interventions were measured between both groups. CCLS support was associated with fewer negative emotional behaviors during immunization administration among 7- to 12-year-old children and a significantly higher provision of psychosocial interventions and topical pain-relieving interventions among all ages. This study demonstrates that the presence of a CCLS can increase the provision of psychosocial and pain-relieving interventions and reduce distress during immunization administration in a busy pediatric primary care clinic.

Breastfeeding sick children in hospital: Exploring the experiences of mothers in UK paediatric wards

There is a paucity of literature exploring the challenges of breastfeeding sick children in hospital. Previous research has focused on single conditions and hospitals which limits understanding of the challenges in this population. Although evidence suggests that current lactation training in paediatrics is often inadequate, it is unclear where the specific training gaps are. This qualitative interview study of UK mothers aimed to explore the challenges of breastfeeding sick infants and children on a paediatric ward or paediatric intensive care unit. From 504 eligible respondents, a sample of 30 mothers of children aged 2-36 months with various conditions and demographic backgrounds was purposively chosen, and a reflexive thematic analysis undertaken. The study identified previously unreported impacts such as complex fluid needs, iatrogenic withdrawal, neurological irritability and changes to breastfeeding behaviour. Mothers described breastfeeding as emotionally and immunologically meaningful. There were many complex psychological challenges such as guilt, disempowerment, and trauma. Wider struggles such as staff resistance to bedsharing, inaccurate breastfeeding information, lack of food and inadequate breast pump provision made breastfeeding more challenging. There are numerous challenges related to breastfeeding and responsively parenting sick children in paediatrics, and these also impacted maternal mental health. Staff skill and knowledge gaps were widespread, and the clinical environment was not always conducive to supporting breastfeeding. This study highlights strengths in clinical care and provides insight into what measures are perceived as supportive by mothers. It also highlights areas for improvement, which may inform more nuanced paediatric breastfeeding standards and training.

Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

Translating evidence: pain treatment in newborns, infants, and toddlers during needle-related procedures

Introduction

Treatment of pain in preterm, sick, and healthy newborns and infants and toddlers (up to 2 years of age) is consistently reported to be inadequate, and effective strategies are poorly implemented.

Objectives

To present existing evidence of effective pain treatment strategies during needle-related procedures and to highlight initiatives focused on translating evidence into practice.

Methods

This Clinical Update focuses on the 2022 International Association for the Study of Pain Global Year for Translating Pain Knowledge to Practice in the specific population of newborns, infants, and toddlers. Best evidence is reviewed, and existing knowledge translation strategies and programs available to implement evidence into practice are presented.

Results

Effective strategies for newborn and young infants during frequently occurring needle procedures include small volumes of sweet solutions, breastfeeding, or skin-to-skin care when feasible and culturally acceptable. In addition, strategies such as nonnutritive sucking, positioning, swaddling, gentle touch, facilitated tucking, and secure holding can be used. For toddlers, the evidence is less robust, and discerning between pain and distress is challenging. However, strategies recommended for needle-related procedures include upright secure comfort holding by parents/caregivers, age-appropriate distraction, and topical anesthetics. Translation of effective pain management needs to involve the family, who need to be supported and empowered to comfort their child during painful procedures. Organizational, nationwide, and global initiatives aimed at improving implementation of effective pain treatments exist.

Conclusion

There is evidence of effective pain management strategies for newborns, infants, and toddlers, and a great deal of effort is being made to translate knowledge into action.

Secukinumab for the Treatment of Psoriasis in Pediatrics: Patient Selection and Acceptability

Psoriasis (PsO) is a chronic, systemic, immune-mediated inflammatory skin disease affecting 1% to 5% population worldwide. In one-third of patients, the first symptoms of PsO manifest in childhood, with a mean age of nine years. Psoriasis in children under 16 years of age constitutes 4% of dermatological problems in this age group. Chronic inflammation of the skin observed in PsO is associated with a development of potentially serious comorbidities, including psoriatic arthritis, hypertension, metabolic syndrome, cardiovascular diseases, inflammatory bowel disease, depression and anxiety. It is reported that among children with psoriasis between 5 and 16 years of age health-related quality of life is reduced by 30.5%. Early diagnosis and effective treatment are crucial in pediatric psoriatic patients to avoid future complications and stigmatization. Treatment for psoriasis consists of a range of topical medications, phototherapy and non-biologic and biologic systemic therapies. Approved biologics for PsO in pediatric patients include etanercept, adalimumab, ustekinumab, ixekizumab and secukinumab. Secukinumab, a recombinant, fully human monoclonal antibody targeting IL-17A, was approved by the EMA (2020) and FDA (2021) in pediatric patients above 6 years of age for the treatment of moderate to severe plaque psoriasis who are candidates for systemic therapy. This review discusses the selection and acceptability of secukinumab in children with psoriasis.

Appropriate procedures to increase the adherence of children to blood collection: A cross-sectional study

Background and Aim

Venipuncture for blood collection elicits fear and pain in children. We investigated factors that affect satisfaction with health checkups that included blood collection in healthy 7-8-year-old children who underwent blood collection with topical anesthesia.

Method

Two studies, one questionnaire survey, and the other structured interviews were conducted to gather insights and understand the emotions of 492 and 20 children, respectively.

Results

We found that the following six points can be applied to encourage children to assess their experience of blood collection positively: (1) prior information using a pamphlet; (2) telling the children that the volume of blood drawn will be small; (3) carefully explaining the risk and benefit of topical anesthesia; (4) conducting the blood collection process swiftly; (5) praising and thanking the children's effort and cooperation; and (6) explaining the results of the research to the children if their blood is going to be used for research.

Conclusion

The findings indicate that with appropriate measures to reduce pain and fear, children's initial negative feelings toward blood collection can be replaced by positive feelings after the procedure.

Effectiveness of parental education about pain in the neonatal period on knowledge, attitudes, and practices: A systematic review and meta-analysis

Background

Despite the availability of effective, safe, and feasible pain management strategies, infant pain remains undertreated. Parents can play a key role in advocating for or delivering pain management strategies if they are educated. To date, a quantitative synthesis of the effectiveness of parental education about pain management in the neonatal period has not been performed.

Objective

To systematically review the effectiveness of parental education during the neonatal period on pain management in infancy.

Methods

MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) and non-randomized trials (NRTs) that evaluated parental education with respect to pain management during the neonatal period in any setting from inception to February 2021. Screening of article titles and abstracts and data extraction were performed in duplicate. The risk of bias was assessed using the Cochrane Risk Bias Tool 2.0 and the Risk of Bias in Non-randomized Studies of Interventions for RCTs and NRTs, respectively. As per the GRADE methodology, critically important and important outcomes were identified. Critically important outcomes included utilization of pain management strategies and infant pain. Important outcomes included parental knowledge about pain mitigation strategies, parental attitudes, compliance with painful procedures, procedure outcomes, and safety. Data were combined and presented as relative risk (RR) or mean or standardized mean difference (MD or SMD) with 95% confidence interval (CI).

Results

Of the six studies eligible for inclusion, four studies were RCTs and two studies were NRTs. Written information and/or video were used to deliver parental education during the neonatal period in hospital settings in all studies. Four studies (two RCTs and two NRTs) reported on critically important outcomes. The risk of bias was low for the two RCTs and moderate to serious for the two NRTs. Utilization of pain management strategies was assessed for heel lance in the first 48 hours of life in two studies and for vaccine injection at 2 to 6 months of life in two studies. Higher utilization rate for pain management strategies was reported in the pain education group in three studies (RR 1.15, 95% CI 1.04, 1.26; N=2712). There was no difference in the mean number of pain management strategies used in one NRT tracking utilization tracking utilization as continuous data (MD 0.20, 95% CI -0.01, 0.41; N=178). Parent-reported infant pain scores were lower in the pain education group in one RCT (MD -0.16, 95% CI -0.27, -0.06; N=1615). The quality of evidence for the outcome of utilization of pain management strategies was very low while for the outcome of infant pain the quality of evidence was moderate. Five studies (3 RCTs and 2 NRTs) reported on important outcomes. The risk of bias was low for two RCTs and high for one RCT and moderate to serious for the two NRTs. Parental knowledge about pain management strategies (SMD 0.54, 95% CI 0.26, 0.82), parental confidence in their ability to manage pain (SMD 0.24, 95% CI 0.14, 0.34), parental satisfaction with education (MD 1.18, 95% CI 0.84, 1.52) and parental satisfaction with pain management (RR 1.05. 95% CI 1.01, 1.08) were increased in the pain education group. None of the included studies reported on procedural outcomes. No adverse events with the pain education nor the use of pain management interventions were reported in one study.

Conclusions

Parental education in the neonatal period was effective in increasing utilization of pain management strategies during painful procedures. Reduction of pain in infants is based on one study of moderate quality. Furthermore, parental education increased parental knowledge about pain management strategies, confidence in their ability to manage infant pain, and satisfaction with the education and pain management. Parental pain education should be incorporated into postnatal care.

The Effects of Breastfeeding and Breast Milk Taste or Smell on Mitigating Painful Procedures in Newborns: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Newborns hospitalized in the neonatal intensive care unit are exposed to an average of 10 painful procedures per day. The pain-related experiences of babies can be associated with neurodevelopmental disorders that may affect them throughout their lives. Aim/Objective: The purpose of this study was to summarize and analyze the analgesic effects of breastfeeding alone, expressed breast milk, and breast milk smell on newborns and present stronger evidence that would guide clinical practice and future studies. Methods: We searched articles published between 2000 and 2021 on the CINAHL, Cochrane Central, Web of Science, PubMed, Scopus, Science Direct, Eric, and OVID databases. Nine full texts that met the inclusion criteria (Population: Newborn term or preterm babies, Intervention: Implementing breastfeeding, expressed breast milk, breast milk taste, or breast milk smell alone or in combinations in the intervention groups, Comparison: Making comparisons to the standard care of the clinic where the study was conducted, Outcomes: Including at least one pain-related criterion, Study design: Randomized-controlled trials) were included in this systematic review and meta-analysis. The nine randomized controlled studies in total that were included in this study were carried out between 2004 and 2021 with 33-130 newborns in their samples. The total number of newborns was 720. The effects of these interventions on pain scale scores, heart rate, and oxygen saturation were also analyzed. Results: According to the results of this systematic review and meta-analysis, the breastfeeding, breast milk smell, or breast milk taste interventions had large effect sizes in terms of pain management during and after the procedures. These interventions had medium effect sizes in terms of heart rate during the procedures and large effect sizes after the procedures. In terms of oxygen saturation, they had large effect sizes during the procedures and medium effect sizes after the procedures. Conclusion: Breastfeeding and breast milk interventions are significantly effective nonpharmacological alternatives for painful procedures.

Effect of using vacutainers with cartoon characters on the pain and fear levels of preschoolers during bloodletting

AIM

Our study aims to analyse the effect of using a vacutainer with cartoon characters on preschoolers' pain and fear levels during the bloodletting process.

METHODS

The experimental, randomised controlled clinical trial was conducted with 102 children aged 3-6 years, randomised into control and experimental groups. The bloodletting routine was applied to the control group. The vacutainer of each child in the experimental group was covered with the illustration of their chosen cartoon character and blood was drawn with it. The fear and pain levels during the bloodletting procedure were examined in both groups.

RESULTS

Pain and fear levels were significantly lower in the experimental group than in the experimental group (P < 0.05).

CONCLUSIONS

Our research highlighted that using a cartoon character sticker with a vacutainer can reduce preschoolers' pain and fear during bloodletting.

Using art to raise awareness of breastfed children with medical complexity

Background

Current infant feeding support is often targeted at establishing breastfeeding in healthy term infants, or supporting lactation for preterm infants in the neonatal setting. Breastfeeding presents different challenges for children beyond the neonatal period who have a medical complexity. The tendency to focus on breastfeeding as a preventative public health intervention overlooks the fact that mothers and children with medical complexity often require additional and targeted support to continue to breastfeed. Despite this identified need, there is very little research, policy or clinically specific teaching within paediatrics that is nuanced enough to support this vulnerable population.

Raising awareness of breastfed children with medical complexity in paediatrics

While research, policy and embedded Baby Friendly Health Initiative (BFHI) standards in both the maternity and neonatal directorates exists, paediatrics is a separate discipline and contrastingly, has very little lactation support infrastructure. To this end, a doctoral study was commenced aiming to identify the differences for this vulnerable and largely overlooked group. One of the related outputs of the ongoing research is the use of creative methods to raise awareness. This commentary highlights a project with an artist to develop a series of portraits alongside a book and health professional education to increase awareness of these children’s needs.

Conclusions

The breastfeeding needs and challenges of children in the paediatric setting are unique and require additional awareness, creativity and skills to support optimal infant and young child breastfeeding. Using art can connect professionals to the lived experiences of families trying to persevere through medical complexity.

Efficacy and safety of combined oral sucrose and nonnutritive sucking in pain management for infants: A systematic review and meta-analysis

Background

Pain management is currently important in neonatal intensive care unit (NICU). The superiority in pain relief of the combined oral sucrose (OS) and nonnutritive sucking (NNS) to other single intervention has not been well established. The administration of sucrose has been considered to potentially induce adverse events, which has been controversial. This study aims to investigate the combined effects and safety in comparison with other single intervention methods, including NNS, OS alone, breast milk and oral glucose.

Methods

We searched databases including Medline (via Pubmed), Embase (via Ovid), web of science, and Cochrane Library for randomized controlled trials from Jan 1, 2000 to Mar 31, 2021. The data were analyzed in the meta-analysis using Review manager Version 5.3. Pain score was the primary outcome in this meta-analysis. The adverse events were assessed qualitatively.

Results

A total of 16 studies were eligible in the meta-analysis. The results demonstrated a significant reduction in pain score in the NNS+OS group compared with NNS alone (SMD = -1.69, 95%CI, -1.69,-0.65) or sucrose alone (SMD = -1.39, 95% CI, -2.21,-0.57) during the painful procedures. When compared NNS+OS with breast milk, no significant difference was detected (SMD = -0.19, 95% CI: -0.5, 0.11).

Conclusion

The combined effects of NNS and OS might be superior to other single intervention method. However, the effects might be mild for moderate-to-severe pain.

Influenza Vaccine Hesitancy and Its Determinants Among Rheumatology Patients

Objective

Patients with rheumatic disease (RD) have an increased risk of influenza and its complications. Despite inactivated influenza vaccine (IIV) recommendations, IIV uptake in patients with RD is suboptimal, a problem of increasing importance in the COVID‐19 era. We estimated the frequency of IIV hesitancy and associated factors among Canadian patients with RD.

Methods

A cross‐sectional vaccine hesitancy survey was completed by rheumatology clinic patients (November 2019 to January 2020). Patients rated their likelihood of receiving the influenza vaccine (scale of 0‐10). We categorized these as follows: likely to refuse (scale of 0‐2), uncertain (scale of 3‐7), or likely to accept (scale of 8‐10). Multivariate logistical regression was used to evaluate factors associated with vaccine hesitancy.

Results

A total of 282 patients (63.5% of those approached) completed the survey, with 165 (58.5%) being likely to accept, 67 (23.8%) being likely to refuse, and 50 (17.7%) uncertain. Uncertain patients were younger and more likely to be employed than those in the other two groups. No previous influenza vaccination (odds ratio [OR] 36.6, 95% confidence interval [CI] 5.3‐252.9), belief that vaccination should not be mandatory (OR 0.1, 95% CI 0.0‐0.7), unwillingness to take time off work to be vaccinated (OR 6.8, 95% CI 1.5‐30.6), and distrust in pharmaceutical companies (OR 41.0, 95% CI 5.6‐301.5) predicted likeliness to refuse. Reluctance to pay for vaccination (OR 2.8, 95% CI 1.1‐7.5) and no previous influenza vaccination (OR 18.9, 95% CI 3.3‐109.7) predicted uncertainty.

Conclusion

More than 40% of rheumatology patients are either likely to refuse or uncertain about receiving IIV. This contributes to suboptimal vaccine coverage in this population. Interventions addressing these concerns are needed, particularly in the COVID‐19 era.

Novel strategies to oral delivery of insulin: Current progress of nanocarriers for diabetes management

Diabetes mellitus is one of the most serious public health problems in the world. Repeated daily injections of subcutaneous insulin is the standard treatment for patients with type 1 diabetes mellitus; however, subcutaneous insulin injections can potentially cause local discomfort, patient noncompliance, hypoglycemia, failure to regulate glucose homeostasis, infections, and fat deposits at the injection sites. In recent years, numerous attempts have been made to produce safe and efficient nanoparticles for oral insulin delivery. Oral administration is considered the most effective alternative route to insulin injection, but it is accompanied by several challenges related to enzymatic proteolysis, digestive breakdown, and absorption barriers. A number of natural and synthetic polymeric, lipid-based, and inorganic nanoparticles have been investigated for use. Although improvements have recently been made in potential oral insulin delivery systems, these require further investigation before clinical trials are conducted. In this review, new approaches to oral insulin delivery for diabetes treatment are discussed, including polymeric, lipid-based, and inorganic nanoparticles, as well as the clinical trials performed for this purpose.

Be Sweet to Hospitalized Toddlers During Venipuncture: A Randomized Controlled Trial of Sucrose Compared With Water

OBJECTIVES

High-quality evidence demonstrates analgesic effects of sweet-tasting solutions for infants during painful procedures. However, evidence of the analgesic effects of sucrose beyond 12 months of age is less certain. The aim of this study was to ascertain the efficacy of oral sucrose in hospitalized toddlers (ages 12 to 36 mo) compared with placebo (water) during venipuncture.

MATERIALS AND METHODS

Blinded, 2-armed randomized controlled trial including hospitalized toddlers aged 12 to 36 months. Toddlers were randomized to either 25% sucrose or water before venipuncture, stratified by age (12 to 24 mo and more than 24 to 36 mo). Standard of care included topical anesthetics for both groups. Pain assessment included cry duration and FLACC (Face, Legs, Activity, Cry, Consolability) scores. Descriptive statistics and linear models were used to report the percentage of time crying and mean differences in FLACC scores. Data analysis was performed using R, version 3.6.3.

RESULTS

A total of 95 toddlers were randomized and 85 subsequently studied. The median percentage of time spent crying between insertion of the first needle and 30 seconds after the end of procedure in both groups was 81% (interquartile range=66%). There was no significant difference in crying time and FLACC scores between groups (P>0.05). When examining effects of sucrose for the younger toddlers (less than 24 mo of age) there was a reduction in crying time of 10% and a 1.2-point reduction in mean FLACC scores compared with the toddlers older than 24 months.

DISCUSSION

Findings highlight that toddlers become highly distressed during venipuncture, despite the standard care of topical anesthetics. In addition, sucrose does not effectively reduce distress especially in the older group of toddlers.

The prevalence and evidence-based management of needle fear in adults with chronic disease: A scoping review

Background

Little is known about the prevalence and best management of needle fear in adults with chronic disease, who may experience frequent and long-term exposure to needles for lifesaving therapies such as renal dialysis and cancer treatment. Identifying interventions that assist in management of needle fear and associated distress is essential to support these patients with repeated needle and cannula exposure.

Method

We followed the PRISMA methodology for scoping reviews and systematically searched PsychINFO, PubMed (MEDLINE), ProQuest, Embase and grey literature and reference lists between 1989 and October 2020 for articles related to needle discomfort, distress, anxiety, fear or phobia. The following chronic diseases were included: arthritis, asthma, chronic back pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental illness, or kidney failure. Literature concerning dentistry, vaccination, intravenous drug users and paediatric populations were excluded.

Results

We identified 32 papers reporting prevalence (n = 24), management (n = 5) or both (n = 3). Needle fear prevalence varied in disease cohorts: 17–52% (cancer), 25–47% (chronic kidney disease) and 0.2–80% (diabetes). Assessment methods varied across studies. Management strategies had poor evidence-base, but included needle-specific education, decorated devices, cognitive-behavioural stress management techniques, distraction, and changing the therapy environment or modality.

Conclusion

Although needle fear is common there is a paucity of evidence regarding interventions to address it among adults living with chronic disease. This scoping review has highlighted the need for improved identification of needle fear in adults and development of interventions are required for these cohorts.

Infovac-France survey in pediatric vaccinology: How does it compare with the literature?

BACKGROUND

Immunization is experienced as painful and may be responsible for needle fear and noncompliance. There are rare evidence-based methods to reduce pain and improve comfort during immunization. There are no French immunization guidelines summarizing the good practices, based on recent studies. This study focused on the methods used by physicians and how they compared with those validated by clinical trials.

METHODS

An online questionnaire was sent to the practitioners from the Infovac network, and a PubMed bibliographic search was conducted.

RESULTS

Almost 2000 doctors responded to this survey. Purging the needle was a habit in 77.9% of them and aspiration before injection in 21.1%. Only one-quarter of the responding doctors injected in the deltoid muscle between 15 and 24 months, and some injected in the buttocks at any age. Half of the physicians vaccinated infants in their parent's arms, children were seated with half of the pediatricians and only one-third of the general practitioners (GPs), and teenagers were seated when vaccinated by three-quarters of the doctors. Anesthetic creams were used by 46.6% of the physicians, mostly by pediatricians (61.9%), and for infants. Breastfeeding was suggested by three-quarters of the physicians for infants under 4 months of age, and sugared solutions were used by 55.5% of the pediatricians and 32.3% of the GPs. Half of the doctors used rocking and cuddling for babies under 24 months of age and toys between 11 and 24 months.

CONCLUSION

Many methods are available to distract and improve comfort during immunization. Physicians should choose those they prefer, adjusting for the child's age. There should be French guidelines for immunization techniques, based to the latest clinical surveys, to help improve immunization practice.

The effect of intramuscular injection technique on injection associated pain; a systematic review and meta-analysis

AIM

To review the effect of different intramuscular injection (IMI) techniques on injection associated pain, in adults.

METHODS

The review protocol was registered on PROSPERO (CRD42019136097). MEDLINE, EMBASE, British Nursing Index and CINAHL were searched up to June 2020. Included studies were appraised and a meta-analysis, where appropriate, was conducted with a random effects model and test for heterogeneity. Standardised mean difference (SMD) with a 95% confidence interval in reported injection pain (intervention cf. control) was reported.

RESULTS

29 studies were included in the systematic review and 20 studies in the meta-analysis. 13 IMI techniques were identified. 10 studies applied local pressure to the injection site. Of these, applying manual pressure (4 studies, SMD = -0.85[-1.36,-0.33]) and Helfer (rhythmic) tapping (3 studies, SMD = -2.95[-5.51,-0.39]) to the injection site reduced injection pain, whereas the use of a plastic device to apply local pressure to the skin (ShotBlocker) did not significantly reduce pain (2 studies, SMD = -0.51[-1.58,0.56]). Acupressure techniques which mostly involved applying sustained pressure followed by intermittent pressure (tapping) to acupressure points local to the injection site reduced pain (4 studies: SMD = -1.62[-2.80,-0.44]), as did injections to the ventrogluteal site compared to the dorsogluteal site (2 studies, SMD = -0.43[-0.81,-0.06]). There was insufficient evidence on the benefits of the 'Z track technique' (2 studies, SMD = -0.20[-0.41,0.01]) and the cold needle technique (2 studies, SMD = -0.73[-1.83,0.37]) on injection pain. The effect of changing the needle after drawing up the injectate on injection pain was conflicting and warming the injectate did not reduce pain. Limitations included considerable heterogeneity, poor reporting of randomisation, and possible bias in outcome measures from unblinding of assessors or participants.

CONCLUSIONS

Manual pressure or rhythmic tapping over the injection site and applying local pressure around the injection site reduced IMI pain. However, there was very high unexplained heterogeneity between studies and risk of significant bias within small studies.

Children's Pain During IV Induction: A Randomized-Controlled Trial With the MEDi® Robot

OBJECTIVE

This study examined the impact of a humanoid robot (MEDi®) programmed to teach deep breathing as a coping strategy, on children's pain and fear as primary and secondary outcomes, respectively, during intravenous (IV) line placement. The completion of IV induction was also examined as an exploratory outcome.

METHODS

In this randomized controlled, two-armed trial, 137 children (4-12 years) were recruited in Short Stay Surgery at a tertiary pediatric hospital. Patients were randomly assigned to standard care (SC) with Ametop© only (N = 60) or SC and robot-facilitated intervention (N = 59) before induction. Pain and fear before, during, and after IV insertion were rated by patients and observers.

RESULTS

No significant differences were found between groups and there were no changes over time for pain or fear (ps > .05). Exploratory analyses show that patients in the MEDi® group were 5.04 times more likely to complete IV induction, compared to SC, Fisher's exact test: X2 (1) = 4.85, p = .04, φc = 0.22, odds ratio = 5.04, 95% CI [1.06, 24.00].

CONCLUSION

This study was the first to examine children's IV induction experience when provided MEDi® support. Reasons for nonsignificance, limitations, and research suggestions were made.

The effectiveness of vibratory stimulation in reducing pain in children receiving vaccine injection: A randomized controlled trial

BACKGROUND

Although vaccine injections are important, children experience pain and discomfort upon their administration. BUZZY®, a vibratory stimulation tool with an ice pack, was reported to be an effective tool for reducing the pain caused to children during injection administration; its mechanisms were explained by gate control theory. However, the evidence is inadequate because of insufficient methodology in previous reports. Therefore, we aimed to assess whether the application of vibration would significantly reduce children's pain during vaccine injections.

METHODS

A single-blind randomized controlled trial recruiting children aged ≤6 years who were receiving vaccine injections was conducted between August and December 2019. If the children's parents consented to their participation, BUZZY® was attached to the child's arm prior to vaccination. BUZZY® was switched on before injection in the intervention group but not in the control group. The vaccination procedure was recorded, and researchers and parents assessed each child's pain using validated pain scales. Researchers conducted their assessment using video data to ensure blinding. Parents were administered a questionnaire after the children's vaccination. Data were analyzed using the t-test or chi-square test.

RESULTS

We analyzed 118 children (intervention group = 62, control = 56). No between-group difference was observed according to the researchers' assessment (mean score = 6.98 and 7.63, respectively; p = 0.25); however, a significant difference was found based on the parents' assessment (mean score = 7.39 versus 8.46; p = 0.02). Most responses received to open-ended questions were positive comments for this study.

CONCLUSIONS

We revealed that the effect of vibration is not significant in reducing vaccine injection pain among children. Further studies are needed to examine the other components of BUZZY®, which include its cooling effect, and the effect of BUZZY® itself in terms of whether children will undergo vaccination without resistance and have reduced trauma related to vaccination.

Nonpharmacological Methods for Reducing Parental Concern for Infant Vaccine-Associated Pain

INTRODUCTION

Numerous studies demonstrate that parental concern for infant pain contributes to vaccine hesitancy. The purpose of this project was to alleviate parental concern for pain and facilitate infant immunization.

METHOD

Pediatric nurses at an urban ambulatory clinic implemented evidence-based nonpharmacological methods (breastfeeding or 24% sucrose solution) for managing vaccine pain in infants aged up to 6 months. A validated survey measured parental concern for vaccine-related pain before and after the implementation of pain relief interventions.

RESULTS

There was a statistically significant decrease in parental concern for vaccine pain from pre- to postintervention between both treatment groups (p = .035).

DISCUSSION

Nurses can effectively use nonpharmacological methods to alleviate the pain of infants undergoing routine vaccination while reducing the parental concern for vaccine-associated pain. Reducing infant pain and parental concern may increase vaccination rates.

The feasibility, acceptability and preliminary efficacy of parent-targeted interventions in vaccination pain management of infants: a pilot randomized control trial (RCT)

Aim: To evaluate the feasibility, acceptability and preliminary efficacy of parent interventions for improving the use of pain management strategies during vaccination of infants, a two-armed pilot randomized control trial (RCT) was conducted. Materials & methods: 151 parents were randomized in two groups: Group 1) 'Be Sweet to Babies' videos and a tip sheet (n = 76); Group 2) As per Group 1 plus a motivational interviewing informed Affirmative Statements and Questions (AS&Q) (n = 75). Results & conclusion: Feasibility was evaluated by success of the recruitment (151 people in a week), rates of completed consent forms (85%), and surveys (59%). Over 94% satisfaction with interventions, processes and 88% intention to recommend the strategies to others determined the acceptability. Preliminary efficacy was evident by over 95% use of pain management strategies following the interventions. Clinical trial registration number: NCT03968432.

Safety of Single-Dose Oral Cefixime, Intramuscular Ceftriaxone, or Intramuscular Gentamicin for the Treatment of Gonorrhea: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the incidence and types of adverse effects between 3 recommended treatment options for gonorrhea and to compare the incidence of injection site pain between single-dose intramuscular ceftriaxone and gentamicin.

DATA SOURCES

A keyword search of MEDLINE (1966 to September 2020), EMBASE (1947 to September 2020), and International Pharmaceutical Abstracts (1970 to September 2020) was conducted. The electronic search was supplemented with manual screening of references.

STUDY SELECTION AND DATA EXTRACTION

Comparator studies reporting adverse effect outcomes of treatment with cefixime, ceftriaxone, or gentamicin for gonorrhea in humans were included. Data extracted included study year, authors, aim, setting, population, dosing protocols, and outcome results.

DATA SYNTHESIS

A total of 298 articles were identified, of which 6 met inclusion criteria. Two randomized controlled trials compared ceftriaxone and gentamicin. Four randomized controlled trials compared cefixime and ceftriaxone. No differences were noted for the occurrence of at least 1 adverse effect between gentamicin and ceftriaxone (odds ratio [OR] = 0.81; 95% CI = 0.56-1.18) or between cefixime and ceftriaxone (OR = 1.11; 95% CI = 0.21-5.93). Injection site pain (ceftriaxone and gentamicin) and other adverse effects (all drugs) were common but occurred at similar rates between groups.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Results of this review show a lack of signal for safety concerns with gentamicin-based regimens for the treatment of gonorrhea. Future research should investigate patient acceptability, especially for intramuscular injections.

CONCLUSIONS

The use of single-dose cefixime, ceftriaxone, and gentamicin-based regimens for treatment of gonorrhea appears to be safe and acceptable for use in practice.

Barriers and Facilitators to Effective Procedural Pain Treatments for Pediatric Patients in the Chinese Context: A Qualitative Descriptive Study

PURPOSE

To explore nurse and physician leaders' perceptions of barriers and facilitators to using evidence-based procedural pain treatments (i.e., sweet solutions, breastfeeding, and topical anesthetics) for hospitalized infants and children in the Chinese context.

DESIGN AND METHODS

A descriptive qualitative study was conducted at three pediatric inpatient surgical units in one hospital in China. Purposive sampling was used to recruit nurse/physician leaders who were engaged in the clinical management of the 3 units. Data collection included a focus group and individual interviews. The Consolidated Framework for Implementation Research (CFIR) was used to guide the analysis of the data.

RESULTS

Ten participants attended the focus group and 13 took part in individual interviews. The findings highlight 41 implementation determinants, including two neutral influencing factors, 22 barriers, and 17 facilitators. These influencing factors aligned with the four CFIR domains and 25 of the 29 CFIR constructs. Common barriers to using evidence-based pain treatments across different contexts were identified, such as health care professionals' limited knowledge and misconceptions on pediatric pain management, no specific policies, low priority, heavy workload, staff shortage, and limited time. Unique determinants in the Chinese context were also identified, including parents' concerns of these new interventions, parent wrath, hierarchical managerial system, and lower authority of nurses.

CONCLUSIONS

Multiple barriers as well as facilitators to using evidence-based pain management strategies were identified.

PRACTICE IMPLICATIONS

The findings inform further development of implementation strategies and could be used as baseline data for comparing the barriers and facilitators evaluated during and after implementation.

Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline

BACKGROUND

Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.

METHODS

Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.

RESULTS

The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.

CONCLUSION

In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.

The Effect of Skin-to-Skin Contact on Maternal Anxiety, Heart Rate, and Oxygen Saturation during the Vaccination of One-Month-Old Infants

This study aimed to reduce maternal anxiety scores and heart rates, increase oxygen saturation linked to vaccination processes with Skin-to skin contact (SSC). The study is a prospective, multicenter, paired, randomized, controlled trial. This experimental study was conducted with a pretest-posttest control group. The study was carried out with 128 mothers of infants. A Sociodemographic Questionnaire, the State Anxiety Inventory and a pulse oximeter were used in the data collection. In the study, SSC began to be given to the infants in the intervention group five minutes before vaccination and the infant was left in SSC for an uninterrupted 15 minutes following the vaccination. The maternal anxiety scores were noted before and after the vaccination process. The mothers' heart rates and oxygen saturation were monitored a total of three times. The anxiety scores of the intervention group decreased while oxygen saturation increased after the vaccination as compared to the control group. The heart rate decreased in the intervention group but increased in the control group. The study revealed that SSC reduced scores of maternal anxiety and heart rates and increased oxygen saturation during the vaccination process.

Narcotic-Sparing Approaches and the Shift Toward Paracetamol in Neonatal Intensive Care

Effective analgesia in neonates is relevant not only because of ethical aspects or empathy, but it is a crucial and integral part of medical and nursing care. However, there is also emerging evidence - although mainly in animal models - on the relation between the exposure to narcotics and impaired neurodevelopmental outcome, resulting in a CATCH-22 scenario. Consequently, a balanced approach is needed with the overarching intention to attain adequate pain management with minimal side effects. Despite the available evidence-based guidance on narcotics in ventilated neonates, observations on drug utilization still suggest an overall increase in exposure with extensive variability between units. This increased exposure over time and the extensive variability is concerning given the limited evidence of benefits and potential harm.Implementation strategies are effective to reduce exposure to narcotics but result in increased paracetamol exposure. We therefore summarized the evidence on paracetamol use in procedural pain management, in minor to moderate as well as major pain syndromes in neonates. While there are sufficient data on short-term safety, there are still concerns on long-term side effects. These concerns relate to neurobehavioral outcome, atopy or fertility, and are at present mainly driven by epidemiological perinatal observations, together with postulated mechanisms.We conclude that future clinical research objectives should still focus on the need to develop better assessment tools to quantify pain and on the need for high-quality data on long-term outcome of therapeutic interventions - also for paracetamol - and exploration of the mechanisms involved.

A Critical Review on the Relevance of Paracetamol for Procedural Pain Management in Neonates

Effective and safe pain relief in neonates matters. This is not only because of ethical constraints or human empathy, but even more because pain treatment is an important and crucial part of contemporary medical, paramedical, and nursing care to improve the outcome in neonatal intensive care graduates. Paracetamol (acetaminophen) is likely one of the pharmacological tools to attain this, with data on prescription practices suggesting that paracetamol is somehow the "rising star" in neonatal pain management. Besides very rare topical clinical scenarios like peripartal asphyxia and subsequent whole body hypothermia or the use of cardiorespiratory support devices, data on paracetamol pharmacokinetics and metabolism were reported throughout neonatal age or weight ranges, and we have summarized these data. In this review, we subsequently aimed to provide the reader with the currently available observations on the use of paracetamol as analgesic for different pain syndromes (major surgery, minor surgery or trauma, and procedural pain), with focus on the limitations of paracetamol when prescribed for neonatal procedural pain management. We hereby intentionally will not discuss other indications (patent ductus arteriosus and fever) for paracetamol administration in neonates. Based on the available evidence, paracetamol has opioid-sparing effects for major pain syndromes, is effective to treat minor to moderate pain syndromes, but fails for effective procedural pain management in neonates. This efficacy failure for procedural pain management should stimulate us to continue to search for more effective interventions, including non-pharmacological interventions and preventive strategies. Furthermore, there are also upcoming association type of epidemiological studies on the relation between exposure to analgesics-including paracetamol-and the negative short- or long-term outcome characteristics (neuro-behavioral, atopy, and fertility). Consequently and in addition to the search for effective alternatives to prevent or treat pain, studies on long-term outcome following paracetamol exposure are needed to inform all stakeholders on the full effect-side effect balance of the different strategies to treat pain.

La gestion de la douleur et de l’anxiété chez les enfants lors de brèves interventions diagnostiques et thérapeutiques

Les interventions médicales courantes utilisées pour évaluer et traiter les patients peuvent causer une douleur et une anxiété marquées. Les cliniciens devraient adopter une approche de base pour limiter la douleur et l’anxiété chez les enfants, notamment à l’égard des interventions diagnostiques et thérapeutiques fréquentes. Le présent document de principes est axé sur les nourrissons, les enfants et les adolescents qui subissent des interventions médicales courantes mineures, mais douloureuses. Il n’aborde pas les soins prodigués à l’unité de soins intensifs néonatale. Les auteurs examinent des stratégies simples et fondées sur des données probantes pour gérer la douleur et l’anxiété et donnent des conseils pour en faire un volet essentiel de la pratique clinique. Les professionnels de la santé sont invités à utiliser des façons de procéder peu invasives et, lorsque les interventions douloureuses sont inévitables, à combiner des stratégies simples de réduction de la douleur et de l’anxiété pour améliorer l’expérience du patient, du parent et du professionnel de la santé. Les administrateurs de la santé sont encouragés à créer des politiques pour leurs établissements, à améliorer la formation et l’accès aux lignes directrices, à créer des environnements propices aux enfants et aux adolescents, à s’assurer de la disponibilité du personnel, de l’équipement et des agents pharmacologiques appropriés et à effectuer des contrôles de qualité pour garantir une gestion de la douleur optimale.

Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures

Common medical procedures to assess and treat patients can cause significant pain and distress. Clinicians should have a basic approach for minimizing pain and distress in children, particularly for frequently used diagnostic and therapeutic procedures. This statement focuses on infants (excluding care provided in the NICU), children, and youth who are undergoing common, minor but painful medical procedures. Simple, evidence-based strategies for managing pain and distress are reviewed, with guidance for integrating them into clinical practice as an essential part of health care. Health professionals are encouraged to use minimally invasive approaches and, when painful procedures are unavoidable, to combine simple pain and distress-minimizing strategies to improve the patient, parent, and health care provider experience. Health administrators are encouraged to create institutional policies, improve education and access to guidelines, create child- and youth-friendly environments, ensure availability of appropriate staff, equipment and pharmacological agents, and perform quality audits to ensure pain management is optimal.

Non-pharmacological pain management in the neonatal intensive care unit: Managing neonatal pain without drugs

Premature infants hospitalized after birth are exposed to repeated painful procedures as part of their routine medical care. Early neonatal exposure to unmanaged pain has been linked to numerous negative long-term outcomes, such as the development of pain hypersensitivity, detrimental psychological symptomology, and altered neurodevelopment. These findings emphasize the crucial role of pain management in neonatal care. The aim of this article is to give an overview of evidence-based non-pharmacological pain management techniques for hospitalized neonates. Research supporting the effectiveness of various proximal, distal, and procedural pain management methods in neonates will be presented. Additionally, understanding the larger biopsychosocial context of the infant that underpins the mechanisms of these pain management methods is essential. Therefore, two important models that inform non-pharmacological approaches to infant pain management (DIAPR-R [The Development of Infant Acute Pain Responding-Revised], Attachment Theory) will be discussed.

Immunization-Associated Pain: Taking Research to the Bedside

BACKGROUND

Immunization-associated pain is the number one cause of pain in pediatric settings. Untreated pain has many short- and long-term detrimental effects. The purpose of this project was to implement a nonpharmaceutical immunization-associated-pain prevention program.

METHOD

This project was implemented at a pediatric primary care clinic. Staff were educated about immunization-associated pain and techniques for decreasing/preventing pain. Families were educated about pain control, and the practitioner and parent/child picked interventions to decrease pain. Preimplementation and postimplementation data were collected using previously validated pain and satisfaction scales.

RESULTS

Pain prevention interventions decreased pain for children between 2 months and 7 years of age by 4.7 points on a Faces, Legs, Activity, Cry, Consolability (i.e., FLACC) scale. For children 7 years and older, pain during immunization decreased on average by 1.76 points on the visual analog scale.

CONCLUSION

Non-pharmaceutical interventions are effective in decreasing immunization-associated pain.

Mothers' Perceptions about Pain in Hospitalized Newborn Infants in Kenya

PURPOSE

Explore views of mothers about pain and pain treatment practices in hospitalized newborn infants.

DESIGN AND METHODS

A Qualitative descriptive study using photo-elicitation technique was conducted in a level I and a level II neonatal units in Kenya. Fifteen semi-structured interviews were conducted with mothers of hospitalized infants. The interviews were audio-recorded, transcribed verbatim and analysed using inductive content analysis approach.

RESULTS

Mothers described the experience of witnessing their infants undergo painful procedures as emotionally and psychologically traumatic. Participants felt helpless for not being able to protect their infants from pain a situation which was made worse by health care providers who appeared less concerned about pain relief during procedures. Mothers' views demonstrated a good understanding of pain-relief strategies; they identified strategies that health care providers should routinely use to relief pain in hospitalized infants. Furthermore, participants desired to be involved in comforting their infants during clinical procedures.

CONCLUSION

Repeated and untreated painful procedures continue to define the hospitalisation experience of newborn infants despite the presence of mothers who desire to be involved in comforting their infants during procedures.

PRACTICE IMPLICATION

Minimizing the burden of pain and using pain-relieving interventions could reduce parental stress and optimize parental role attainment following hospitalisation.

Acute pain responses in dairy calves undergoing cornual nerve blocks with or without topical anesthetic

Dairy calves are routinely administered medicines, vaccines, and anesthesia via injection. Although injections are painful, little is known about methods to alleviate this pain. The aim of this study was to determine whether lidocaine-prilocaine cream, a topical anesthetic, reduced calves' pain response to a subcutaneous injection around the cornual nerve. Calves were assigned 1 of 2 treatments: lidocaine-prilocaine cream at the sites of injection (n = 10) or no cream (n = 9). Thirty minutes after treatment, calves received a subcutaneous injection of 2% buffered lidocaine hydrochloride around the left and right cornual nerves. Contrary to our hypothesis, calves that received anesthetic cream beforehand displayed more escape behaviors during the injections than control calves. Both treatments had similarly low amounts of head-related behaviors afterward. Maximum eye temperature did not differ between the calves that received anesthetic cream and control calves, although eye temperature increased over time for both treatments. Heart rate increased during the 30 s following the first injection in both treatments. There were no treatment differences for any heart rate measures over the 5-min period after the first injection (mean heart rate, root mean square of successive differences, high-frequency power, and the ratio of low-frequency power to high-frequency power). These results suggest that cornual nerve blocks with buffered lidocaine are painful and that a lidocaine-prilocaine cream was not only ineffective in reducing this pain but that it may also worsen it.

Effects of Vapocoolant Spray Prior to SC LMWH Injection: An Experimental Study

The aim of this study was to evaluate the effects of vapocoolant spray administration prior to subcutaneous (SC) low molecular weight heparin injection on local ecchymosis, hematoma, and pain. This randomized controlled study was carried out on 64 patients (n = 128 injections) in an orthopedics and traumatology clinic. After randomization, vapocoolant spray and then heparin injection was applied on one arm. The second necessary dose of heparin was applied to his or her other arm as a placebo by a water spray. Then, the pain of the patients was assessed. After 2 days, ecchymosis and hematoma were evaluated. Significant lower pain scores were determined in applications in which the vapocoolant spray was used. There was no statically significant difference between the mean diameter values of ecchymosis in both arm groups. There was no hematoma on the injection site after injections. However, this method did not create any significant reductive effect on ecchymosis. Nurses are advised to take advantage of vapocoolant spray effects prior to SC heparin injection.

Development of an Intervention to Reduce Pain and Prevent Syncope Related to Adolescent Vaccination

INTRODUCTION

There is a lack of research into the perspectives of patients, parents, and clinicians regarding strategies for vaccine-related pain and syncope prevention that may improve the adolescent vaccination experience and encourage future vaccination.

OBJECTIVE

To develop an intervention on the basis of preference for strategies to reduce pain and prevent syncope associated with adolescent vaccination.

METHODS

We conducted focus groups and interviews with 8 recently vaccinated Kaiser Permanente Northwest (KPNW) members aged 11 to 17 years and their parents to explore perceptions of pain and syncope after vaccination as well as receptivity to potential interventions. Additionally, we interviewed 7 clinical staff who routinely vaccinate children. We conducted content analysis to identify promising interventions and conducted a data synthesis workshop to select a final intervention for piloting.

RESULTS

All participants expressed willingness to use previsit education, breathing exercises, social support or distraction, and water consumption. Patients and parents expressed a need for verbal education and messaging about potential vaccine-related outcomes, and clinicians noted a need to identify patients who are anxious before a vaccination visit. Most participants suggested a "comfort menu" intervention, to include comfort and distraction items that medical staff offer adolescents before and during vaccination.

CONCLUSION

Patients, parents, and clinicians acknowledged the value of interventions to reduce pain and syncope after adolescent vaccination. Stakeholders identified a comfort menu as the intervention to be piloted at 2 KPNW pediatric clinics. Further research is needed to test the effectiveness of the "Vaccination Comfort Menu" intervention in improving vaccination experiences and continued receipt of vaccinations.

Using feeding to reduce pain during vaccination of formula-fed infants: a randomised controlled trial

OBJECTIVES

To assess the effectiveness and potential side effects of formula feeding to reduce pain during vaccination among infants.

STUDY DESIGN

In the setting of well-baby clinics we recruited a community-based sample of full-term born infants who were already formula fed by the choice of the parents (n=48, aged 4-10 weeks) and received their first DTaP-IPV-HepB-Hib and pneumococcal vaccinations and randomised them into two groups. To evaluate pain experienced during vaccination we compared infants who drank formula feeding before, during and after vaccination with infants who did not. Outcomes were observed cry duration and pain scores measured by means of the Neonatal Infant Pain Scale (NIPS) and the Face, Legs, Activity, Cry and Consolability (FLACC) scale. Side effects of drinking during vaccination were recorded. We performed intention-to-treat analyses using regression models, crude and adjusted for sex and age of the infant.

RESULTS

Pain at the moment of the second injection did not differ between groups. Drinking infants cried 33.5 s shorter (-56.6; -10.3). In the first minute after injection drinking infants experienced a faster pain reduction on the NIPS_Δt: regression coefficient 3.86 (95% CI 2.70 to 5.02) and FLACC_Δt: 4.42 (95% CI 2.85 to 5.99).

CONCLUSIONS

In line with findings of previous studies regarding breast feeding, formula feeding reduced vaccination pain in the recovery phase in full-term born infants receiving their first vaccinations between ages 4 and 10 weeks with no adverse effects. Professionals should discuss this non-costly and feasible pain-reducing intervention with parents of infants who receive vaccinations.

TRIAL REGISTRATION NUMBER

IRCTN 31383, post-results.

[Evaluation of pain in children of 2, 4 and 6 months after the application of non-pharmacological analgesia methods during vaccination]

INTRODUCTION

Young children perceive pain as much, or even more than adults, and the pain may have short- and long-term consequences. The literature describes the use of non-pharmacological interventions to alleviate pain during vaccination. The aim of this study was to assess 3such interventions for analgesia during vaccination: non-nutritive sucking (NNS), breastfeeding (BF), and administration of a 50% dextrose solution (D50W).

MATERIALS AND METHODS

A prospective, non-randomised cohort study was carried out on infants aged 2, 4 and 6 months that received 1, 2, or 3 vaccines, respectively, according to the routine immunisation schedule. There were 3treatments: NNS, BF, and 2mL of D50W combined with NNS. Pain was assessed using the LLANTO scale, and the duration of crying.

RESULTS

The study included 387 infants. The mean scores in the LLANTO scale at ages 2 and 6 months were significantly lower in breastfed infants compared to infants managed with NNS (P=.025 and P<.001, respectively), or infants given D50W (P=.025 and P=.001), and the difference was not statistically significant at age 4 months (P=.21 and P=.27). There were no significant differences between infants managed with NNS and D50W at 2, 4, and 6 months (P=.66, P=.93 and P=.45, respectively). The duration of crying was significantly lower at age 6 months in breastfeed infants compared to infants managed with NNS or D50W (P=.013 and P=.017). No breastfed child (n=129) experienced side effects.

CONCLUSIONS

In infants born to term with adequate weight for gestational age, breastfeeding reduces pain on the administration of 1 or 2 vaccines. When 3 vaccines are given, the reduction is minimal. Administration of D50W does not have any additional analgesic effect in infants compared to being held by a parent combined with NNS during vaccination. BF during vaccination is not associated with any side effects.