Pain Reduction in Pediatric Vaccinations
Shana Porter
Indiana University
The policy for vaccine administration for pediatric patients at IU Health Bloomington Hospital outlines the purpose, procedure and documentation for health care professionals administering vaccines in neonatal infants, children and adolescents (Indiana University Health Bloomington, 2012). Hospitals have policies regarding vaccines because vaccines are one of the earliest and most scientifically reinforced topics of public health nursing to date. Vaccines have improved public health immensely and have a major impact in reducing human suffering. Currently there are fourteen vaccine-preventable diseases that can be given during childhood, and most states mandate vaccine documentation for school eligibility by law. Public health efforts have strived to make vaccines available to all children, regardless of ability to pay, because it benefits not only the individual but also the overall immunity of the population (Givens, 2015).
Nurses are typically the health care providers that administer vaccines to children. Nurses are given the responsibility to ensure that vaccination education is given to patients or their legal guardians and administration is safe and up-to-date. However, the pain and anxiety children experience with vaccinations can be a barrier to other aspects of health care. Worry can overtake the entire visit for a child, which may include vaccinations as well as other interventions or a well check. The anxiety and fear could negatively impact other interventions or assessments planned during the visit (Schechter et al., 2007). In ten percent of the population this fear and anxiety continues throughout the lifespan, affecting compliance of vaccine schedules and other medical procedures. Any healthcare professional today can explain the importance of preventative health care and regular primary care visits. If a person experiences anxiety and fear in the clinical setting they may choose to not seek care, preventative or immediate, which could lead to a decrease in early recognition of disease processes. A negative experience in a health care setting can harm the trust relationship between health care provider and patient (Taddio et al., 2010). Nurses are the key player in promoting a trusting relationship between themselves and the patient. Because pain and anxiety about childhood vaccinations can negatively influence health choices later in life, individuals and the greater community are at an increased risk for preventable health conditions.
The policy for vaccine administration affects the children being vaccinated, the parents of that child, and the health professional administering the vaccine. The child immediately benefits from the vaccination by gaining immunity to the specific illness. Having more people who are immunized and cannot spread the disease benefits the population as a whole through the concept of herd immunity. Herd immunity protects vulnerable populations that cannot be vaccinated for medical reasons by decreasing the available exposure to the illness (Grimes, 2015). Nurses are advocates not only for the individual patients they serve, but also the entire population including the vulnerable populations that cannot be vaccinated. Parents are impacted because they provide the consent for vaccinations given to their child, and they are directly affected by the pain their child experiences (Schechter et al., 2007). One study researched the amount of money parents would be willing to pay to eliminate the pain associated with vaccinations for their child and found on average parents would be willing to pay between fifty and eighty dollars (Meyerhoff, Weniger & Jaccobs, 2001). Nurses are impacted by the policy for vaccine administration because they are responsible for safe and evidence based administration, and the policy is the guideline nurses are instructed to use.
The IU Health Bloomington Hospital policy regarding childhood vaccination administration does not include any techniques for pain or anxiety reduction (Indiana University Health Bloomington, 2012). The evidenced research indicating attempts at pain reduction are effective contraindicates this current policy. There is no evidence supporting that pain can be completely avoided in all situations for pediatric patients receiving vaccinations, but efforts to reduce pain can greatly decrease the anxiety and stress related to vaccinations and medical appointments in general (Schechter et al., 2007). I found no evidence opposing pain reduction efforts for pediatric vaccinations or any evidence that stated pain was not decreased enough to be effective or useful when attempted to be reduced.
The current research regarding pain reduction in children during vaccinations includes many components. From the preparation phase, it is recommended that parents are well educated regarding the benefits of the vaccinations as well as the step-by-step procedure for administration. The recommended preparation for the child given prior to vaccine administration is dependent on the age and the developmental level of the child, as well as parent preference (Schechter et al., 2007). As far as specific techniques for pain reduction before or during administration, sucrose water given orally has been proven effective for pain reduction in neonatal infants during vaccinations (Hatfield, 2008). Some topical agents can be applied to reduce pain, although medications have many more considerations as opposed to non-pharmacological methods of pain reduction. Topical anesthetics may not be the most time efficient option because of the length of time it takes to desensitize the subcutaneous and intramuscular tissue (Schechter et al., 2007).
I found the Buzzy pain blocker to be the least invasive and the most evidence-supported intervention. The Buzzy is a product designed by a pediatrician that uses cold and vibration tactile stimulation to reduce pain prior to a painful stimulus for children and adults. It is a small bee shaped device that vibrates and has a cold pack strapped underneath. The buzzy is simple to use and easy to clean and reuse. The Buzzy uses no medication and has essentially no risks associated (Vaccinations, 2016). There is currently no evidence that I could locate contradicting the use of the Buzzy in pain reduction during pediatric vaccinations. A randomized controlled trial indicated the Buzzy significantly diminished pain and anxiety in seven-year-old children receiving the DTaP vaccine (Sahiner, Inal & Akbay, 2015). One of the advantages to this approach of pain reduction is that it is cost effective. The small buzzy costs seventy dollars, and the large buzzy costs ninety dollars. For something that can be used multiple times, and is battery powered, this is a cost effective strategy for a hospital (Vaccinations, 2016). I would anticipate that in Bloomington Hospital, each unit would need three to five devices to make them accessible where pediatric vaccinations are given. This would include the pediatric unit, the mother-baby unit, and the neonatal intensive care unit. If each of these units were to receive five small size Buzzy devices the initial purchase would cost the hospital $1,050 total.
If the Bloomington Hospital policy for pediatric vaccination administration was to be revised to include pain relief, speaking to nurses on the pediatric units would be the starting point. If nurses feel that pain reduction is something that could be improved on the unit they would need to bring it to the unit’s shared governance meeting or the nurse manager of the unit. Gaining a consensus among nurses on a single pediatric unit and with other pediatric units would help provide the correct representation needed to convince Dana Watters, the original person to approve this policy and who is the executive director for the regional center for women and children at Bloomington Hospital, that an update is warranted (IU Health, n.d.). From there, all methods for pain reduction would need to be considered for evidence-based support, cost and training necessary for staff.
I would anticipate that the potential pushback to revising this policy would be predominantly financial. Competing for funding for resources in the hospital can be challenging, and often all the requests from other units in the hospital are significant and important. There may be nurses who do not believe pain reduction in pediatric vaccinations is a significant issue or that it is worth the effort to change the policy. If a new policy was to be adopted, nurses on the unit would need to be trained on the new protocol or equipment and this may frustrate nurses. Even considering the potential pushback, I find the evidence supporting attempts to reduce pain in pediatric vaccinations to be indisputable based on the public health implications.
As mentioned previously, the importance of vaccinations for reducing disease on the individual and population level has been supported by scientific research for decades (Grimes, 2015). The pain and anxiety associated with vaccinations in children can threaten the trust relationship between the patient and health care later in life (Schechter et al., 2007). There are many options for attempting to reduce this pain and anxiety, from as early in life as neonatal infancy, and ranging from pharmacological topical anesthetics to the Buzzy pain blocker device. I believe that the Bloomington Hospital policy for vaccine administration in children needs to be updated to include pain reduction methods with the intention of improving the relationship between patient and health care, starting as early in life as possible. The impact that the updated policy could have on the local, state and national level is massive. On an acute or individual level, I believe pediatric patients would experience less stress and anxiety while getting vaccinated at IU Health Bloomington. If the pain reduction efforts are successful, for example with the Buzzy, then it could be a policy all of IU Health pediatrics could adopt, affecting even more patients and a state population base. The upstream, or wider, even potentially national impact of this policy update could be later in life, when these children grow up to be adults and decide to participate in preventative health care. The more individuals participating in preventative health care, the more chronic disease and infection are decreased. This aids the population by improving health, and can also cut costs associated with chronic disease and infection. Generations of health behavior choices could be influenced and improved by this single policy change.
References
Givens, S. R. (2015). Child and Adolescent Health: Immunization. In Community/Public Health Nursing (6th ed., pp. 296-297). St. Louis, MO: Elsevier.
Grimes, D. E. (2015). Communicable Disease. In Community/Public Health Nursing (6th ed., pp. 489-495). St. Louis, MO: Elsevier.
Hatfield, L. (2008). Sucrose decreases infant biobehavioral pain response to immunizations: a randomized controlled trial. Journal Of Nursing Scholarship, 40(3), 219-225 7p. doi:10.1111/j.1547-5069.2008.00229.x
Indiana University Health Bloomington. (May 25, 2012). Vaccine Administration in Children.
IU Health. (n.d.). Retrieved March 5, 2016, from http://iuhealth.org/bloomington/about/nursing-excellence/nursing-leaders/
Meyerhoff, A. S., Weniger, B. G., & Jaccobs, R. J. (2001). Economic value to parents of reducing the pain and emotional distress of childhood vaccine injections. The Pediatric Infectious Disease Journal, 20(11), 57-62. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11704725
Sahiner, N. C., Inal, S., & Akbay, A. S. (2015). The Effect of Combined Stimulation of External Cold and Vibration During Immunization on Pain and Anxiety Levels in Children. Journal of PeriAnesthesia Nursing, 30(2), 228-235. doi:10.1016/j.jopan.2014.05.011
Schechter, N. L., Zempsky, W. T., Cohen, L. L., McGrath, P. J., McMurty, M. C., & Bright, N. S. (2007). Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations. American Academy of Pediatrics, 119(5), 1184-1198. doi:10.1542/peds.2006-1107
Taddio, A., Appleton, M., Bortolussi, R., Chambers, C., Dubey, V., Halperin, S., . . . Shah, V. (2010). Reducing the pain of childhood vaccination: An evidence-based clinical practice guideline. Canadian Medical Association Journal, 182(18), 843-855. doi: 10.1503/cmaj.092048
Vaccinations. (2016). Retrieved March 3, 2016, from https://buzzyhelps.com/for/vaccinations