Reducing Vaccination Pain

From Medscape Medical News

Physical Intervention Eases Vaccination Pain in Infants

Ricki Lewis, PhD

April 16, 2012 — Infant immunizations are stressful for parents and painful for recipients. A study published online April 16 in Pediatricsfound that the pain-reducing effect of a physical intervention with or without sucrose water was superior to sucrose water alone.

Evidence is scant that a pain reliever such as acetaminophen is effective postvaccination, and this drug may dampen the antibody response to certain vaccine antigens. To investigate a nonpharmacological intervention to alleviate injection pain, John W. Harrington, MD, from the Department of Pediatrics, Eastern Virginia Medical School, and Department of Pediatrics, Section of General Academic Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, and colleagues conducted a prospective, randomized, placebo-controlled trial to test an intervention termed the "5 S's," for swaddling, side/stomach position, shushing, swinging, and sucking.

The researchers divided 230 infants being immunized at 2- or 4-month well-baby check-ups into 4 groups that received either 2 mL of water or 2 mL of a 24% sucrose solution 2 minutes before vaccination, and either standard comfort care from the parent or guardian or a 5 S's intervention from a researcher. Sucrose is added to acetaminophen products to improve palatability, and in some studies appeared to relieve pain.

The investigators used the Modified Riley Pain Score (cry quality, grimace, movement) to assess pain every 15 seconds for 2 minutes, and subsequently every 30 seconds for up to 5 minutes after vaccination. A 1-way analysis of variance evaluated mean pain across groups over time, and repeated-measure general linear modeling evaluated pain scores at each time interval across the groups. The vaccines were for rotavirus (oralRotarix, GlaxoSmithKline) and hepatitis B (Pentacel, Sanofi Pasteur; Prevnar, Wyeth, marketed by Pfizer), injected intramuscularly into the thigh.

Pain scores ranged from 0 to 9. Mean pain scores were 4.46 for the control group (water, parental comfort), 3.95 for the sucrose group (sucrose, parental comfort), 3.24 for the physical group (water, 5 S's), and 3.61 for the physical with sucrose group (sucrose, 5 S's). The difference in mean pain scores was significantly lower in all treatment groups compared with the control group, and the mean pain score for the 5 S's–only group was significantly less than the sucrose group. However, the difference between the 2 5 S's groups was not statistically significant.

The 2 groups implementing the 5 S strategy had less pain and shorter duration of crying than the 2 groups without the strategy, and the 5 S intervention was about equally effective with or without sucrose. The researchers conclude, "The 5 S's appear to be a viable nonpharmacologic option for clinics to implement when providing analgesia during vaccinations." In addition to minimizing suffering, pain control during immunizations may calm parents who are hesitant to have their children vaccinated, the researchers point out.

Limitations of the study include that the 3 researchers who provided the 5 S's might have differed slightly in their technique, the disproportionate number of 2-month-olds, and the difficulty of assessing movements to evaluate pain in a swaddled baby. Finally, the parents may have been providing the 5 S's as well.

Pediatrics. Published online April 16, 2012.