The information contained in this guideline is generalizable to healthy children undergoing injection of vaccines worldwide. We offer the following suggestions to assist in implementing the guideline in various settings.
Context and facilitation
Organizations and health care providers involved in immunization are encouraged to adopt pain management as an integral component of the vaccination process. Supports should be put in place to facilitate the implementation of these recommendations by health care providers.
Some costs may be incurred by the incorporation of these recommendations into practice, because of required training of staff, required time to practise pain management and expenditures to acquire aids (e.g., bubbles) and resources (e.g., pamphlets for parents and children). For the most part, these costs are relatively modest and may be offset by shorter duration of the procedure (because the child’s distress and struggling are lessened) and faster recovery time. Many of the practice recommendations are cost-neutral to parents and the health care system (e.g., rapid intramuscular injection without aspiration).
Setting for vaccinations
Most of these practice recommendations can be incorporated in many settings without adding any time to the vaccination process (e.g., holding infants, tactile stimulation). Pain-relieving strategies that require additional time (e.g., education and preparation, application of topical anesthetics) can be implemented ahead of time, either at home or upon arrival at the vaccination setting, while the child is waiting to be vaccinated. Parents can be asked to pay a nominal fee to cover the cost of analgesic interventions (e.g., topical anesthetics, bubbles for blowing, sugar water). Alternatively, analgesic interventions can be provided free of charge.
To date, the guideline has been piloted in an outpatient clinic setting and a public health vaccination setting at a middle school. Feedback received suggests that the strategies are feasible and effective, and that parents and children appreciate efforts made to reduce the children’s pain.
Assessment and documentation of pain
Assessment and documentation of pain during vaccine injections are important aspects of providing quality care. These processes allow determination of the effectiveness of analgesic strategies employed and planning for future vaccine injections.
In preverbal children, various behavioural cues signal the presence of pain, including crying, facial grimacing and writhing body movements. Older, verbal children (three years or older) may express pain through similar behaviours but can usually supplement the behaviours with a verbal report, which is considered the primary source for pain assessment. In all age groups, pain may be accompanied by physiologic changes (e.g., increase in heart rate), but these are neither specific to pain nor clinically feasible and therefore are not recommended for monitoring pain in practice.
Here, we provide specific guidance regarding the method of pain assessment for children of different ages, according to our consensus interpretation of the vaccination literature, considering the validity and feasibility of currently available pain assessment methods. For preverbal children and infants, adult observers (parents, health care providers or both) are required to assess pain. We recommend that health care providers use one of two observational tools: the Modified Behavioural Pain Scale96–98
(for infants up to 18 months of age) or the Face Legs Activity Crying Consolability scale99
(for infants over 18 months of age). Parents should use a global rating scale (e.g., numerical rating scale or visual analogue scale). Verbal children can be asked to self-report pain100
using age-appropriate techniques: either the Poker Chip tool101
(3 to 6 years of age), the Faces Pain Scale — Revised102
(4 to 16 years of age) or a numerical rating scale103,104
(9 years of age and older). We encourage health care providers to document the strategies used to reduce acute pain at the time of vaccine injection, as well as the child’s pain score.
Some judgment about the suitability and feasibility of the recommendations is required, as not all of the recommendations will be appropriate or effective in all situations or for all children. In selecting specific pain-relieving strategies for use in a particular situation, clinicians and parents are advised to consider the analgesic effectiveness of individual modalities, the goals for the child, and the preferences of the child, the parents and the clinician.
Health care providers should offer pain-relieving options to parents and children (as appropriate) when they are counselling about other aspects of immunization or well-baby and child care, as parents and children are largely unaware of effective pain-relieving strategies.
No single pain-relieving strategy recommended in this guideline has been demonstrated to reliably reduce pain to zero (i.e., to prevent pain). Clinicians are advised to combine different pain-relieving strategies, as such combinations improve pain relief.12
However, combining pain-relieving strategies does not ensure pain-free injections.
Tools to support training and implementation
We developed a knowledge translation plan to facilitate dissemination and implementation of the guideline. This plan incorporates several educational tools, including a guide to pain management for parents and caregivers (Appendix 1), a guide to pain management for health care providers (Appendix 2) and a tool that health care providers can use to assess and document pain (Appendix 3) (all appendices are available at www.cmaj.ca/cgi/content/full/cmaj.101720/DC1
). A website and educational video for parents and health care providers has also been created (available online and freely accessible at www.sickkids.ca/Learning/SpotlightOnLearning/profiles-in-learning/help-eliminate-pain-in-kids/index.html
). These various tools can be customized to the needs of individual practice settings. In addition, several professional organizations (listed at the end of the article) have endorsed or supported this guideline and will assist in its dissemination. This assistance includes online links to the guideline and associated tools and incorporation of recommendations in immunization resources. Educational workshops are being offered to various stakeholder groups.
The guides for parents and health care providers are similar and include information about pain-relieving strategies that are relevant to each user group, as well as information about how to implement them during vaccine injections. The documentation tool allows the health care provider to record information about the vaccine or vaccines administered, the child’s age, age-appropriate pain assessment techniques and the child’s pain score. The form can be inserted into the child’s medical chart and/or given to parents and caregivers. The educational video demonstrates the use of pain-relieving strategies.
Updates to the guideline
We will review feedback from users of the guideline and determine the appropriate timing for revision and update of the guideline.