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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Monday, June 15, 2009

Shots Hurt! How to Ease the Pain for Kids (and Parents)

It breaks my heart to give injections to kids, but they are definitely necessary. Vaccinations save lives and sometimes we must give an injection of an antibiotic. Either way, shots (usually) hurt and kids know it. Before kids turn two, we are poking them with needles about twenty times.

Pain is always in the mind of the beholder. I have seen infants goo and smile as they were given multiple vaccinations in their thighs. I have seen big ‘ol high school football players beg and plead, trying to get out of a tetanus shot. Yesterday, a teenager fainted during a routine vaccination and hit her head on the floor. She had been hyperventilating in anticipation of the injection.

As a child, our small town doctor would make house calls. It seemed that no matter what you had, he would always seem to find a (painful) shot to give you, like penicillin. An injectible antibiotic that we often use is called Rocephin (Ceftriaxone sodium). This one can really hurt and sting, unless it is mixed with lidocaine, an anesthetic agent. Mixed with sterile water, this one will definitely get your attention. Often used to treat sexually-transmitted diseases, I have known ER docs that will use the sterile water mix so it WILL hurt, reminding the recipient to use safe sex practices next time.

In the 1950s, school and public health nurses would come to our classroom and give routine vaccinations. I can still see some of my classmates freaking out about them. Some would try and run away and others would cry. The crying would increase in intensity as soon as the alcohol swab was used. Some would just stand there, stoic and in shock, as the school nurse administered them.

The armed services are notorious for their group vaccination efforts. They line those frightened recruits up like cattle and use pressurized air injection guns to give multiple injections. Like the traditional needles, air injections can hurt just as bad; sometimes worse if they move. Air injection guns can tear the skin.

Some people like shots. Some of my Hispanic patients actually ask for shots, feeling that injections work faster and better than the same medication in pill form. An old osteopath that used to work in our group gave ALL of his patients, at every visit, a shot of vitamin B12. Of course, unless you had pernicious anemia, this shot was just a placebo, but his patients always seemed to feel better after their vitamin injection.

Insulin-dependent diabetics have to give themselves shots once or several times per day. At first, many are reluctant to do stick themselves, but after a short while, they are no longer bothered by doing this simple procedure.

Parents are now refusing vaccines more and more. Unfounded fears of autism and even fears of subjecting their kids to pain are common reasons. The pain of most injections is usually brief. The fear and anticipation of getting a shot is often worse than the shot itself. Our medical assistants give injections all day long. They are fast, efficient, and often over before the kids know it, but there are still some things that we can do to minimize the discomfort.

A Baker’s Dozen Things That Can Be Done to Reduce Injection Pain

  1. Attitude plays a big role. If the parent AND the medical provider are supportive and calm, the child will feel confident and will not nearly be as frightened.
  2. What’s in a name? The word “shot” is really a scary word for kids under age 7 or so. Bad guys are “shot”. I use the word “booster” when they need to get a vaccination, or sometimes I call them “power boosters” since the vaccinations help them get strong. Booster is a much nicer word.
  3. Choices. Children tend to like choices. If a child is going to get one injection, I ask them if they “Would like a shot or a booster?” Then I ask if they would like ONE or TWO (they only need one). I can extend the choices to “Would you like a big needle, or the little, tiny needle that we use for babies?” Or, “Would you like it in your arm, leg, or EYE!” When given those choices, they will pick (a) one booster, (b) with the baby needle, and (c) in the arm or leg, NOT the eye.
  4. Honesty. Will it hurt? I always answer honestly and say, “Sometimes. But, if it does, all you need to do is tell the nurse, and she will take it out right away!” Think about it.
  5. Empathy. Tell them that you understand that they don’t want any shots but in order to go to school, you have to have it.
  6. Distraction. Do what you can as a parent to distract them from any anticipated pain from the injections. Hold your baby or child snuggly; reassure them that you will be help. Babies who are breast fed while they are getting vaccinations tend to cry or react less, or you can nurse the baby afterwards to calm them down. When I have to inject a toe for a toenail removal on a teenager, it can be quite painful. I have noticed that the ones who bring their music on iPods have less pain response.
  7. Order of Shots. Nurses need to give the least painful shot first. A new Canadian study found that when you must give the DTaP vaccine (diphtheria, tetanus, and pertussis) and the Prevnar (pneumococcal conjugate) vaccine at the same visit, giving the less-painful DTaP first is much easier on the kids.
  8. Give a little sugar. Newborns boys getting circumcised require an anesthetic injection in the penis (ouch!). Several studies have shown that a sweet liquid (sugar water) placed in a nipple, that the babies are unusually calm. Under six months old, a pacifier can be dipped in a sweet liquid for a sweet distraction. A sugar-free lollipop, usually after the injection, is a good bribe for younger kids.
  9. Numbing medicines. EMLA cream (lidocaine-prilocaine) or cooling sprays can be used to temporarily numb the skin for injections. These are particularly helpful for planned blood draws or when a child may need an intravenous injection. EMLA needs to be put on an HOUR before the injection, and of course, applied to the site where the injection will be made. The cooling sprays only last precious seconds, so the nurse needs to be fast – very fast.
  10. Direct Pressure. A little plastic device called a Shot Blocker creates a bit of “neurological confusion” to those pain sensors on the skin. There are some tiny spikes on the back of the device that will block much of the pain of an injection. And, of course, rubbing a recently injected site can also help afterwards. I once saw an old nurse slap a teen’s butt real hard before giving a gluteal injection. It worked, although he was a bit surprised.
  11. Tylenol? Many parents will give a dose of Tylenol (acetaminophen) before coming in for routine vaccinations. Personally, if I were getting five shots, I don’t think that Tylenol would really help my pain, but many parents feel that it does.
  12. Not all vaccines are “shots”. The FluMist influenza vaccine is a good example of an effective vaccine that does not require a needle. It is expec
    ted that more and more vaccines will have non-injection alternatives in the future.
  13. Use Combination vaccines. More vaccines in one syringe; one needle is really the goal. We now routinely use a five-in-one vaccine containing the DTaP, Hib, and polio vaccines. My dog and cat gets a seven-in-one vaccine, but of course, animals are not children. More combination vaccines are on the horizon, but they need to be well-tested before giving them to our children.

Until we have those painless, Star Trek-like “neck injections” that cure just about everything, medical providers will still need to needle around from time to time. We can help the kids, but for the rest of us, my advice is to just Grin and Bare It.

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Posted by: Rod Moser, PA, PhD at 1:37 pm

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