Multifaceted distraction intervention reduced vaccination discomfort

A pain reduction strategy implemented at a California pediatric practice successfully reduced discomfort among children receiving vaccines and is the first to address both the anticipatory anxiety and physical discomfort associated with vaccine administration.

“It is both worthwhile and possible to reduce the discomfort of childhood immunizations,” F. Ralph Berberich, MD, of the Pediatric Medical Group in Berkeley told Infectious Diseases in Children. “Causing pain has reduced trust, which in turn negatively affects future pediatric encounters.”

Berberich and colleague Zachary Landman devised a method adding hypnotic suggestions to visual, verbal and physical sensory stimuli to help children dissociate from vaccine pain. Berberich and Landman were able to substantially reduce scores on two different pain scales among patients aged 4-to-6 years who were randomly assigned to vaccination with the intervention (n=21) or standard protocol (n=20).

Both study groups received intramuscular injections of diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed and polio virus vaccine (inactivated) in one arm and a subcutaneous injection of measles, mumps and rubella vaccine in the other arm.

Children who received the intervention rated discomfort at a mean of 2.00 on the Faces Pain Scale-Revised (0-to-10 scale) compared with a mean score of 6.57 among children who were vaccinated without the intervention.

Similar differences between the two groups were noted by the investigators using the Face-Legs-Activity-Crying-Consolability (FLACC) scale. A mean FLACC score of 1.65 was recorded among patients who received the intervention compared with a mean score of 5.71 among those who underwent standard vaccination procedure.

Berberich and Landman applied a cooling spray (ethyl chloride, Gebauer) to the arms of intervention group patients while simultaneously providing verbal suggestions about coolness and reduced sensation. The researchers also applied a multipronged arm gripper to the injection site, which they suggested would help confuse the patient as to what was sharp and what was not and they instructed intervention group patients to watch the descent of a vibrating instrument applied to the opposite arm. Patients were asked to indicate when the instrument reached the elbow, which was timed to occur at the same time as the injections were administered.

Despite success in the 4-to-6 year age group, Berberich said that children younger than 3 are less responsive to the technique. “A certain level of imaginative and focusing response is required. By the age of 3 or 4 years it is also the dominance of anticipatory fear that makes it possible to offer suggestions about less bother and sensation that makes this technique effective.” – by Nicole Blazek

Berberich FR et al. Pediatrics. 2009;doi:10.1542/peds.2007-3466.

This quite intriguing albeit small study, presents an apparently effective approach to the dreaded vaccine process for preschool children. Using multifaceted distractions, Berberich et al were able to reduce the apprehension of their young patients. However, two caveats must be addressed for routine patient care. The arm gripper device and the vibrating distracter would require an additional person to help the "shot nurse," which could be quite logistically problematic and costly in a busy office practice. The arm gripper could also distort the anatomy significantly, making an intramuscular injection inappropriately subcutaneous instead. Regardless, for the more than occasional highly anxious or delirious patient the approach could be beneficial.

– Stan L. Block, MD

Infectious Diseases in Children Editorial Board