Journal Club Presentation

1. Journal Club Presentation Bonnie Sawyer-Banda, RN, BSN

2. What is a journal club? • It is a group of nurses that meet regularly to discuss and critique research articles appearing in scientific journals. • A journal club is a good way to get started using evidence based practice (Beyea and Slattery, (2009).

3. Today’s Article: • Pain Reduction During Pediatric Immunizations: Evidence Based Review and Recommendations • Journal: Pediatrics • Authors: Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N. • Published: May, 2007 • A literature review

4. Background • Children receive between 14 and 20 separate injections before the age of 2 • Immunizations are the most frequently occurring painful procedures performed in pediatric patients • Pain of injections causes stress and anxiety in the patients, their parents and in the nurses that must administer the injections. • All children have a pain memory and react more intensely if they have had previous painful experiences without analgesia.

5. Background (cont) • There are many variables that can heighten or lessen the response to injections. • Parents – concern about injection pain can affect compliance with medical care • Physicians – have strong concerns about giving 3-4 injections per visit • Physicians and nurses are 6 times less likely to administer all immunizations at one visit if the child is scheduled for ≥3 injections than if the child were schedule for ≤2 injections.

6. PICOT question: • (Population, Intervention, Control, Outcome, Time) • In pediatric patients, what effects do pain reduction techniques have compared to no pain reduction interventions during routine immunizations?

7. Before the injections • Preparation for Immunization • Studies have shown that preparation for procedural pain can reduce the anxiety and pain of many medical events, such as • Venipuncture • Dental procedures • Surgery • VCUG • However, there are few studies that look at preparation for immunizations. 2 studies were inconclusive (Vapo-coolant and training video).

8. Recommendations based on preparation for other painful procedures • For Parents: • Reason for the vaccine • Emphasis on benefits • Realistic information about he pain that is to be expected • Provide parent with coaching and coping techniques – breathing, story telling

9. Recommendations based on preparation for other painful procedures (cont) • For Children: • Preparation is guided by age. More relevant >2 • Preparation should consist of • What will happen (where, how long, what will be done) • How it will feel (pressure, temperature, level of discomfort to be expected) • Strategies to cope – (Give choices of strategies) • Optimal timing for particular age ranges: • Toddlers and pre-schoolers – as close to actual administration as possible • Older children – depends on their coping styles • There are no clear guidelines because there are limitations specific to pediatric immunizations

10. Injection site selection • Anterolateral thigh – large muscle mass and lack of vital structures • When to shift to arm? • At 18 months, more severe pain, decreased movement and limping when given in thigh. • Option: ventrogluteal • Lower rates of systemic reaction and local reactions

11. Needle length • Longer needles cause less pain and fewer adverse reactions • Studies indicate that there is greater redness and swelling when immunizations are administered with smaller needle rather than a longer needle. • Conclusion: Individualization of needle length based on patient size and injection technique.

12. Injectate Properties • Temperature – in patients >16, no difference in pain scores whether the vaccine was cold, rubbed or warmed. • Injectate formulation – Vaccines with higher pH cause less pain. If there is a choice

13. During the injection • Parental behavior • Parental behavior during the immunization significantly influences the amount of pain and distress children experience

14. Parental behaviors that increase coping: • Commands to use coping strategies • Distraction techniques • Humor • Non procedural talk

15. Parental behaviors that increase child distress: • Empathy • Criticism • Apologies • Giving control to the child • Reassurance – most common adult vocalization during immunizations - it is counter intuitive that reassurance causes more distress, but fathers believe “comforting encourages more crying”

16. Educate the parents • Teaching parents techniques to promote coping can reduce their sense of helplessness and benefit the child by reducing distress and increasing mastery.

17. Securing the child • Young children: • Parent holds the child in his or her lap • Older children: • Sit in parent’s lap facing forward or face the parent with legs wrapped around the parent (big-hug)

18. Distraction • Recognized as a key intervention • Possible explanations: • Gate control theory – cognitive attention might affect processing and perception of pain. • If some attention is allocated to a distracting task, then there are fewer resources available to attend to the pain

19. Examples of distraction stimuli • Movies • Party blowers • Non procedural talk • Virtual reality goggles • Kaleidoscopes • Bubble blowing • Short stories • Music

20. Distraction • A meta analysis showed that distraction decreased distress behavior but had minimal impact on self-reported pain. Most effective in children <7. • Interactive distraction decreased children’s pain more effectively. The more the children are engaged in the distraction (regardless of the type) the lower the pain. • Most research has been done in pre-school age children. More research is needed in non pre school aged children.

21. Things to consider when choosing a distraction stimulus • Age and cognitive maturity of the patient • Age appropriate and engaging stimuli • Cost • Time • Space • Children’s natural coping tendencies and temperament • Patient preferences

22. Clinicians should routinely use distraction for pediatric immunizations • Ease of use • Growing body of evidence • Lack of negative consequences

23. Use of Sucrose • Sucrose water (1 packet of sugar mixed in 10ml of water) has been shown to decrease pain in neonates. • It has been suggested that Sucrose interacts with opioid pathways to accomplish this phenomenon. Can be administer with a pacifier or instilled directly into the mouth. Loses efficacy by 4-6 months. • Nonnutritive sucking also has analgesic properties. • Combination of direct parental contact and sucrose have an additive effect • Breastfeeding also provides analgesia • There seems to be sufficient data to recommend sucrose use as a routine part of immunization administration for infants ≤6 months of age.

24. Topical anesthetics • Should be • Safe • Inexpensive • Should have rapid onset • Should have effect on vaccine immunogenicity

25. Examples • EMLA • Decreases pain as needle penetrates the skin • Reduction of underlying muscle spasm • Onset of action – 1 hour • Vapo-coolant sprays • Provides anesthesia in 30 seconds and are inexpensive • Some studies show them to be no better than placebo • Universal use of local anesthetics can not be endorsed as there is lack of availability of one that is rapid acting.

26. Technical Variables • Injection technique • For Intramuscular Injections • Hold skin taunt • Inject dart-like at 90° • Do not pull back on the plunger • Inject vaccine at steady pressure • Withdraw needle at the same angle • For Subcutaneous • Pinch or bunch the skin • Insert needle at 45°

27. Site Pressure • 10 seconds of direct pressure at the injection site - reduction of immediate pain

28. Simultaneous injections • No decrease in discomfort, but parents preferred

29. References • Beyea, S and Slattery, M.J. (2009). Ask the expert: What is a journal club? Retrieved 07/02/2012 from http://www.hcpro.com/NRS-243376-975/Ask-the- expert-What-is-a-journal-club.html • Grady, D. (n.d.) a recommended journal club format Retrieved 07/02/2012 from http://www.unmc.edu/intmed/geriatrics/docs/journalclubf ormat.pdf • Red Book (2010) Site and needle length by age for intramuscular injections. Retrieved 07/02/2012 from http://www.unboundmedicine.com/redbook/ub/view/Red Book/187027/all/Table_1_4__Site_and_Needle_Length_by_A ge_for_Intramuscular_Immunization?q=needle%20length • Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N. (2007). Pain reduction during pediatric I mmunizations: Evidence based review and recommendations. Pediatrics. 119(5). e1184-e1198.

30. The end