Journal Club Presentation

Bonnie Sawyer-Banda, RN, BSN

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).

Today’s Article:

Pain Reduction During Pediatric Immunizations: Evidence Based Review and RecommendationsJournal: PediatricsAuthors: Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M., and Bright, N.Published: May, 2007A literature review

Background

Children receive between 14 and 20 separate injections before the age of 2Immunizations are the most frequently occurring painful procedures performed in pediatric patientsPain 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.

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 carePhysicians – have strong concerns about giving 3-4 injections per visitPhysicians 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.

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?

Before the injections

Preparation for ImmunizationStudies have shown that preparation for procedural pain can reduce the anxiety and pain of many medical events, such asVenipunctureDental proceduresSurgeryVCUGHowever, there are few studies that look at preparation for immunizations. 2 studies were inconclusive (Vapo-coolant and training video).

Recommendations based on preparation for other painful procedures

For Parents:

Reason for the vaccineEmphasis on benefits

Realistic information about he pain that is to be expected

Provide parent with coaching and coping techniques – breathing, story telling

Recommendations based on preparation for other painful procedures (cont)

For Children:Preparation is guided by age. More relevant >2Preparation should consist ofWhat 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 possibleOlder children – depends on their coping stylesThere are no clear guidelines because there are limitations specific to pediatric immunizations

Injection site selection

Anterolateral thigh – large muscle mass and lack of vital structuresWhen 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

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.

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

During the injection

Parental behavior

Parental behavior during the immunization significantly influences the amount of pain and distress children experience

Parental behaviors that increase coping:

Commands to use coping strategies

Distraction techniquesHumor

Non procedural talk

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”

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.

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)

Distraction

Recognized as a key interventionPossible 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

Examples of distraction stimuli

MoviesParty blowersNon procedural talkVirtual reality gogglesKaleidoscopesBubble blowingShort storiesMusic

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.

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

Clinicians should routinely use distraction for pediatric

immunizationsEase of use

Growing body of evidence

Lack of negative consequences

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 effectBreastfeeding also provides analgesiaThere seems to be sufficient data to recommend sucrose use as a routine part of immunization administration for infants ≤6 months of age.

Topical anesthetics

Should be

Safe

Inexpensive

Should have rapid onset

Should have effect on vaccine immunogenicity

Examples

EMLADecreases pain as needle penetrates the skinReduction of underlying muscle spasmOnset of action – 1 hour

Vapo-coolant spraysProvides anesthesia in 30 seconds and are inexpensiveSome studies show them to be no better than placeboUniversal use of local anesthetics can not be endorsed as there is lack of availability of one that is rapid acting.

Technical Variables

Injection techniqueFor Intramuscular InjectionsHold skin tauntInject dart-like at 90°Do not pull back on the plungerInject vaccine at steady pressureWithdraw needle at the same angle

For SubcutaneousPinch or bunch the skinInsert needle at 45°

Site Pressure

10 seconds of direct pressure at the injection site - reduction of immediate pain

Simultaneous injections

No decrease in discomfort, but parents preferred

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/journalclubformat.pdfRed Book (2010) Site and needle length by age for intramuscular injections. Retrieved 07/02/2012 from http://www.unboundmedicine.com/redbook/ub/view/RedBook/187027/all/Table_1_4__Site_and_Needle_Length_by_Age_for_Intramuscular_Immunization?q=needle%20length Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurty, M.,

and Bright, N. (2007). Pain reduction during pediatric Immunizations: Evidence based review and recommendations. Pediatrics. 119(5). e1184-e1198.

The end