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CME/CE

Physical Intervention Alleviates Pain in Infants Receiving Vaccinations

  • Authors: News Author: Ricki Lewis, PhD
    CME Author: Penny Murata, MD
  • CME/CE Released: 5/1/2012
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 5/1/2013
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Target Audience and Goal Statement

This article is intended for primary care clinicians, infectious disease specialists, and other specialists who provide care to infants requiring immunizations.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe whether physical intervention of the 5 S's (swaddling, side or stomach position, shushing, swinging, and sucking) with or without sucrose water is effective in reducing pain response in infants receiving immunizations.
  2. Describe whether physical intervention with or without sucrose water is effective in reducing crying time in infants receiving immunizations.


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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Author(s)

  • Ricki Lewis, PhD

    Ricki Lewis is a freelance writer for Medscape.

    Disclosures

    Disclosure: Ricki Lewis has disclosed no relevant financial relationships.

Editor(s)

  • Brande Nicole Martin, MA

    CME Clinical Editor, Medscape, LLC

    Disclosures

    Disclosure: Brande Nicole Martin, MA, has disclosed no relevant financial relationships.

CME Author(s)

  • Penny Murata, MD

    Clinical Professor, Pediatrics, University of California, Irvine, California
    Pediatric Clerkship Director, University of California, Irvine, California

    Disclosures

    Disclosure: Penny Murata, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC

    Disclosures

    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

Nurse Planner

  • Laurie E. Scudder, DNP, NP

    Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

    Disclosures

    Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.


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CME/CE

Physical Intervention Alleviates Pain in Infants Receiving Vaccinations

Authors: News Author: Ricki Lewis, PhD CME Author: Penny Murata, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME/CE Released: 5/1/2012

Valid for credit through: 5/1/2013

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Clinical Context

One of the main barriers to timely immunizations in children is the parents' concern about the associated pain and discomfort, as reported by Jacobson and colleagues in the March 21, 2001, issue of Vaccine. In the December 14, 2010, issue of the Canadian Medical Association Journal, Taddio and colleagues noted that concentrated sucrose alone is effective for pain control in infants receiving immunizations. Breast-feeding, which combines comforting, skin-to-skin contact, distraction, and the sweetness of lactose, is another effective method of analgesia, as reported by Shah and colleagues in the June 2007 issue of Breastfeeding Medicine. In The Happiest Baby on the Block, published in 2003, Karp described a calming intervention called the 5 S's: swaddling, side or stomach position, shushing, swinging, and sucking.

This prospective, randomized, placebo-controlled trial by Harrington and colleagues assesses whether sucrose water alone, physical intervention with the 5 S's alone, or sucrose water plus physical intervention are effective forms of analgesia for infants receiving immunizations.

Study Synopsis and Perspective

Infant immunizations are stressful for parents and painful for recipients. A study published in the May issue of Pediatrics found that the pain-reducing effect of a physical intervention with or without sucrose water was superior to sucrose water alone.

Evidence is scant that a pain reliever such as acetaminophen is effective postvaccination, and this drug may dampen the antibody response to certain vaccine antigens. To investigate a nonpharmacological intervention to alleviate injection pain, John W. Harrington, MD, from the Department of Pediatrics, Eastern Virginia Medical School, and Department of Pediatrics, Section of General Academic Pediatrics, Children's Hospital of The King's Daughters, Norfolk, Virginia, and colleagues conducted a prospective, randomized, placebo-controlled trial to test an intervention termed the "5 S's," for swaddling, side/stomach position, shushing, swinging, and sucking.

The researchers divided 230 infants being immunized at 2- or 4-month well-baby check-ups into 4 groups that received either 2 mL of water or 2 mL of a 24% sucrose solution 2 minutes before vaccination, and either standard comfort care from the parent or guardian or a 5 S's intervention from a researcher. Sucrose is added to acetaminophen products to improve palatability, and in some studies appeared to relieve pain.

The investigators used the Modified Riley Pain Score (cry quality, grimace, movement) to assess pain every 15 seconds for 2 minutes, and subsequently every 30 seconds for up to 5 minutes after vaccination. A 1-way analysis of variance evaluated mean pain across groups over time, and repeated-measure general linear modeling evaluated pain scores at each interval across the groups. The vaccines were for rotavirus and hepatitis B, injected intramuscularly into the thigh.

Pain scores ranged from 0 to 9. Mean pain scores were 4.46 for the control group (water, parental comfort), 3.95 for the sucrose group (sucrose, parental comfort), 3.24 for the physical group (water, 5 S's), and 3.61 for the physical with sucrose group (sucrose, 5 S's). The difference in mean pain scores was significantly lower in all treatment groups compared with the control group, and the mean pain score for the 5 S's–only group was significantly less than the sucrose group. However, the difference between the two 5 S's groups was not statistically significant.

The 2 groups implementing the 5 S strategy had less pain and shorter duration of crying than the 2 groups without the strategy, and the 5 S intervention was about equally effective with or without sucrose. The researchers conclude, "The 5 S's appear to be a viable nonpharmacologic option for clinics to implement when providing analgesia during vaccinations." In addition to minimizing suffering, pain control during immunizations may calm parents who are hesitant to have their children vaccinated, the researchers point out.

Limitations of the study include that the 3 researchers who provided the 5 S's might have differed slightly in their technique, the disproportionate number of 2-month-olds, and the difficulty of assessing movements to evaluate pain in a swaddled baby. Finally, the parents may have been providing the 5 S's as well.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2012;129:815-822.

Study Highlights

  • 230 infants scheduled for a 2- or 4-month-old well-child visit were enrolled from the outpatient practice of an academic children's hospital in Virginia during a 6-month period.
  • Inclusion criteria were gestational age between 32 and 42 weeks at delivery and postnatal age of younger than 20 weeks.
  • Exclusion criteria were acetaminophen or ibuprofen use within 4 hours before immunization, neurologic disorder, genetic anomaly, moderate to severe illness with or without fever, anaphylactic reaction to previous vaccine, or previous enrollment at age 2 months.
  • 75% of infants were 2 months old, 54% were boys, 81% were African American, and 13% were Caucasian.
  • Infants were randomly selected to 1 of 4 groups: a control group, a sucrose group, a physical intervention group, and a physical intervention plus sucrose group.
  • Demographic traits were not different among the groups.
  • 56 infants in the control group received 2 mL of water 2 minutes before immunization and comfort from a parent or guardian after immunization.
  • 58 infants in the sucrose group received 2 mL of 24% oral sucrose water 2 minutes before immunization and comfort from a parent or guardian after immunization.
  • 58 infants in the physical intervention group received 2 mL of water 2 minutes before immunization and 5 S's intervention after immunization.
  • 58 infants in the physical intervention plus sucrose group received 2 mL of 24% oral sucrose water 2 minutes before immunization and the 5 S's intervention after immunization.
  • The 5 S's physical intervention was provided by 1 of 3 pediatric residents trained to provide swaddling within 15 seconds after vaccination. Side or stomach positioning with shushing and swinging or swaying with the pacifier was provided after 30 seconds.
  • Vaccinations were given by senior nursing staff, with the infant on the examination table.
  • The first vaccine was the oral rotavirus vaccine, followed by 3 intramuscular injections of vaccines.
  • The primary outcome measure was postvaccination pain response, assessed with the Modified Riley Pain Score at 15-second intervals for 2 minutes and then every 30 seconds for up to 5 minutes.
  • The Modified Riley Pain Score ranging from 0 to 9 is based on the quality of cry, facial grimace, and body movement. A low score indicated less pain.
  • The pain scores improved for all groups as time progressed, from immediately after the vaccination to 120 seconds.
  • The lowest mean pain scores occurred in the 5 S's group (3.24) and the 5 S's plus sucrose group (3.61), followed by the sucrose group (3.95), then the control group (4.46).
  • The mean pain scores were significantly different among all groups, except there was no significant difference between the 5 S's group and the 5 S's plus sucrose group.
  • The secondary outcome measure was duration of crying from immediately after vaccination to 120 seconds.
  • The results for duration of crying were similar to the pain score results.
  • The lowest proportions of children crying at each interval were in the 5 S's group and the 5 S's plus sucrose group.
  • The mean pain scores were lower for 2-month-old infants vs 4-month-old infants who received sucrose water, 5 S's, and 5 S's plus sucrose water.
  • The study included the following limitations:
    • There were more 2-month-old infants.
    • The 5 S's technique was easier to perform on 2-month-old infants.
    • The swaddling element of the 5 S's intervention might have impeded an evaluation of body movement for the modified Riley Pain Score.
    • The control infants might have received some elements of the 5 S's from the guardians.
    • The interval of 2 minutes between sucrose water intake and vaccine administration might have affected analgesia.

Clinical Implications

  • In infants receiving immunizations, the pain scores are lowest in those who either receive physical intervention alone or physical intervention with sucrose water, followed by receipt of sucrose water alone, and lastly no specific intervention (control).
  • In infants receiving immunizations, the proportion of children crying as time progressed is lowest in those who receive physical intervention alone or physical intervention with sucrose water, followed by receipt of sucrose water alone, and lastly no specific intervention (control).

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