PL Detail-Document #320207
−This PL Detail-Document gives subscribers
additional insight related to the Recommendations published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
February 2016
Vaccine Administration Strategies
Patients often avoid vaccine recommendations due to fears of pain, injury, and/or needles.1 Those administering vaccines can do a lot to alleviate
these concerns for patients. And, this can help increase rates of vaccination, providing benefit to both individuals and the community. A positive
vaccination experience can also help prevent patients from developing anxiety that could transfer to a general fear of needles/injections with
repercussions into other areas of their health care.1 Below you will find various strategies to help reduce a patient’s fears, prevent injuries, and make
the injections less painful.2 Training on such strategies should be provided to everyone who administers vaccines.2 It is also important to involve and
train patients and caregivers on some of these strategies, beginning prior to the day of vaccination if possible (e.g., providing information prenatally,
at well-child visits, at routine check-ups, etc).2 For more information on the administration of vaccines, see our PL Self-Study Course, Immunization
Update 2015 Part 3: Vaccine Storage and Handling, Administration, and Adverse Events.
Abbreviations: IM = intramuscular; Subcut = subcutaneous
Suggested Checklist to Minimize Patient Anxiety
Be calm, collaborative, and well-informed.2
Let anxious patients/caregivers know what will happen, how it will feel, and what they can do. Provide information in advance if possible.1
Use neutral phrases like “Here I go.” rather than “Here comes the sting.” 2
Be truthful with the patient to promote trust.2
Ensure privacy to help decrease anxiety.2
Suggest anyone with a history of fainting to lie down for the injection, when possible.2
Let caregivers know that their behavior can influence a child’s response and distress. Give them information and tools to help them remain
calm.1 Let caregivers know they should never threaten or scare a child about injections.3
Make sure caregivers remain present with children, especially if less than ten years.1
More. . .
Copyright © 2016 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #320207: Page 2 of 4)
Suggest infants and children sit on their caregivers lap to calm them, and help hold their arms if necessary. But, do not forcibly restrain a child
as this will increase their fear. Sitting provides a stronger sense of control.1,2
Consider having patients hold neonates with skin-to-skin contact to reduce acute stress.1
Recommend breastfeeding infants, if acceptable to caregiver, during or shortly after injections.1,2 This can reduce stress with physical comfort,
sucking distraction, and sweet-tasting ingestion.1 Bottle feeding throughout may provide some benefit as well.2
Use distraction to divert attention, particularly in children less than six years, with toys, music, or conversation with an adult.2 Encourage
caregivers to bring a child’s favorite toy, book, blanket, or other comfort item.3
Suggested Checklist to Minimize Pain
Choose the proper needle size based on type of injection (IM vs Subcut) and your patient (i.e., age and weight).
See our PL Chart, Choosing the Correct Needle Size.
Select a 23 to 25 gauge needle for Subcut administration to decrease discomfort.4
Consider topical anesthetic creams, gels, or patches, particularly in children under 12 years if there is significant anxiety or fear of pain.1
Application must be done in advance (exact time will depend on the product chosen) and cost may be a barrier for some patients.1,2
Topical ethyl chloride and other vapocoolants are not generally recommended due to lack of proven effectiveness.5
Don’t recommend oral analgesics, such as acetaminophen, prior to injections.2 They likely don’t help and it has been suggested that they could
decrease the immune response.5,6,7 Save for after the injections for fever or discomfort.2
Sucrose (e.g., TootSweet) is recommended in infants less than two years if they are not breastfed during vaccination for pain control. Give 2 mL
of a 24% to 50% solution one to two minutes before the injection. Give rotavirus oral vaccine first if using as it contains sucrose.1
Encourage deep breaths, then give shot during exhalation when muscles are most relaxed. Have adults take deep breaths and children can blow
out into a toy pinwheel, party blower, or bubble blower.8 Adults can also give a slight cough as you inject the vaccine, being sure that the cough
doesn’t cause any arm movement or result in them holding their breath.2
Don’t pull back the plunger with IM administration.1,2,4 This technique is unnecessary and increases pain due to longer needle contact/dwell time
and the lateral movement/wiggling of the needle.1,2
More. . .
Copyright © 2016 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #320207: Page 3 of 4)
Consider Buzzy, a $40 device that combines vibration and cold to decrease pain. Small studies done mostly in children undergoing venipuncture
show some benefit in pain reduction.9,10
You may hear about ShotBlocker, a disposable plastic disk that is placed to surround the injection site. The device has many blunt contact points
that press into the patient’s skin to “saturate the sensory signals” near the injection site to reduce perceived pain. Studies are small and many do
not show decreased pain in patients getting injections.11,12
DO NOT warm the vaccine (rubbing between your hands), rub or pinch the injection site (manual stimulation), rub the skin adjacent to the
injection site, or apply pressure prior to the injection.13
Suggested Checklist to Reduce Injury
A rare vaccine-related injury, Shoulder Injury Related to Vaccine Administration (SIRVA), is believed to occur as a result of inappropriate
administration of IM vaccines.14-16 This particular injury appears to be more than trauma to the tissues and is thought to be an inflammatory
response to the injection of antigenic material into the synovial tissues.15 This can occur when an IM vaccine is administered too high on the arm
and goes into the subdeltoid bursa. Resultant symptoms can include permanent pain, lack of motion, weakness, and impaired
mobility/functionality.15
Inject IM vaccines into the central, thickest part of the deltoid. Injections that are too high (i.e., upper third of the arm) have been associated with
severe shoulder injuries such as rotator cuff tears, bursitis, and tendonitis that could require surgery or cause permanent injury.4,15
Choose the correct needle size for the size of your patient. Short needles risk underpenetration with potential for skin reactions and decreased
immunogenicity.14 Long needles risk overpenetration with potential for injection into the synovial tissue with possible pain and injury.14
See our PL Chart, Choosing the Correct Needle Size.
Don’t rely on the “Three finger rule” (i.e., inject IM vaccines three finger widths below the upper crest of the arm or acromion process) to find
the right spot for injection. This “rule” won’t always guide you to the correct place (i.e., the thickest part of the deltoid muscle).
Take the same position as recipient (both would usually sit). This helps to give the injection into the correct area of the deltoid.15
Avoid lowering a patient’s shirt down over their shoulder for administration, this can lead to the injection being given too high.17
More. . .
Copyright © 2016 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #320207: Page 4 of 4)
Users of this PL Detail-Document are cautioned to use
their own professional judgment and consult any other
necessary or appropriate sources prior to making
clinical judgments based on the content of this document.
Our editors have researched the information with input
from experts, government agencies, and national
organizations. Information and internet links in this
article were current as of the date of publication.
9.
10.
11.
Project Leader in preparation of this PL DetailDocument: Annette Murray, BScPharm
12.
References
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2.
3.
4.
5.
6.
7.
8.
Taddio A, McMurtry CM, Shah V, et al. Reducing
pain during vaccine injections: clinical practice
guideline. CMAJ 2015;187:975-82.
WHO. Reducing pain at the time of vaccination:
WHO position paper, September 2015 –
recommendations. Vaccine (pub online Nov 11,
2015). doi:10.1016/j.vaccine.2015.11.005.
CDC.
Tips for a Less Stressful Shot Visit.
http://www.cdc.gov/vaccines/parents/tools/tipsfactsheet.pdf. (Accessed December 2, 2015).
Angelo LB, Ed. APhA’s Immunization Handbook. 3rd
ed.
Washington, DC: American Pharmacists
Association, 2015.
Shah V, Taddio A, McMurty CM, et al.
Pharmacological and combined interventions to
reduce vaccine injection pain in children and adults:
systematic review and meta-analysis. Clin J Pain
2015;31(Suppl 10):S38-63.
Chen RT, Clark TA, Halperin SA. The yin and yang
of paracetamol and paediatric immunisations.
Lancet 2009;374:1305-6.
Prymula R, Siegrist CA, Chilbek R, et al. Effect of
prophylactic paracetamol administration at time of
vaccination on febrile reactions and antibody
responses in children: two open-label, randomised
controlled trials. Lancet 2009;374:1339-50.
Schechter NL, Bernstein BA, Zempsky WT, et al.
Educational outreach to reduce immunization pain in
office settings. Pediatrics 2010;126:e1541-21.
13.
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17.
Schreiber S, Cozzi G, Rutigliano R, et al. Analgesia
by cooling vibration during venipuncture in children
with cognitive impairment.
Acta Paediatr
2016;105:e12-6.
Canbulat Sahiner N, Inal S, Sevim Akbay A. The
effect of combined stimulation of external cold and
vibration during immunization on pain and anxiety
levels in children. J Perianesth Nurs 2015;30:22835.
Drago LA, Singh SB, Douglass-Bright A, et al.
Efficacy of ShotBlocker in reducing pediatric pain
associated with intramuscular injections.
Am J
Emerg Med 2009;27:536-43.
Cobb JE, Cohen LL. A randomized controlled trial of
the ShotBlocker for children’s immunization distress.
Clin J Pain 2009;25:790-6.
Taddio A, Ho T, Vyas C, et al. A randomized
controlled trial of clinician-led tactile stimulation to
reduce pain during vaccination in infants.
Clin
Pediatr (Phila) 2014;53:639-44.
Barnes MG, Ledford C, Hogan K. A “needling”
problem: shoulder injury related to vaccine
administration. J Am Board Fam Med 2012;25:91922.
Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R.
Shoulder injury related to vaccine administration
(SIRVA). Vaccine 2010;28:8049-52.
Dalle-Tezze
T.
National
Vaccine
Injury
Compensation Program (VICP): ?prevention of
SIRVA?
June
4,
2015
http://www.hrsa.gov/vaccinecompensation/sirva0604
2015.pdf. (Accessed November 30, 2015).
Ross M. Compensation growing for botched vaccine
administration.
September 10, 2015. Pharmacy
Times.
http://www.pharmacytimes.com/news/compensationgrowing-for-botched-vaccine-administration.
(Accessed November 30, 2015).
Cite this document as follows: PL Detail-Document, Vaccine Administration Strategies.
Letter/Prescriber’s Letter. February 2016.
Evidence and Recommendations You Can Trust…
3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249
Copyright  2016 by Therapeutic Research Center
Subscribers to the Letter can get PL Detail-Documents, like this one,
on any topic covered in any issue by going to www.PharmacistsLetter.com,
www.PrescribersLetter.com, or www.PharmacyTechniciansLetter.com
Pharmacist’s
Common Concerns About Childhood Vaccinations
Infants and children get a lot of shots (vaccinations) to prevent many different diseases. Because
some people are concerned about vaccine side effects, parents or caregivers sometimes ask their
health care provider to delay or not give some vaccines. Parents worry that it is not good to give so
many shots at the same time. This handout gives facts about vaccines, to help parents make good
decisions about what’s best for their child.
CONCERN
“Infants get too many shots at once.”
FACTS
Infants get a lot of shots. But, they could handle even more. Each day, infants come into contact
with millions of particles like pollen, viruses, and bacteria that affect their immune system. The
particles in vaccines are only a very small amount compared to those found in your child’s world.
Vaccines will not “overload” your child’s immune system.
Some parents think that it would be better if their child didn’t get so many shots at the same time.
But delaying or not giving some vaccinations is not a good idea. This could leave your child
unprotected against some diseases. Many of these diseases are bad for children. So it is best to
make sure your child is protected by not waiting to give them their shots. Also, it is much easier to
have your child get their shots at the right time instead of trying to catch up later.
CONCERN
“Vaccines have too many side effects. Besides, the diseases that vaccines prevent are not that bad.”
FACTS
Before we had vaccines, many infants and children died from diseases we can now prevent. The
diseases that vaccines prevent can be dangerous. Older people remember how bad these diseases
were. Diseases like whooping cough, polio, and measles may be much worse and more dangerous
for your child than the side effects of the vaccine. Even chickenpox can be serious. Every year,
there are infants and children who have to go to the hospital due to chickenpox. Children have also
died from chickenpox.
CONCERN
“Everyone else gets vaccines, so my child doesn’t need them.”
FACTS
It is true that your child has a lower chance of getting sick when your child plays with children who
got their shots. But this doesn’t mean that your child can’t get sick. Your child should also get
their shots. Even though most children get vaccinated, children who do not get their shots have
gotten measles or whopping cough, and some have even died.
Also, children who don’t get vaccines may get the disease, and then spread it to people who can’t
get the vaccine and who could become very sick like infants, pregnant women, or older people.
Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2015 by Therapeutic Research Center
www.PharmacistsLetter.com ~ www.PrescribersLetter.com
Common Concerns About Childhood Vaccinations
CONCERN
“Vaccines are not tested enough.”
FACTS
Just like medicines, vaccines are tested in many children for a long time before they are given to all
children. Most vaccines are tested in even more children and for an even longer time than most
medicines that you give your child.
CONCERN
“Vaccines contain things which are not safe for my child.”
FACTS
Shots that are given to infants and children are safe. Shots for infants and children do not have
mercury or thimerosal in them anymore. Some shots do have aluminum in them, but the amount of
aluminum is much smaller than the amount found in baby formula.
CONCERN
“Vaccines cause autism.”
FACTS
Some people think that the thimerosal or mercury in vaccines causes autism. But this is not true.
And, most of the common pediatric vaccines do not have thimerosal or mercury. A few of the flu
vaccines have a very small amount of thimerosal or mercury, but many don’t. Let your prescriber
or pharmacist know if you prefer a flu vaccine that does not contain thimerosal.
PROTECT YOUR CHILD AND VACCINATE
Infants and children receive more vaccines than ever before. But, these vaccines are safe and
protect our children from diseases. These vaccines are given to your child because your health care
provider wants to keep them healthy. If you have questions about any vaccine your child is to get,
talk to your prescriber or pharmacist. Remember, vaccines save lives!
[This handout may not cover all possible information. It does not replace the need for professional medical care. Always follow
the instructions from your health care provider.][February 2015]
Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2015 by Therapeutic Research Center
www.PharmacistsLetter.com ~ www.PrescribersLetter.com
Preocupaciones comunes acerca de las vacunas infantiles
Los bebés y los niños reciben una gran cantidad de vacunas para la prevención de diferentes
enfermedades. Porque algunas personas están conscientes sobre los efectos secundarios sobre
vacunas, padres o las personas responsables de su cuidado algunas veces le preguntan a su
médico dejen pasar más tiempo o no dar algunas vacunas. Padres se preocupen que no es bueno
dar muchas vacunas a la misma vez. Este panfleto proporciona información sobre las vacunas
para de esa forma ayudar a los padres a tomar una decisión buena acerca de lo que es mejor para
sus hijos.
PREOCUPACIÓN
“Los bebés reciben muchas vacunas al mismo tiempo.”
HECHOS
Los bebés reciben una gran cantidad de vacunas. Sin embargo, podrían recibir muchas más sin
problemas. Todos los días los niños entran en contacto con millones de partículas de polen, de
virus y de bacterias que activan su sistema inmunitario. Las partículas en vacunas son solamente
una porción muy pequeña a comparación al mundo de su hijo. Las vacunas no “sobrecargan” el
sistema inmunológico de su hijo.
Algunos padres piensan que sería mejor si su hijo no recibiera tantas vacunas al mismo tiempo.
Sin embargo, el retrasar o el no darle algunas vacunas no es una buena idea. Esto puede
provocar que su hijo se encuentre no protegido de algunas enfermedades. Muchas de estas
enfermedades pueden ser malas para niños. Entonces es mejor que su hijo sea protegido y no
esperar para recibir sus vacunas. Y también es más fácil que su hijo que tenga sus vacunas al
tiempo apropiado en vez de que tengan que apresurarse para tenerlas.
PREOCUPACIÓN
“Las vacunas tienen muchos efectos secundarios. Por otra parte, las enfermedades que son
prevenidas por las vacunas no son tan graves.”
HECHOS
Antes de tener las vacunas, muchos bebés y niños morían de enfermedades que ahora se pueden
prevenir. Las vacunas pueden prevenir enfermedades peligrosas. Gentes mayores recuerdan que
tan malas eran estas enfermedades. Enfermedades como la tos ferina, la poliomielitis y el
sarampión pueden ser mucho más peligrosas para su hijo que los efectos secundarios de la
vacuna. Incluso la varicela puede ser grave. Cada año, hay infantes y niños que tienen que ir al
hospital por razones de la varicela. También niños han muerto por razones de la varicela.
PREOCUPACIÓN
“Todo los otros niños reciben vacunas, por lo que mi hijo no las necesita.”
HECHOS
Es cierto que su hijo tiene menos oportunidad de enfermarse cuando su hijo juega con niños que
han sido vacunados. Pero esto no significa que su hijo no se pueda enfermar. Su hijo también
debería tener sus vacunas. A pesar de que la mayoría de los niños son vacunados, ha habido
casos de sarampión y tos ferina entre los niños que no han recibido sus vacunas. Incluso ha
habido muertes.
Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2015 by Therapeutic Research Center
www.PharmacistsLetter.com ~ www.PrescribersLetter.com
Preocupaciones comunes acerca de las vacunas infantiles
Por otra parte, los niños que no reciben las vacunas pueden contraer la enfermedad y luego
infectar a otras personas que no pueden ser vacunadas y que podrían enfermarse de gravedad
como infantes, mujeres embarazadas o personas mayores.
PREOCUPACIÓN
“Las vacunas no son investigadas suficientemente.”
HECHOS
Al igual que los medicamentos, las vacunas se ponen a prueba en muchos niños por un largo
tiempo antes de que se les dé a todos los niños. La mayoría de las vacunas se prueban en aun
más niños y por un tiempo aun más largo que la mayoría de los medicamentos que usted le da a
su hijo.
PREOCUPACIÓN
“Las vacunas contienen cosas que no son seguras para mi hijo.”
HECHOS
Las vacunas que se administran a los infantes y a los niños son seguras. Las vacunas para los
bebés y los niños ahora no contienen mercurio o timerosal. Eso sí, algunas vacunas contienen
aluminio, pero la cantidad de aluminio es mucho más baja que la cantidad de aluminio que se
encuentra presente en las fórmulas para bebés.
PREOCUPACIÓN
“Las vacunas causan autismo.”
HECHOS
Algunas personas piensan que el timerosal o el mercurio en las vacunas causan el autismo. Sin
embargo, esto no es cierto. Y, la mayoría de las vacunas pediátricas más comunes no contienen
timerosal o mercurio. Algunas de las vacunas para la gripe tienen una pequeña cantidad de
timerosal o mercurio, pero no muchas. Deje saber a sus prescriptor o farmacéutico si usted
prefiere una vacuna para la gripe que no contiene timerosal.
PROTEJA A SUS HIJOS Y VACÚNELOS
Los bebés y los niños reciben ahora más vacunas que nunca. Sin embargo, estas vacunas son
seguras y protegen a nuestros niños de enfermedades. Estas vacunas son dadas a su niño porque
su médico quiere mantenerlos saludables. Si usted tiene preguntas acerca de cualquier vacuna
que su hijo va a recibir, hable con su prescriptor o farmacéutico. Recuerde, ¡las vacunas salvan
vidas!
[Este panfleto puede no tener toda la información posible. También no reemplaza la necesidad de atención médica profesional.
Siempre siga las instrucciones de su profesional de atención de la salud.][Febrero 2015]
Prepared for the subscribers of
Pharmacist’s Letter / Prescriber’s Letter to give to their patients.
Copyright © 2015 by Therapeutic Research Center
www.PharmacistsLetter.com ~ www.PrescribersLetter.com