News & Views: Successful Distraction for Childhood Immunizations: A Novel Technique

Editor’s Note: In the October 2015 Vaccine Update when we summarized the World Health Organization’s publication of their position paper related to the pain of injections, it was one of our most popular articles for the year. We recently were in touch with F. Ralph Berberich, MD, FAAP, a practicing pediatrician in California who has been studying pain related to injections for several years. We are pleased that he was willing to author a follow-up article related to this topic and share information about the technique he has been using in his practice. We would like to thank Dr. Berberich for sharing his experiences, and we hope you find this guest-authored article to be helpful.

The potential impact of needle phobia, anticipatory anxiety and parental foreboding as they relate to immunization adherence is likely underestimated and may not be acknowledged by parents or physicians. The recommendations put forth in the World Health Organization’s (WHO) position paper (Weekly Epidemiological Review, Sept. 25, 2015) and other experts who have disseminated evidence-based guidelines for pain reduction may not yet be followed with rigor (summarized in Vaccine Update, October 15, 2015). 

As indicated in the WHO publication, distraction has been shown to be an effective way to reduce the discomfort associated with immunizations; however, techniques must be formulated in a manner acceptable to most children realizing that the approach will compete with fear and avoidance responses. The process of distraction for immunization can be shaped by attending to a few areas of focus:

• Preparation of the child — Children like to be informed about what is going to happen as it provides some small measure of autonomy and control. Likewise, they should be allowed to have their own reactions rather than being told how they will feel or should act. Word choices that avoid potentially frightening associations (e.g., shots, pinch, bite) are also preferable because such associations may inadvertently increase, rather than decrease, fear. Alternatives that impart less negative valence, such as “poke” and “put in the medicine” may be better choices. Invoking authentic positive expectations and creating a sense of familiarity through repetition will enhance patient participation, which will more likely lead to a sanguine outcome.
• Good and bad distraction — A variety of distraction techniques can be effective, provided the child is taught and becomes accustomed to using them during injections.  Examples include blowing bubbles or watching a video. Likewise, children who engage in activities, such as sports, may be reminded that they can be relatively impervious to minor pain when caught up in their activity. Other forms of distraction may be less effective, particularly if they result in a painful, unexpected “surprise.” Looking out the window or being instructed to take a deep breath can lead to unintended and lasting negative outcomes, including subsequent distrust.
• Leading and pacing — The art of inducing attention shifts is emphasized in the emerging discipline of pediatric hypnosis.  The novel distraction method scripted below is grounded in those principles and leads children through a multifaceted sequence of kinesthetic experiences accompanied by carefully formulated verbal suggestions moving the focus away from the arm receiving the injection. Each of three statements and sensations, demonstrated before injection in a dry run builds toward acceptance of the process as a “game” while diminishing the potential for distress caused by penetration of the needle. 

The sequence is easily learned, adds less than four minutes to the encounter, gives willing parents a role, and is self-reinforcing when the child receives injections without experiencing a traumatic event. The technique has been found to be highly effective in two small trials (see references).

The script

View a video of the technique in practice.

STEP 1: Vapocoolant (Pain Ease®)

• Permission: “Can I show you something? This is cold spray.”
• Demonstration on self: Hold spray 6” away and spray on the back of your hand for one to two seconds. “It’s very cold.”
• Demonstration on child: “Would it be alright to show you?” Hold spray 6 inches away and spray on the back of the child’s hand for one to two seconds, and then touch lightly. “See how it’s cold and you can’t feel as much? When it’s time for your shot, we are going to spray your arm with this cold spray so that the shot doesn’t have to bother you.”

STEP 2: Gripper (ShotBlocker®)

• Permission: “Can I show you something else?”
• Demonstration on self: Hold ShotBlocker out in front of child with prong side up. “You can touch it.” Hold on forearm or upper arm. “When this holds your arm, the arm gets mixed up about what’s sharp and what isn’t.”
• Demonstration on child: Hold on child’s arm. “After the cold spray, we are going to hold your arm with this to mix it up about what’s sharp and what isn’t.”

STEP 3: Buzzer “game” (vibrating massager)

• Permission: “Can I show you more?”
• Demonstration on self: “This is the buzzer.” Turn on and touch on face, arm, or hand. “It can tickle you.”
• Demonstration on child: Hold on child’s face, arm or hand.“See how it can tickle you. (Pause for effect). Now … we’re going to play a game with this buzzer. When you get your shot (poke) in that arm, watch the buzzer go down this arm (demonstrate buzzer slowly moving down child’s arm from shoulder to elbow). Watch closely so you can say ‘elbow’ as soon as it touches you here (touch child’s elbow with buzzer). Ready?” (Demonstrate three times and playfully comment on lack of responses, or delayed responses, by child, such as “What happened to the ‘elbow?’”) “Now let’s make this game more fun. I may go slowly, I may go fast. I may go this way or that way (demonstrating a few different routes), but watch closely so you can say ‘elbow’ when it touches here (touch child’s elbow with buzzer). Let’s practice.” Practice at least three times.
• Optional involvement of caregiver, providing that person expresses comfort and willingness to be involved. “We’re going to have your (mom/dad/nanny) do the fun part so you can beat the buzzer. See how fast you can say ‘elbow’ when the buzzer gets there.” But not too soon or too late!

References

Franck LS, Berberich FR, Taddio A. Parent participation in a childhood immunization pain reduction method. Clin Pediatr (Phila). 2015 Mar; 54(3)228-235.

Berberich FR, Schechter NL. Pediatric office pain: Crying for attention. Pediatrics. 2012 Apr;129:e1057-e1059.

Berberich FR, Landman Z. Reducing immunization discomfort in 4- to 6-year-old children: A randomized clinical trial. Pediatrics. 2009 Aug;124(2):e203-e209.