Recommendations for reducing pain during vaccine injections
| Treatment | Recommendation | Confidence | Infants and young children (≤ 3 yr) | Children (3–12 yr) | Adolescents (12–17 yr) | Adults (≥ 18 yr) |
|---|---|---|---|---|---|---|
| Strong recommendations | ||||||
| Procedural interventions | ||||||
| No aspiration | We recommend no aspiration during intramuscular vaccine injections | Very low | Yes | Yes | Yes | Yes |
| Order of injection | We recommend injecting the most painful vaccine last during vaccine injections | Moderate | Yes | Yes | Yes | Yes |
| Physical interventions | ||||||
| Breastfeeding* | We recommend breastfeeding during vaccine injections | Very low | Yes (≤ 2 yr) | — | — | — |
| Positioning: skin-to-skin contact† | We recommend skin-to-skin contact during vaccine injections | Moderate | Yes (≤ 1 mo) | — | — | — |
| Positioning: holding† | We recommend holding during vaccine injections | Very low | Yes | — | — | — |
| If holding is not used during vaccine injections, we recommend a combined holding intervention (including patting and/or rocking) after vaccine injections | Low | Yes | — | — | — | |
| Positioning: sitting up | We recommend sitting up during vaccine injections | Low | — | Yes | Yes | Yes |
| Pharmacologic interventions | ||||||
| Topical anesthetics | We recommend topical anesthetics before vaccine injections | Very low | Yes | Yes | —§ | —§ |
| Sweet-tasting solutions†‡ | We recommend sucrose solutions before vaccine injections | Moderate | Yes (≤ 2 yr) | — | — | — |
| We recommend glucose solutions before vaccine injections | Moderate | Yes (≤ 2 yr) | — | — | — | |
| Process interventions | ||||||
| Education of clinicians | We recommend education of clinicians administering vaccine injections about vaccine injection pain management | Low | Yes | Yes | Yes | Yes |
| Parent presence | We recommend presence of parents during vaccine injections | Very low | Yes | Yes (≤ 10 yr) | — | — |
| Education of parents | We recommend education of parents about pain management for vaccine injection before the day of vaccination | Low | Yes | Yes | Yes | — |
| We recommend education of parents about pain management for vaccine injection on the day of vaccination | Very low | Yes | Yes | Yes | — | |
| Education of individuals undergoing vaccination | We recommend education of individuals about pain management for vaccine injection on the day of vaccination | Very low | — | Yes | Yes | Yes |
| Weak recommendations | ||||||
| Procedural interventions | ||||||
| Simultaneous injection | We suggest simultaneous injections (rather than sequential injections) during vaccine injections | Low | Yes (≤ 1 yr)§ | —§ | — | — |
| We suggest against simultaneous injections during vaccine injections | Very low | Yes§ (1–3 yr) | Yes (≤ 10 yr) | — | — | |
| Vastus lateralis | We suggest the vastus lateralis (rather than the deltoid) as the site of injection during vaccine injections | Low | Yes (≤ 11 mo) | — | — | — |
| Physical interventions | ||||||
| Breastfeeding* | If breastfeeding is not used during vaccine injections, we suggest breastfeeding before vaccine injections | Low | Yes (≤ 2 yr) | — | — | — |
| Nonnutritive sucking† | We suggest nonnutritive sucking (using a thumb/finger, pacifier) during vaccine injections | Low | Yes (≤ 2 yr) | — | — | — |
| Vibrating device with cold | We suggest an external vibrating device with cold during vaccine injections | Low | — | Yes | Yes | — |
| Muscle tension | We suggest muscle tension for vaccine injections in individuals with a history of fainting | Very low | — | Yes (≥ 7 yr) | Yes | Yes |
| Manual tactile stimulation | We suggest against manual tactile stimulation during vaccine injections | Very low | Yes | Yes | Yes | Yes |
| Warming the vaccine | We suggest against warming the vaccine before vaccine injections | Low | Yes | Yes | Yes | Yes |
| Pharmacologic interventions | ||||||
| Topical anesthetics | We suggest topical anesthetics before vaccine injections | Moderate | —§ | —§ | Yes | Yes |
| Topical anesthetics and breastfeeding* | We suggest combining topical anesthetics before vaccine injections and breastfeeding during vaccine injections | Low | Yes (≤ 2 yr) | — | — | — |
| Sweet-tasting solutions and nonnutritive sucking†‡ | We suggest sweet-tasting solutions (sucrose, glucose) before vaccine injections and nonnutritive sucking (thumb/finger, pacifier) during vaccine injections | Very low | Yes (≤ 2 yr) | — | — | — |
| Vapocoolants | We suggest against applying vapocoolants before vaccine injections | Low | Yes | Yes | Yes | —§ |
| We suggest that vapocoolant spray be used before vaccine injections | Low | —§ | —§ | —§ | Yes | |
| Acetaminophen | We suggest against giving acetaminophen before vaccine injections | Low | Yes | Yes | Yes | Yes |
| Ibuprofen | We suggest against giving ibuprofen before vaccine injections | Very low | Yes | Yes | Yes | Yes |
| Sweet-tasting solutions and breastfeeding | We suggest against using sweet-tasting solutions (sucrose, glucose) and breastfeeding in combination before vaccine injections | Low | Yes (≤ 2 yr) | — | — | — |
| Psychological interventions | ||||||
| Verbal signal of impending procedure | We suggest a verbal signal of the impending procedure (v. a signal of impending pain) before vaccine injections | Very low | Yes | Yes | Yes | Yes |
| Distraction | We suggest directed video distraction during vaccine injections | Very low | Yes | —§ | — | — |
| We suggest directed toy distraction during vaccine injections | Very low | Yes | — | — | — | |
| We suggest nondirected toy distraction during vaccine injections | Very low | Yes | — | — | — | |
| We suggest verbal distraction during vaccine injections | Low | — | Yes | — | — | |
| We suggest video distraction during vaccine injections | Very low | —§ | Yes | — | — | |
| We suggest music distraction during vaccine injections | Low | — | Yes | —§ | —§ | |
| We suggest against music distraction during vaccine injections | Very low | — | —§ | Yes | Yes | |
| We suggest against visual distraction during vaccine injections | Very low | — | — | — | Yes | |
| Breathing distraction | We suggest breathing with a toy distraction (e.g., blowing bubbles, pinwheel) during vaccine injections | Very low | — | Yes | — | — |
| We suggest against breathing without a toy distraction (blowing, deep breathing) during vaccine injections | Very low | — | Yes | — | — | |
| We suggest against breathing interventions (cough) during vaccine injections | Low | — | Yes | Yes | —§ | |
| We suggest breathing interventions (cough, breath-hold) during vaccine injections | Very low | — | —§ | —§ | Yes | |
| Using suggestion | We suggest against using false suggestion during vaccine injections | Low | Yes | Yes | Yes | Yes |
| Using reassurance | We suggest against using repeated reassurance during vaccine injections | Very low | Yes | Yes | Yes | Yes |
↵* Alternatively, bottle feeding with expressed breast milk or formula can be used, or combined interventions that simulate breastfeeding (e.g., holding, sweet-tasting solution, sucking), as appropriate.
↵† If not breastfeeding.
↵‡ Alternatively, if oral rotavirus vaccine is being administered at the same time as injectable vaccines, rotavirus vaccine can be given first as it contains sucrose.
↵§ See elsewhere in the table for a recommendation in this age group.