1. Jang, Emily
  2. Zhimanov, Ekaterina
  3. Parsh, Bridget EdD, RN, CNS

Article Content

I work in a clinic where we administer vaccines to young children. Do you have any guidelines for managing their pain and anxiety during these procedures?-T.D., S.C.


Emily Jang, Ekaterina Zhimanov, and Bridget Parsh, EdD, RN, CNS, reply: For children, the experience of a painful injection can result in needle phobia, long-term traumatic memories, and increased pain sensitivity into adulthood.1-3 To decrease the pain and anxiety these procedures can trigger, healthcare professionals can use play, distraction, and other strategies, depending on the child's age. Here are some quick tips that can help nurses minimize a child's distress.


General guidelines

These tips, which are readily implemented, can make be employed for most children.


* Inform the child of an impending needle stick and involve parents in helping the child cope. If willing, parents can hold the child on their lap or hug the child during the injection. Positive parental behaviors such as humor, nonprocedural talk, and suggestions on how to overcome fear have been shown to decrease the distress that a child experiences during a needle stick.4 On the other hand, false reassurances (such as, "this won't hurt much") and apologies have the opposite effect and may raise the child's anxiety levels.


* Consider applying a topical anesthetic before the procedure. Local anesthetic creams, gels, and patches can effectively block pain transmission, but these interventions take time and increase costs.1


* If administering multiple vaccinations, give the most painful last.


* Do not aspirate during the procedure.1



For infants

Having a parent or familiar caregiver hold an infant with skin-to-skin contact has been shown to be effective to decrease pain during immunizations.5 Positioning the infant supine appears to be more effective than an upright position for this age group.1,5 Breastfeeding before needle sticks and nonnutritive sucking during the procedure is also recommended for infants.1


For young children

Encourage a parent to hold the child with the child sitting up during the procedure.1,5 This positioning helps give the child a feeling of control.


Distraction minimizes anxiety, pain, and distress by moving a child's focus onto something attractive and engaging and away from the painful stimulus.6 Distraction cards with pictures and shapes, such as ladybugs, monkeys, and comets, can be helpful tools. During painful procedures, ask the children questions about the cards; for example, "How many monkeys do you see?"7


Balloons can also be used as a distraction. Allow the child to select a balloon color and inflate the balloon before, during, and after the procedure.7 After the procedure, let the child keep the inflated balloon. Consider mylar balloons instead of latex to avoid issues with sensitivities and aspiration risk for young children.8


Medical clowning, another form of distraction, can be used to distract the child with music, magic, and stories until the procedure is completed.9,10 Blowing bubbles or spinning a pinwheel can also distract young children.1


For school-age children

As with younger children, encourage the family to stay with an older child. Remind family members that remaining calm will reduce the child's anxiety.1


Playing music from popular cartoons or TV programs and asking the child to identify which program the music is from can be an effective form of distraction.7 Continue playing music and asking questions until the procedure ends.


Virtual reality programs can distract children with lifelike visuals of computer-generated three-dimensional images.11 During the procedures, a virtual reality program could show a relaxing scene that children can interact with until the procedure ends. Though this method may be effective, the equipment can be expensive and is not available in all settings.


Commercial devices that vibrate and chill the skin during the procedure work well for some children.12,13 Applied during the needle stick, the combination of cold and vibration decreases pain by blocking or slowing nerve impulse conduction from the target area.12


Time, cost, and implementation should all be considered when determining which method will work best for children in your clinic. Using methods to decrease a child's pain and anxiety may reduce vaccine hesitancy among caregivers and improve adherence to the recommended childhood vaccine regimen.14




1. Taddio A, McMurtry CM, Shah V, et al Reducing pain during vaccine injections: clinical practice guideline. Can Med Assoc J. 2015;187(13):975-982. [Context Link]


2. Bergomi P, Scudeller L, Pintaldi S, Molin AD. Efficacy of non-pharmacological methods of pain management in children undergoing venipuncture in a pediatric outpatient clinic: a randomized controlled trial of audiovisual distraction and external cold and vibration. J Pediatr Nurs. 2018;42:e66-e72.


3. Moadad N, Kozman K, Shahine R, Ohanian S, Badr LK. Distraction using the BUZZY for children during an IV insertion. J Pediatr Nurs. 2016;31(1):64-72. [Context Link]


4. Taddio A, Appleton M, Bortolussi R, et al Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Can Med Assoc J. 2010;182(18):1989-1995. [Context Link]


5. Yin HC, Cheng SW, Yang CY, Chiu YW, Weng YH. Comparative survey of holding positions for reducing vaccination pain in young infants. Pain Res Manag. 2017;2017:3273171. [Context Link]


6. Kleiber C, McCarthy AM. Evaluating instruments for a study on children's responses to a painful procedure when parents are distraction coaches. J Pediatr Nurs. 2006;21(2):99-107. [Context Link]


7. Sahiner NC, Bal MD. The effects of three different distraction methods on pain and anxiety in children. J Child Health Care. 2016;20(3):277-285. [Context Link]


8. Duckett SA, Bartman M, Roten RA. Choking. In: StatPearls. Treasure Island, Fla.: StatPearls Publishing; 2020. [Context Link]


9. Medical Clown Project. What we do. 2018. [Context Link]


10. Meiri N, Ankri A, Hamad-Saied M, Konopnicki M, Pillar G. The effect of medical clowning on reducing pain, crying, and anxiety in children aged 2-10 years old undergoing venous blood drawing-a randomized controlled study. Eur J Pediatr. 2016;175(3):373-379. [Context Link]


11. Chan E, Hovenden M, Ramage E, et al Virtual reality for pediatric needle procedural pain: two randomized clinical trials. J Ped. 2019;209:160-167.e4. [Context Link]


12. Bilgen BS, Balc[latin dotless i] S. The effect on pain of Buzzy(R) and ShotBlocker(R) during the administration of intramuscular injections to children: a randomized controlled trial. J Korean Acad Nurs. 2019;49(4):486-494. [Context Link]


13. Yilmaz G, Alemdar DK. Using Buzzy, Shotblocker, and bubble blowing in a pediatric emergency department to reduce the pain and fear caused by intramuscular injection: a randomized controlled trial. J Emerg Nurs. 2019;45(5):502-511. [Context Link]


14. American Academy of Pediatrics. Red Book Online. 2018. [Context Link]