One of the questions not significantly highlighted in the article was if individuals would participate in a pilot study for NAPNAP toolkit. Out of more than 300 respondents, 11 stated that they would be interested, and only 1 committed but later backed out because of COVID-19.

[The effect of the COVID-19 pandemic] was not assessed during this survey but adds a significant barrier to immunization and pain prevention going forward. For a variety of reasons, immunization rates plummeted by up to 95% for certain vaccines across the country throughout the pandemic.4,5 As our nation and the world is going through a mass immunization effort and catch-up childhood immunizations, we need to include pain management during these encounters. 


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Q: In addition to the toolkit, what are other recommendations on how to resolve these barriers to vaccine pain prevention in practice?

Dr Cwynar: Clinicians can address barriers in a variety of ways. Being an office or unit champion can help to ignite change. Providing education to families in the waiting room, sending education through patient portals or in the mail prior to appointments in which immunization is expected, taking time to learn the various interventions, and providing all involved staff members with the education to confidently carry out interventions are just a few ways that clinicians can start to overcome barriers. 

One of the top barriers identified through the national survey was time. To address this barrier, clinicians need to recognize that addressing immunization-associated pain is a critical part of patient care. We know that one of the top side effects associated with immunizations is pain. We also know that parents are concerned about pain associated with immunizations and want to do something to make the experience more comfortable.

During this very critical time, in the midst of a pandemic, we are also seeing plummeting immunization rates that put the general population and our more vulnerable populations at increased risk for contracting diseases that we rarely see or haven’t seen in years. Given this state of affairs, clinicians need to prioritize immunizations. As a part of this, immunizations should be readily available and made as painless as possible. Creating a patient-specific plan for pain management during immunizations should become a part of standard immunization practice. 

Anecdotally, I believe that a huge barrier to utilization of pain prevention techniques during immunizations is attitude and the more general health care culture. I have worked with many providers who have been resistant to utilizing these interventions with reasoning ranging from “It doesn’t work,” to “It really isn’t that painful,” to “It isn’t safe.” None of these statements have been supported by research. This barrier, I believe, is very significant to getting these interventions utilized consistently at the bedside. 

Q: What are the implications for both systems and individual practitioners in terms of increasing education regarding pain prevention techniques that can be used during immunizations?

Dr Cwynar: Health care systems can adopt educational modules (like the one created by the NAPNAP Immunization Special Interest Group) as a part of staff training. Education should be integrated into staff orientation for anyone administering injections (immunizations, insulin, enoxaparin, heparin, etc.), individuals recommending injections, and staff supporting with injections (such as technicians and child life specialists).

Health care systems should adopt standardized practices around utilizing these interventions, helping to create a culture of pain prevention during injections. Individual practitioners can advocate for standards of practice, changes in policy, access to resources, and champion practice/unit-based quality improvement projects. 

Implementing consistent use of pain prevention techniques during immunizations and other injections will provide a better patient experience, increase immunization compliance, help address short-term and long-term consequences associated with immunization-associated pain, and build trust between patient-family-provider triads. On a system and individual level, education comes with time and monetary costs in some cases, but this cost is minimal given the significant benefits to patients. 

Q: What are some of the most pressing remaining needs in this area?

Dr Cwynar: I think one significant need going forward is national clinical guidelines on this topic. Currently, none exist in the United States. Setting a national standard will help bring this issue to the attention of clinicians and institutions alike. 

References

1. Cwynar C, Cairns C, Eden L, Vondracek H, Eller B. Barriers to the use of pain prevention techniques during immunization. J Pediatr Health Care. 2021;35(2):e1-e3. doi:10.1016/j.pedhc.2020.12.007

2. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics. 2011;127 Suppl 1:S92-9. doi:10.1542/peds.2010-1722N

3. Taddio A, Appleton M Bortolussi R. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ. 2010;182(18):E843-E855. doi:10.1503/cmaj.101720

4. National Foundation for Infectious Diseases. Issue brief: the impact of COVID-19 on US vaccination rates. August 2020. Accessed April 19, 2021. https://www.nfid.org/keep-up-the-rates/issue-brief-the-impact-of-covid-19-on-us-vaccination-rates/

5. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591-593. doi:10.15585/mmwr.mm6919e2

This article originally appeared on Clinical Advisor