Best evidence statement (BESt). Reducing pain for children and adolescents receiving injections.
General
Guideline Title
Best evidence statement (BESt). Reducing pain for children and adolescents receiving injections.
Bibliographic Source(s)
- Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Reducing pain for children and adolescents receiving injections. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Jan 16. 9 p. [9 references]
Guideline Status
This is the current release of the guideline.
Recommendations
Major Recommendations
The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the “Major Recommendations” field.
- It is strongly recommended that age-appropriate interventions with strong evidence, be used to reduce pain during injections (Chambers et al., 2009 [1a]; Shah et al., 2009 [1a]; Taddio et al., 2009 [1a]; Uman et al., 2010 [1a]; Kassab et al., 2012 [1b]; Harrington et al., 2012 [2a]). See cells marked “Strongly” in Table 1 below. See Table 2 in the original guideline document for intervention-specific citations.
Note : Combining an intervention with distraction is more effective than a single intervention (Uman et al., 2010 [1a]).
- It is recommended that, when strongly recommended interventions are not sufficient or feasible to reduce pain during injections, additional age-appropriate consensus-based interventions are used (Local Consensus [5]). See cells marked “Local Consensus” in Table 1 below. See Table 2 in the original guideline document for intervention-specific citations.
Note : Combining an intervention with distraction is more effective than a single intervention (Uman et al., 2010 [1a]).
Table 1: Recommendations for Interventions by Developmental Level to Reduce Pain during Injections
| Infants | Toddlers | Preschool-age Children | School-age Children | Adolescents | |
|---|---|---|---|---|---|
| Sucrose solution* | Strongly | -- | -- | -- | -- |
| Breastfeeding | Strongly | -- | -- | -- | -- |
| Holding the infant | Strongly | -- | -- | -- | -- |
| Distraction* , age-appropriate | Strongly | Strongly | Strongly | Strongly | Strongly |
| Topical agent , containing lidocaine/prilocaine | Strongly | Strongly | Strongly | Strongly | Strongly |
| Sequential injection* | Strongly | Strongly | Strongly | Strongly | Strongly |
| Rapid combined injection* | Strongly | Strongly | Strongly | Strongly | Strongly |
| Preparation* , developmentally appropriate | -- | Local consensus | Strongly | Strongly | Local consensus |
| Positioning | -- | Local consensus | Strongly | Local consensus | Local consensus |
| Breathing exercises*† | -- | -- | Strongly | Strongly | Local consensus |
| Hypnosis* | -- | -- | Strongly | Strongly | Strongly |
Note : See the original guideline document for additional details on interventions.
- See the definitions under “Supporting Information” in the original guideline document.
†Including blowing bubbles, using party blowers, deep breathing, and breathing exercises
Definitions:
Table of Evidence Levels
| Quality Level | Definition |
|---|---|
| 1a† or 1b† | Systematic review, meta-analysis, or meta-synthesis of multiple studies |
| 2a or 2b | Best study design for domain |
| 3a or 3b | Fair study design for domain |
| 4a or 4b | Weak study design for domain |
| 5a or 5b | General review, expert opinion, case report, consensus report, or guideline |
| 5 | Local Consensus |
†a = good quality study; b = lesser quality study
Table of Recommendation Strength
| Strength | Definition |
|---|---|
|
It is strongly recommended that…
It is strongly recommended that…not… |
When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations) |
|
It is recommended that…
It is recommended that… not… |
When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens. |
| There is insufficient evidence and a lack of consensus to make a recommendation… | |
Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Conditions requiring injections
Guideline Category
- Management
Clinical Specialty
- Family Practice
- Internal Medicine
- Pediatrics
Intended Users
- Advanced Practice Nurses
- Nurses
- Physician Assistants
- Physicians
Guideline Objective(s)
To evaluate, in pediatric patients receiving injections, if pharmacological interventions (including topical anesthetic agents), psychological, and physical interventions versus no intervention, reduces pain during injections
Target Population
Children ranging from infancy to eighteen years of age, receiving an injection
Interventions and Practices Considered
- Sucrose solution
- Breastfeeding
- Holding the infant
- Distraction (age-appropriate)
- Topical agent containing lidocaine/prilocaine
- Sequential injection
- Rapid combined injection
- Preparation (developmentally appropriate)
- Positioning
- Breathing exercises (including blowing bubbles, using party blowers, deep breathing)
- Hypnosis
Major Outcomes Considered
Reduced pain level
Methodology
Methods Used to Collect/Select the Evidence
- Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Search Strategy
- Databases : BMJ, CINAHL, Cochrane Database, ERIC, Nursing Reference Center, Psycho Info, PubMed
- Search Terms : Children, injections, immunization, pain, distress, EMLA, LMX-4, Gebauers Spray and Stretch, Zingo, Paineze, Synera, J-tip, Pediatric, Ice
- Limits, Filters, Search Dates : 1992 – January, 2012, Articles in English only
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
- Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Table of Evidence Levels
| Quality Level | Definition |
|---|---|
| 1a† or 1b† | Systematic review, meta-analysis, or meta-synthesis of multiple studies |
| 2a or 2b | Best study design for domain |
| 3a or 3b | Fair study design for domain |
| 4a or 4b | Weak study design for domain |
| 5a or 5b | General review, expert opinion, case report, consensus report, or guideline |
| 5 | Local Consensus |
†a = good quality study; b = lesser quality study
Methods Used to Analyze the Evidence
- Review of Published Meta-Analyses
- Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
- Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Table of Recommendation Strength
| Strength | Definition |
|---|---|
| It is strongly recommended that… It is strongly recommended that…not… | When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations) |
| It is recommended that… It is recommended that… not… | When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens. |
| There is insufficient evidence and a lack of consensus to make a recommendation… |
Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
- Peer Review
Description of Method of Guideline Validation
This Best Evidence Statement has been reviewed against quality criteria by two independent reviewers from the Cincinnati Children’s Hospital Medical Center (CCHMC) Evidence Collaboration.
Evidence Supporting the Recommendations
References Supporting the Recommendations
- Chambers CT, Taddio A, Uman LS, McMurtry CM, HELPinKIDS Team. Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther. 2009;31(Suppl 2):S77-S103. [40 references] PubMed
- Harrington JW, Logan S, Harwell C, Gardner J, Swingle J, McGuire E, Santos R. Effective analgesia using physical interventions for infant immunizations. Pediatrics. 2012 May;129(5):815-22. PubMed
- Kassab MI, Roydhouse JK, Fowler C, Foureur M. The effectiveness of glucose in reducing needle-related procedural pain in infants. J Pediatr Nurs. 2012 Feb;27(1):3-17. PubMed
- Shah V, Taddio A, Rieder MJ, HELPinKIDS Team. Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: systematic review and meta-analyses. Clin Ther. 2009;31 Suppl 2:S104-51. [97 references] PubMed
- Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V, HELPinKIDS Team. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31(Suppl 2):S48-76. [73 references] PubMed
- Uman LS, Chambers CT, McGrath PJ, Kisely SR. Psychological interventions for needle-related procedural pain and distress in children and adolescents. In: Cochrane Database of Systematic Reviews [database online]. Issue 11. Hoboken (NJ): John Wiley and Sons Ltd.; 2010
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Reduced pain during injections
Potential Harms
- Gagging and coughing were the minimal side effects noted when using the sucrose solution in infants
- Lidocaine-prilocaine had minimal transient local skin reaction
Qualifying Statements
Qualifying Statements
This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.
Implementation of the Guideline
Description of Implementation Strategy
Applicability Issues
Breastfeeding in infants, developmentally supportive positioning, and injection technique (the use of sequential injection and rapid combined injection) do not require additional funds, resources, or staffing. The use of developmentally appropriate preparation and distraction, deep breathing, and bubble blowing/party blowers can be taught to patients and caregivers. These interventions fall within the scope of practice of a Child Life Specialist. When involved, they can give recommendations to patients and caregivers on which techniques are most appropriate. At that time, the child and family can choose which of these options will best meet their needs. The additional time needed to involve these techniques or a Child Life Specialist may be counterbalanced by more cooperative patients, shorter length of time spent giving an injections, as well as increase family satisfaction. The use of sucrose and lidocaine/prilocaine poses a monetary cost. However, evidence shows the use of these products reduces pain for infants, children, and adolescents. Use of these products may increase compliance with injections, specifically vaccinations, in turn offsetting costs of pharmacological agents and increasing the overall health and wellbeing of children.
Implementation Tools
- Audit Criteria/Indicators
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
- Getting Better
- Staying Healthy
IOM Domain
- Effectiveness
- Patient-centeredness
Identifying Information and Availability
Bibliographic Source(s)
- Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Reducing pain for children and adolescents receiving injections. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Jan 16. 9 p. [9 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2013 Jan 16
Guideline Developer(s)
- Cincinnati Children’s Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding
Cincinnati Children’s Hospital Medical Center
Guideline Committee
Not stated
Composition of Group That Authored the Guideline
Group/Team Members : Melissa Liddle, BS, CCLS, CTRS, Inpatient Psychiatry; Annette Bonjour, BS, CCLS, Division of Developmental and Behavioral Pediatrics; Courtney Tyra, MS, CCLS, GI/Colorectal Center for Children; Lauren Kathman, BS, CCLS, Complex Airway & Pediatric Primary Care Center; Jennifer Staab, MS, CCLS, Child Life Specialist at Denver Children’s Hospital; Mary Ellen Meier, MSN, RN, CPN, Center for Professional Excellence and Business Integration: Research and Evidence Based Practice: Evidence Based Practice Mentor
Financial Disclosures/Conflicts of Interest
Conflict of interest declaration forms are filed with the Cincinnati Children’s Hospital Medical Center Evidence-based Decision Making (CCHMC EBDM) group.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Available from the Cincinnati Children’s Hospital Medical Web site.
Availability of Companion Documents
The following are available:
- Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
- Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 1 p.
- Table of evidence levels. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
In addition, suggested process or outcome measures are available in the original guideline document.
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on April 9, 2013.
Copyright Statement
This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:
Copies of this Cincinnati Children’s Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:
- Copies may be provided to anyone involved in the organization’s process for developing and implementing evidence based care
- Hyperlinks to the CCHMC website may be placed on the organization’s website
- The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
- Copies may be provided to patients and the clinicians who manage their care
Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.
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