No Pain, a Real Gain!

Having come from the trenches of general pediatrics, it was very clear to me that needle phobia and fear of pain was an all-consuming theme for many of the children in my practice, but also teens, and even many parents, as well. When I left my first group and opened my own office, I was determined to address the issue of pain relief for procedures and vaccines head on. My philosophy was to make it so comfortable to come to the doctor, that fear would not set in, thus setting the stage for more trust in doctors and patients who would happily take the time to take care of themselves in the future.
I wholeheartedly agree with Amy Baxter, MD, a pediatric ER physician, who opines that empathy in the medical setting is sorely lacking when it comes to pain management. In 1995, a study was done that showed that 25 percent of children feared needles and 10 percent of adults did, as well. A follow up survey in 2012 revealed that 63 percent of children are now needle phobic and 24 percent of adults are, too. Why has this happened?

  • In 1983, children typically received 6 vaccinations, all given before the age of 2.
  • In 2014, children receive between 30-36 shots before they are 6 and often several in one sitting.
  • As the number of injections has risen and the age at which they are administered has advanced, the rate of needle phobia has risen. No surprise!
  • People that fear needles avoid healthcare.

With an estimated 6 percent of pediatricians conscientiously offering pain relief in the office setting, 94 percent are missing the opportunity to set the stage for a more comfortable office visit, greater compliance with vaccines, and hopefully impressing on future generations that doctors really care about how patients feel, even for seemingly “minor” procedures.
Here are some tools and methods currently available for effective pain relief – not only for vaccines, but also for splinter removal, IV starts, blood drawing and more. It’s important to discuss your desire for pain relief with your physician and create a plan for your child so that you pave a path of comfort and those procedures that need to happen, do so with kindness and less pain. All of these methods are evidence-based and,while they may not erase 100 percent of the pain, they are expected to make a significant dent in the discomfort a child (or adult) may feel. It’s important to do a little of all of these things to make it better – address pain, fear and your child’s focus.

Prepare your child

Prepare your child.

  • Describe what technique will be used and assure your child you will be there to be part of it.
  • DO NOT tell children that “it won’t hurt” – evidence shows this is ineffective.
  • When kids ask “Will it hurt?” say, “You know, a lot of kids aren’t that bothered by it. I don’t know how you will be, but if you want we can do things to make it more comfortable.”
  • Offer pain relief before the procedure, if okayed by your doctor.
  • Collaborate with your child (if old enough) about what tools he/she would like to try for distraction purposes (as distraction is part of ALL pain relief strategies). Make sure you bring the appropriate choices!

Distraction.

  • Taking your anxiety “elsewhere” serves a great purpose. Patients who are appropriately distracted have less pain (muscles are relaxed, rather than tensed during a shot), veins don’t flatten (fear and anxiety makes us release hormones that constrict veins). Distraction should be part of all pain relief strategies.
    • For babies: blowing bubbles, singing, playing with a toy, reading a favorite book, blowing on a pinwheel
    • For toddlers: toys, bubbles, pop-up books, singing, blowing on a pinwheel, directing attention to pictures and objects in the exam room
    • For children: using distraction cards and focusing on specific questions about the objects on the cars, stories, videos, books, telling jokes, listening to music, quizzing about trivia, friends, etc.
    • For teens: tuning on MP3 player, video, books, distracting conversation
  • Stay focused on your child and interact throughout the procedure.
  • Cue your child to stay focused on the distraction activity.
  • Maintain a positive attitude.
  • Praise your child for being willing to engage in distraction techniques.

Babies

  • Breastfeeding during injections (make sure of a good latch) is a good way for baby to release natural pain killers called endorphins. The natural sugars in breast milk trigger their release.
  • Alternately, dipping a pacifier in sugar water or giving sugar water in a bottle (1 packet of sugar with 2 tsp water) within a minute of an injection can also trigger endorphin release.
  • Keep in mind sugar water is for painful procedures only, not as a daily remedy for a fussy baby.
  • Holding your baby sitting upright, in your lap or arms is comforting as it increases a sense of security.
  • If your doctor is not opposed, using a topical anesthetic (like EMLA or ELA-Max), applied 15-30 minutes before injection to the site can give local relief.

Toddlers, Children and Adolescents

  • Plan a few distractions.
  • Administer oral pain relief before the office visit, if desired and okayed by your doctor.
  • Topical anesthetics containing Lidocaine should be applied 15-30 minutes before the anticipated procedure – these require a prescription if not available in your doctor’s office and are pricey (about $2.80/dose for EMLA and $5-7/dose for LMX). So planning ahead is key.
    • How do they work? Topical anesthetic reduces pain by inhibiting the transmission of nerve impulses that tell the brain there is pain.
  • Vapocoolant sprays like Ethyl Chloride or Fluori-Methane are very effective and inexpensive (about $0.25/dose). These cool the skin temporarily to 0 degrees with a 4-7 second spray directed at the injection site. Alternately a cotton ball can be saturated with the spray, held closely to the skin for 5-10 seconds and then the injection given immediately after.
    • We used “Mr. Freeze” in our office very successfully. Some children didn’t like the cold sensation, however, so they would opt for topical anesthetic agents.
    • These sprays must be ordered by your doctor for use in the office, so checking a few weeks ahead of time with the office manager or head nurse is key.
  • Vibration and Cold devices, like Buzzy, are available and studies have shown a very effective decrease in pain for injections, vaccines, procedures, blood draws and even oral injections during dental procedures. Vibration (from the Buzzy device) and Cold (from the frozen wings) essentially override the local nerves’ ability to sense pain (think of this as confusing the local pain brigade) and if held “between the pain and the brain” for 15-60 seconds before the procedure, combined with the use of distraction cards (and good parental planning), Buzzy can be used over and over again through a child’s life.
    • For children, teens and adults who have to inject medications daily (for growth hormone, insulin, arthritis medications, and others), or prick fingers multiple times to check blood sugars, the use of a device like this can make the difference between wellness and compliance, or a daily fight.
    • This device was invented by Amy Baxter, MD, a pediatric ER physician who is determined to change the face of procedural pain from fear to contentment.

No pain really is a real gain! Good luck!

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