Vaccination pain management for children: Guidance for health care providers

On this page

• Overview
• Improving the vaccination experience
• Infants and children under 3 years
• Children 3 to 17 years
• Children of all ages
• Create positive vaccination spaces

Overview

Vaccination begins in infancy and plays an important role in keeping people healthy throughout every stage of life. Early experiences can influence how caregivers and children will respond to vaccination later on in life.

You can help make vaccinations a more positive experience for children by minimizing their pain and fear. This can:

• build trust with caregivers
• improve a child's comfort and experience
• increase the likelihood of future vaccine acceptance

Improving the vaccination experience

There are a number of ways to make the vaccination experience more comfortable for children and their caregivers. The CARD system  is an evidence-based framework for delivering vaccinations that reduces stress-related responses:

• Comfort: provide comfortable spaces for vaccination with available seating
• Ask: let people ask questions and address their concerns
• Relax: reduce the number of things that might scare them
• Distract: take attention away from the procedure for those who request it

Learn more about:

• The CARD system

Infants and children under 3 years

Discuss options ahead of time that require planning, such as topical anesthetic medications and sweet solutions (sucrose water).

Be calm, positive and attentive to the child, and encourage the caregiver to do the same.

Encourage breastfeeding before, during and after the vaccination. Alternatively, encourage the use of a bottle or pacifier.

Provide physical comfort during vaccination by positioning the child on the caregiver's lap throughout the vaccination process for comfort. Skin to skin contact can be used by the caregiver for infants one month or younger.

If the child is being held, ensure that the site of vaccination is easily accessible.

Suggest the caregiver use a distraction, such as toys or talking to the child.

Learn more about:

• Safety information regarding topical anesthetics and serious adverse events

Children 3 to 17 years

Encourage the use and combination of strategies to reduce pain and fear. Some coping strategies may require planning, for example:

• distraction, such as:
  • toys
  • music
  • games
  • talking
  • singing
  • electronic devices
• topical anesthetic medications
• relaxation techniques, such as deep belly breathing

Encourage caregivers to be present during vaccination to support the child if possible.

Be calm, positive, supportive and attentive to the child, and encourage the caregiver to do the same.

Position the child or adolescent upright during vaccination. It may be necessary for the caregiver to hold younger children in a supportive position to keep them comfortable and still.

Older children and adolescents who have had a previous stress related experience or are very anxious may prefer to lie down instead.

Prevent fainting by identifying warning signs like:

• nausea
• dizziness
• sweating
• weakness
• headaches

If these symptoms occur, encourage the use of the muscle tension technique. Tell the child to:

1. Squeeze the muscles in their legs and stomach.
2. Keep squeezing for 10 to 15 seconds until their face feels warm.
3. Relax for 20 to 30 seconds and then repeat a few times or until they start feeling better.

Children of all ages

Invite children to use their preferred coping strategies to help ease pain and fear during vaccination.

Educate caregivers and children about pain management strategies before and on the day of the appointment. Answer questions or concerns that the child or their caregivers have about vaccination.

Talk to caregivers and children about applying a topical anesthetic medication before the appointment.

Communicate using neutral language and do not use:

• words that elicit fear, such as ‘the needle stings’
• repetitive reassurance, such as ‘don't worry, it's okay, you'll be fine’

Do not promise that the vaccination will not hurt or that everything is okay. Describe sensations using language like ‘pressure’ or ‘pinch’. Invite the child to report on how they feel.

Avoid visual cues that may trigger fear such as preparing the vaccine in front the child. Consider obscuring your workspace with posters or a privacy screen.

Ask the child and caregivers about their preferences. For example, ask ‘Do you want to be distracted?’

Do not impose coping interventions that may:

• increase distress
• counter the child’s preferred coping strategy

Do not aspirate during injection.

Inject vaccines quickly.

If giving multiple separate injections, start with the vaccine that causes the least amount of pain.

Select the appropriate needle length and gauge to minimize pain.

It can help both children and caregivers have a positive experience with vaccination if you share information about these strategies:

• in a culturally safe manner
• using accessible plain language

If a child has a high level of needle fear, consider referral to a mental health expert such as a psychologist. Treating needle fear can help children and caregivers accept vaccination and other needle procedures.

Create positive vaccination spaces

Help children and caregivers to prepare by sharing information about managing pain and fear:

• ahead of time
• on the day of vaccination

Create vaccination settings that are visually appealing. For example, display posters for children to look at that include child-friendly scenes or activities.

Include separate waiting and vaccination space.

Provide private spaces for vaccination, whenever possible.

Provide seating for caregivers.

Reduce visual cues that elicit fear (such as needles) and minimize excessive noise and activity to promote calmness.

Include references to clinical practice guidelines and CARD system.

Related links

• Immunization stress-related responses (PDF, World Health Organization)
• Immunization pain management: Clinician focus (Immunize Canada)
• Pain management during immunizations for children (Immunize Canada)
• Health worker training module: Managing pain during vaccine administration (CANVAX)
• Canadian Immunization Guide: Techniques to decrease immunization injection pain
• CARD system: Coping with fear and anxiety for parents and caregivers (Immunize Canada)
• Provincial and territorial routine and catch-up vaccination schedule for infants and children in Canada
• Clinical practice guideline on management of vaccination pain from birth to adulthood (Immunize Canada)
• Communicable Disease Control Manual: Reducing Immunization Injection Pain (PDF, BC Centre for Disease Control)
• Meeting of the Strategic Advisory Group of Experts on Immunization: Conclusions and recommendations reducing pain and distress at the time of vaccination (PDF, World Health Organization)