Original articles

Vaccine-related pain: randomised controlled trial of two injection techniques

Moshe Ipp¹, Anna Taddio², Jonathan Sam³, Morton Gladbach⁴, Patricia C Parkin¹

¹ Division of Pediatric Medicine and Pediatric Outcomes Research Team (PORT), Department of Pediatrics, Faculty of Medicine, University of Toronto, Canada
² Leslie Dean Faculty of Pharmacy, University of Toronto, Toronto, Canada
³ Faculty of Medicine, University of Toronto, Toronto, Canada
⁴ Department of Pediatrics, Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Canada

Moshe Ipp, Department of Paediatrics, Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8; mm.ipp{at}utoronto.ca

Objective: To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.

Design: Randomised controlled trial.

Setting: Single-centre, urban paediatric primary care practice.

Subjects: Healthy infants 4–6 months of age receiving their routine DPTaP-Hib immunisation.

Interventions: Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.

Main outcome measures: Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).

Results: 113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7–35.6) vs 0 s (0–11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9–10.3) vs 0.9 s (0.8–1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6–5.5) vs 1.9 (0.1–3.1) and VAS paediatrician, 2.8 (2.0–5.1) vs 1.4 (0.2–2.4). There were no adverse events.

Conclusion: Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.

Keywords: needle aspiration; injection speed; immunisation; pain

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This article has been cited by other articles:

• Ipp, M., Parkin, P. C., Lear, N., Goldbach, M., Taddio, A. (2009). Order of Vaccine Injection and Infant Pain Response. Arch Pediatr Adolesc Med 163: 469-472 [Abstract] [Full Text]  
• Santoro, N, Grandone, A (2008). Vaccine-related pain: picking up the child soon after the injection reduces the time of crying. Arch. Dis. Child. 93: 449-450 [Full Text]  
• Kemp, C. (2008). Injection technique reduces vaccine-related pain. AAP News 29: 2-2 [Full Text]