A Flu Season Without FluMist? Making Shots Less Painful for Children

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The Checkup

This flu season, many children who were expecting drops in their nostrils are going to get needles in their arms instead.

That’s because a federal health committee decided that nasal flu vaccine (the brand name is FluMist) should no longer be used because it has been less effective in protecting people the past couple of flu seasons. For the first time since FluMist was introduced 13 years ago, everyone is supposed to get the shot.

On hearing this news, some children will shrug and roll up their sleeves. But others will burst into tears at the thought.

Turns out, there’s a lot of research on what makes immunizations less painful — and what helps children handle them without too much distress. Parents can ask the pediatrician in advance for topical anesthetics that can be applied to the skin before the shot is given. And modifications in immunization technique can reduce the pain. For example, in the past, doctors and nurses were sometimes taught to add an extra step — pull back on the syringe to make sure the needle hasn’t inadvertently landed in a blood vessel; that’s no longer recommended.

If you do that, “you add a lot of time to the procedure, you wiggle the needle around and create more tissue trauma,” said Dr. Anna Taddio, professor of pharmacy at the University of Toronto, and the first author on a 2015 set of Canadian clinical practice guidelines for reducing pain during vaccinations.

Much has been written about psychological strategies that can help reduce the distress around immunizations even for young children. In a 2013 review of psychological interventions for “needle-related procedural pain and distress,” researchers found that there was strong evidence that distraction techniques work for children, including such simple strategies as reading stories or watching television.

“The primary message is that the most proven technique is distraction,” said Lindsey Cohen, a professor of clinical psychology at Georgia State University.

“Simple things like breast-feeding or sugar water for kids younger than 1 have been really shown to be pretty powerful in terms of reducing pain,” said Marc Connelly, a pediatric psychologist who is professor of pediatrics at University of Missouri-Kansas City School of Medicine.

For older children, he said, you want something that actively engages the child’s attention, whether it’s reading a book, spinning a pinwheel or blowing bubbles. “Something that changes what they’re attending to is enough to change what the brain does, so the child doesn’t feel it in the same way.”

There is also research, Dr. Cohen said, on how parental behaviors affect children’s distress. There’s some evidence suggesting that more extensive parental reassurance is actually correlated with more prolonged distress — though that doesn’t tell you whether more child distress prompts more parental reassurance, or whether more parental reassurance prolongs the distress.

Parents should instead concentrate on helping with distraction. “Encourage children to deep breathe, count backward from 10,” Dr. Cohen suggested. “More distraction, less reassurance.”

“A lot of parents spend a lot of time on, it won’t hurt too much, it’ll be O.K.,” Dr. Connelly said. “That makes kids worry more.”

On the other hand, parents should help prepare children beforehand, so they know what’s going to happen, and know that they have some strategies for coping.

“Everybody’s anxious when they don’t know what is going to happen to them,” Dr. Taddio said. “The idea is to tell kids with words what’s going to be involved in the procedure — a pinch, pressure on your arm, then it goes away — this bothers some kids, doesn’t bother other kids, we’re going to try to find a way to help you so it doesn’t bother you.”

And then, she said, parents can bring along the iPad or the iPod or whatever is most likely to distract.

But it’s also the clinic’s job to build in distraction techniques, and to build in those other strategies for minimizing the pain of getting shots.

“Immunizations are necessary, but the pain is not always necessary as a side effect,” Dr. Connelly said. “Getting immunizations doesn’t absolutely have to lead to a lot of distress and pain.”

It’s kind of amazing to see, in the clinic, how children vary in their approach to needles.

Even by the age of 5, there are kids who are proud to show you that it’s no big deal, or interested to watch the needle go in — and of course, there are kids who are terrified, crying so hard before they get the shot or the blood draw that it’s hard to believe the actual needle makes any difference at all.

Children who remember extreme distress will be much more frightened the next time around.

“Do your best not to make it a big event,” Dr. Taddio said

You can trace the development of needle fear as children grow up; about a quarter of adults continue to fear needles, she said. Adults who dread needles can also request topical anesthesia to reduce pain, and those with serious needle phobia may find that cognitive behavioral therapy can offer useful strategies, so that they can help their children get that annual flu shot—or come in for their own.

And that, of course, is the whole point: making it easier to do the thing that keeps you safe, said Flor Munoz, an associate professor of pediatric infectious diseases at Baylor College of Medicine who is a member of the committee on infectious diseases at the American Academy of Pediatrics. “The goal of people who vaccinate is to protect their kid against the disease,” Dr. Munoz said.