Learning outcome, instructions for completing the evaluation, and ... - Pediatric Nursing · 2017-06-20 · PEDIATRIC NURSING /November-December 2 016/Vol. 42/No. 6 267 V accinations

PEDIATRIC NURSING/November-December 2016/Vol. 42/No. 6 267

V accinations are one of themost common proceduresin childhood (Uman et al.,2013). A child may have as

many as 22 injected vaccinations byone year of age, eight more by fouryears of age, and 10 more by 11 yearsof age (Advisory Committee of Immu -nization Practices [ACIP], 2013).These needlesticks are often associat-ed with anxiety, avoidance, somaticsymptoms, and considerable distress(Taddio, Ilersich, Ipp, Kikuta, & Shah,2009). Distressing procedures canplace children at risk for impairedcoping mechanisms during futuremedical visits, vaccinations, and pro-cedures (Cohen et al., 2006; Kennedy,Luhmann, & Zempsky, 2008; MacLaren& Cohen, 2007). Children react moreintensely to vaccinations if they havehad previous negative medical experi-ences compared to those who havehad fewer negative experiences(Walco, 2008).

Parents can also feel distressed,concerned, and overwhelmed whentheir children receive immunizationsand may be dealing with needle pho-bias of their own, resulting in delay orrefusal of vaccinations (Gaskell,Binns, Heyhoe, & Jackson, 2005;Luthy, Beckstrand, & Peterson, 2009).Multiple surveys of parents andpatients revealed that fear of pain is acontributing factor into vaccine hesi-tancy and refusal (Bhat-Schelbert etal., 2012; Kempe et al., 2011; Miller,Wickliffe, Jahnke, Linebarger, &Humiston, 2014).

For clinicians, procedures withchildren who have poor coping skills

Continuing Nursing Education

Vaccinations are often associated with anxiety, avoidance, and considerable dis-tress for children and parents. These issues can also impair coping during futurehealth care visits. Parents, children, and clinicians can benefit from strategiesdesigned to enhance coping. However, an important barrier to implementation ofcoping strategy interventions is lack of knowledge among both parents and staff.We produced two sets of tailored handouts designed to enhance education forprimary care staff and parents using 41 clinical guidelines, reviews, and random-ized controlled trials. Articles were selected from vaccine-specific literature byrelevance and practicality for primary care. Handouts provide suggestions forparent and staff interventions before, during, and after vaccinations, focusing ontechniques that are effective, cost-efficient, and adaptable. For children of allages, tailored adult vocabulary and tone can also support coping.

Evidence-Based Recommendations For Reducing Pediatric Distress During

VaccinationKristen E. Stevens and Donna J. Marvicsin

Learning outcome, instructions for completing the evaluation, and statements of disclosure can be found on page 274.

Kristen E. Stevens, MS, CPNP, is a ClinicalInstructor, George Washington University,Ashburn, VA.

Donna J. Marvicsin, PhD, PNP-BC, CDE,is a Clinical Assistant Professor, Universityof Michigan, Ann Arbor, MI.

can be unpleasant, stressful, and time-consuming (Schecter et al., 2007).Although there are multiple effectivecognitive behavioral and pharmaco-logic strategies to help families copewith needlesticks, not many of thesestrategies are implemented (Harrison,Elia, Royle, & Manias, 2012; Taddio,Chambers et al., 2009). Barriers to im -plementation of strategies includecost, effort required, lack of consistentuse, and lack of staff and parent edu-cation to its effectiveness. Staff mis-conceptions can be the result of per-sonal biases and inadequate knowl-edge or skills. Examples of commonmyths are that young children do notremember painful procedures and thatpain-reducing measures take too longto implement (Royal AustralasianCollege of Physicians [RACP], 2006a).In addition, adult language, tone, anddoting behaviors may unknowinglyincrease a child’s distress (RACP,2006a; Schecter et al., 2007).

To overcome some of these barri-ers, we developed two handouts sum-marizing evidence-based findingsaccording to patient age groups; one istailored for parents and the other is forstaff. Our handouts recommend beha -vioral strategies for use in the primarycare setting during routine vaccina-tions, with a goal of decreasing patientdistress before, during, and after ad -

ministration. For all age groups, teach-ing staff to coach parents and childrenthrough procedures can help relieveanxiety and distress (MacLaren &Cohen, 2005; RACP, 2006a). Our goalwas to increase education and knowl-edge about coping behaviors amongstaff, patients, and families.

Literature SearchA literature search of CINAHL,

Medline, PubMed, and the CochraneDatabase was performed using combi-nations of the following terms: pedi-atric, vaccination, immunization, coping,and needlestick. Guidelines, reviews,meta-analyses, and randomized con-trolled trials (RCTs) were used to pro-duce two sets of tailored handouts.Study populations ranged from new-born to 18 years, varying according toage-appropriateness of interventions.Studies used a wide variety of objec-tive pain scales in addition to parent-reported and patient-reported subjec-tive scales. The following is a summa-ry of the evidence that we incorporat-ed into the handouts.

Findings that Impact All Age Groups

Before vaccination. Staff are in akey position to effectively help relieveanxiety and distress through coach-ing. Nearly 35% of parents in one

268 PEDIATRIC NURSING/November-December 2016/Vol. 42/No. 6

study reported that pain and anxietywere major concerns regarding im -munizations, and a parent’s level ofcomfort greatly influences a child’sresponse; therefore, staff should assessa family’s previous experiences andexpectations to help build on effec-tive coping strategies (Luthy et al.,2009; McMurtry, McGrath, Asp, &Chambers, 2007; Riddell, Stevens,Cohen, Flora, & Greenberg, 2007) (seeFigure 1). Families may want to bringfamiliar security and distractionitems, like toys or books.

During vaccine administration.Simple instructions for the parent atthe beginning of the encounter may behelpful to both parent and child. Theseinstructions include how to positionthe child or when to take deep breaths.In addition, staff should incorporateparent and patient preferences for com-fort holds and distraction techniques(Hensel, Morson, & Preuss, 2013;MacLaren & Cohen, 2007) (see Figures2, 3, and 4). Clinicians should knowthat injection order and techniquematter: 1) use a rapid injection tech-nique without aspiration, 2) choose anappropriate needle size, and 3) injectmultiple vaccinations simultaneouslywhen possible (Ipp, Taddio, Sam,Goldbach, & Parkin, 2007; Schecter etal., 2007; Taddio et al., 2010). Rapidinjection is pragmatic and results in adecreased pain response (Ipp et al.,2007) (see Figure 4).

After administration. After theprocedure, continue distraction tech-niques and provide tangible rewardsfor younger children, as well as specif-ic praise for things they did well, espe-cially actions that the clinician re -quested, such as staying still (Gaskellet al., 2005). Teens may also respondwell to specific, positive feedback.Parents, particularly anxious ones,may also benefit from positive rein-forcement for their roles as coaches(Gaskell et al., 2005) (see Figure 4).Patients and families may also wel-come a vaccination record that con-tains both vaccinations given, as wellas a list of personalized coping strate-gies for use at future visits.

Recommendations For Vaccination PracticeAccording to DevelopmentalStage

Infants. Infants and newbornsbenefit from comfort measures, suchas oral stimulation (pacifier or breast-feeding) and swaddling, or snuglywrapping the child’s upper body in a

The attitude, demeanor, and lan-guage use of the parents and clini-cians present at administration cangreatly influence a child’s level of dis-tress, particularly when the parent isupset or anxious (RACP, 2006a; Riddellet al., 2007; Schecter et al., 2007).Excessive reassurance, apologies, andthe use of comments like “I’m sorry”and “It’ll be all right” may increase achild’s distress (Chambers et al., 2009;Luthy et al., 2009; McMurtry et al.,2007; RACP, 2006a). Positive instruc-tions, such as “this is the time to holdstill” should replace “don’t move.”

School age. School-age childrenare capable of more complex learning,and this wide range from preschool (3to 4 years) to preteens (11 to 12 years)encompasses the processes of becom-ing more independent and engagingin goal-directed exploration (Bickley& Szilagi, 2009). Studies recommendage-appropriate preparatory discus-sion, ample opportunity to ask ques-tions, and acceptable choices for thechild, such as which arm to use or thecolor of bandage (Chambers et al.,2009; RACP, 2006a; Schecter et al.,2007; Uman et al., 2013). Instructionsand explanations should still be con-crete (Bickley & Szilagi, 2009).

Review studies endorsed clini-cian-coached distraction (Chamberset al., 2009; Schecter et al., 2007;Uman et al., 2013). Distraction waspar ticularly effective; studies used avariety of cognitive, visual, and audi-tory distractions that included deepbreathing, guided imagery, interactivetoys (pinwheels, wands, and bubbles),and coached activities, like picturebooks and movies (Birnie et al., 2014,Boivin et al., 2008; RACP, 2006a; Taddioet al., 2010). Similarly, non-pro ce -dural talk, such as asking about petsor school, is recommended (Cohen,2008; Gaskell et al., 2005; RACP,2006a) (see Figure 3). Search gamesand interactive toys can help distractchildren from fixating on the proce-dure (Boivin et al., 2008).

From a practical perspective,providers may encourage willing par-ents to take on a supportive coachingrole after they receive instructions,role modeling, and information aboutthe vaccination (Boivin et al., 2008).It is worthwhile to give parents a fewinstructions about non-proceduraltalk rather than “soothing” words orsaying, “It won’t hurt” (MacLaren &Cohen, 2007; RACP, 2006a; Taddio etal., 2010).

Studies also investigated physical

blanket with upper thighs exposed(Cohen, 2010; RACP, 2006b). Clini -cians can involve parents during theprocedure with these interventions(RACP, 2006b).

Substances, such as sugar solu-tions, and breastfeeding have beenfound to be short-acting and effectiveoptions for children under sixmonths of age (Cohen, 2008; Curry,Brown, & Wrona, 2012; Dilli, Küçük,& Dallarthe, 2009; Hatfield, Gusic,Dyer, & Polomano, 2008; Hensel etal., 2013; Shah, Taddio, & Rieder,2009). Similarly, pacifiers and non-nutritive sucking are also options(RACP, 2006b).

Physical interventions, such asswaddling and warmth, also decreasedistress (Cavender, Goff, Hollon, &Guzetta, 2004; Gray, Lang, & Porges,2012; Harrington et al., 2012; RACP,2006b; Taddio, Ilersich et al., 2009).Further, older infants who are in theprocess of learning cause/effect andobject permanence may benefit fromdistraction items, such as rattles,beads, or a flashlight (MacLaren &Cohen, 2007).

Toddlers. Toddlers, from one tothree years old, transition from sensori-motor learning (for example, whentoys with flashing lights or sounds areentertaining) to preoperational think-ing, where they can engage in play,sing songs, and listen to stories (Bickley& Szilagi, 2009). Studies did not specif-ically address preschool as a separatedevelopmental stage. Some childrenmay benefit from interventions aimedat toddlers, while others might be morereceptive to school-age interventions.

Preparatory explanations shouldbe simple and concrete, while jewelry,bubbles, pinwheels, and cartoons pro-vide distraction (Chambers, Taddio,Uman, & McMurtry, 2009). Singingalong to music, directed movie watch-ing, and reading a story with focusedquestions are also effective (Chamberset al., 2009).

Comfort holds, where the parentor assistant holds the child snugly,help children feel secure and comfort-able while keeping limbs accessiblefor intervention (Taddio et al., 2010)(see Figure 4). For children who havegood head and trunk control, a sittingposition nestled in a parent’s armsprovides both emotional security andphysical immobilization in a non-threatening manner, as opposed tosupine positions (Hensel et al., 2013;Taddio et al., 2010). Either a parent orstaff assistant may be the holder.

Evidence-Based Recommendations for Reducing Pediatric Distress During Vaccination


At�hom

e,�after�y

our�s

hots…

Before�yo

u�com

e�to�t

he�of

fice�o

r�clin

ic…

Figure 1.

Tips for P

arents and Fam

ilies – Front of H

andout



After�its̒�ov

er…

SAMPLE

COMFORT

HOLDS

with

�2�health

care�pr

ovide

rs

NOTE:

Strategie

s�for�du

ring�t

he�pr

ocedure…Figure 2.

Tips for P

arents and Fam

ilies – Ba

ck of H

andout


NOTE:

A�multimodalapproach�works�best:try�a�varietyof�distractions!

Tips�for�clinical�staffto�make�shots�and�procedures�less�scary

Figure 3.Tips for Clinical Staff – Front of Handout



SAMPLECOMFORTHOLDSwith�2�healthcare�providers

Injection�technique�notes:

Figure 4.Tips for Clinical Staff – Back of Handout


distractions. Pressure near the injec-tion site to relieve pain was effectivein two studies, (Taddio, Ilersich et al;2009; Taddio et al., 2010). A vibratingtoy was part of an effective multimodalapproach (Berberich & Landman, 2009).

For school-age children, thestrongest evidence supports multi-modal interventions that incorporatecognitive-behavioral techniques(Berberich & Landman, 2009; Boivinet al., 2008; RACP, 2006a; Shah et al.,2009; Taddio et al., 2010; Uman et al.,2013) (see Figure 3). Most interven-tions combine a form of distractionwith pharmacologic therapy. How -ever, a wide variety of non-pharmaco-logic interventions was used in multi-modal approaches, some using up tothree simultaneous techniques. Givenvarious child temperaments, a multi-modal intervention may be the mosteffective approach for each patient.

The following sample scenarioincorporates physical, cognitive, andbehavioral distractions: a parentholds the child in a “bear hug” (seeFigure 4) while the clinician coachesthe child using a movie for distractionand gives cues about what the childmight feel (“I’m going to wash yourarm, and it’s going to feel cold”). Tofurther engage the child, the parentasks questions about the movie plotand characters (“What do you thinkwill happen next?”).

Adolescents. Adolescents mayalso respond well to verbal, auditory,cognitive, and physical distractions.For example, playing music on speak-ers and non-procedural talk, such as“What did you do this summer?” are useful distraction techniques(Chambers et al., 2009; Kristjásdóttir &Kristjánsdóttir, 2011). Adolescents areexpected to be developing a sense ofidentity and establishing independ-ence; therefore, clinicians should allowadolescents the opportunity to takecontrol by offering choices (Bickley &Szilagi, 2009). For example, cliniciansmay allow the patient to decide if he orshe wants a parent present. Otheroptions include preference to watch ornot watch the preparation of the vac-cine and the injection, in addition toand offering multiple injections to begiven either one at a time or at thesame time. An important considerationis determining how much explanationthe patient may want about the vac-cine. In addition, distraction questionsmay still be useful in reducing anxietyand to reveal potential topics for dis-cussion with a healthcare provider.

Conclusion and FutureDirections

Vaccinations at a primary careoffice can be a stressful experience forchildren and parents. Patient-cen-tered care requires that patients andfamilies are knowledgeable aboutboth what vaccinations the child willreceive, and about strategies to man-age pain and anxiety. Frequent andconsistent implementation of evi-dence-based recommendations is apressing challenge. Printed patienteducation material, written at theappropriate reading level, can em -power parents and families to becomeactive and engaged partners in theirhealthcare. Regarding these educa-tional materials, evaluation of imple-mentation, family and staff satisfac-tion, and continued use are nextsteps.

More broadly, further researchshould address the relationshipbetween coping skills and barriers tovaccination, such as anxiety and lackof staff and parent education. Forexample, reduced patient distress mayhelp increase adherence to vaccineschedules. More information abouttiming and amount of educationalinterventions (how far in advanceaccording to developmental age)would be useful, in addition to clarifi-cation of the adult coaching role(Birnie et al., 2014). Additionally, re -search into combination vaccines andless painful formulations (like intra -nasal or transdermal) may also assistadherence rates by reducing the num-ber of needlesticks (Dodd, 2003;Gildengil et al., 2009).

ReferencesAdvisory Committee on Immunization

Practices (ACIP). (2013). Recommen -ded immunization schedule for personsaged 0 through 18 years – United States,2013. Atlanta, GA: Centers for DiseaseControl. Retrieved from http:// www.cdc.gov/mmwr/preview/mmwrhtml/su6201a2.htm

Berberich, F.R., & Landman, Z. (2009).Reducing immunization discomfort in 4-to 6-year-old children: A randomizedclinical trial. Pediatrics, 124, e203-e209.doi:10.1542/peds.2007-3466

Bhat-Schelbert, K., Lin, C.J., Matam -banadzo, A., Hannibal, K., Nowalk,M.P., & Zimmerman, R. (2012) Barriersto and facilitators of child influenza vac-cine – Perspectives from parents,teens, marketing and healthcare profes-sionals. Vaccine, 30, 2448-2452. doi:10.1016/j.vaccine.2012.01.049

Handout DevelopmentOur goal in developing these

handouts was to educate staff andfamilies about practical coping strate-gies that are quick and easy to imple-ment. The readability is aimed to ad -dress a broad range of literacy levels.We have included many ideas forinspiration about distraction tech-niques because parents and cliniciansmay want or need to try several strate-gies before finding the best approachfor a particular child.

Topical Local Anesthetics And Sucrose

Many studies evaluated topicallocal anesthetics, both alone and incombination with other therapies. Toincrease use across a variety of prac-tice sites that have varying pharmaco-logic availability, we omitted topicalanesthetics from the handouts. Rath -er, we chose to emphasize the effec-tiveness and ease of distraction tech-niques to make the handouts moregeneralizable. A similar thought pro -cess resulted in the inclusion ofbreastfeeding and pacifier use, but notthe inclusion of sucrose.

Comfort Holds We have also included photos of

suggested comfort holds that providea sense of security for the child cou-pled with physical safety and immo-bility of the limb to be vaccinated.The goal of providing photos on bothhandouts is to remind staff to encour-age these positions and inspire par-ents to ask about alternatives to thechild lying supine and alone on theexam table.

Scripts Most articles did not include

ways to verbally introduce or imple-ment distraction techniques. Rather, atypical description dryly describes amethod as “uses toy” or “adult makescomments about toy.” Short scriptsgive staff and parents a starting pointfor directions to the child and age-appropriate word choices. Some sug-gestions for verbal instructions aroundevidence-based interventions weregleaned from personal interactionswith peer experts who are child lifespecialists or nurses who specialize inpain management during needle-sticks.


Bickley, L.S., & Szilagi, P.G. (2009). Bates’guide to physical examination (10th ed.).Philadelphia, PA: Wolters KluwerHealth.

Birnie, K.A., Noel, M., Parker, J.A.,Chambers, C.T., Uman, L.S., Kisely,S.R., & McGrath, P.J. (2014). Syste -matic review and meta-analysis: Dis -traction and hypnosis for needle-relatedpain and distress in children and adoles-cents. Journal of Pediatric Psycho logy,39(8), 1-26. doi:10.1093/jpepsy/ jsu029

Boivin, J.M., Poupon-Lemarquis, L., Iraqi, W.,Fay, R., Schmitt, C., & Rossignol, P.(2008). A multifactorial strategy of painmanagement is associated with lesspain in scheduled vaccination of chil-dren. Family Practice, 25, 423-429.

Cavender, K., Goff, M.D., Hollon, E.C., &Guzzetta, C.E. (2004). Parents’ position-ing and distracting children duringvenipuncture: Effects on children’s pain,fear, and distress. Journal of HolisticNursing, 22(1), 32-56. doi:10.1177/0898010104263306

Chambers, C.T., Taddio, A., Uman, L.S., &McMurtry, C.M. (2009). Psychologicalinterventions for reducing pain and dis-tress during routine childhood immu-nizations: A systematic review. ClinicalTherapeutics, 31(Suppl. 2), S77-S103.

Cohen, L.L. (2008). Behavioral approaches toanxiety and pain management for pedi-atric venous access. Pediatrics, 122,S134-S139. doi:10.1542/peds. 2008-1055f

Cohen, L.L. (2010). A multifaceted distractionintervention may reduce pain and dis-comfort in children 4-6 years of agereceiving immunization. Evidence Bas -ed Nursing, 13, 15-16. doi:10.1136/ebn1014

Cohen, L.L., MacLaren, J.E., Fortson, B.L.,Friedman, A., DeMore, M., Lim, C.S., …Gangaram, B. (2006). Randomized clin-ical trial of distraction for infant immu-nization pain. Pain, 125, 165-171. doi:10.1016/j.pain.2006.05.016

Ipp, M., Taddio, A., Sam, J., Goldbach, M., &Parkin, P.C. (2007). Vaccine-relatedpain: Randomised controlled trial of twoinjection techniques. Archives ofDisease in Childhood, 92, 1105-1108.doi:10.1136/adc.2007.118695

Kempe, A., Daley, M.F., McCauley, M.M.,Crane, L.A., Suh, C.A., Kennedy, A.M.,…Dickinson, L.M. (2011). Prevalence ofparental concerns about childhood vac-cines: The experience of primary carephysicians. American Journal ofPreventive Medicine, 40(5), 548-555.doi:10.1016/j.amepre.2010.12.025

Kennedy, R.M., Luhmann, J., & Zempsky,W.T. (2008). Clinical implications ofunmanaged needle-insertion pain anddistress in children. Pediatrics, 122,S130-S133. doi:10.1542/peds.2008-1055e

Kristjásdóttir, O., & Kristjánsdóttir, G. (2011).Randomized clinical trial of musical dis-traction with and without headphonesfor adolescents’ immunization pain.Scandinavian Journal of CaringSciences, 25, 19-26. doi:10.1111/j.1471-6712.2010.00784.x

Luthy, K.E., Beckstrand, R.L., & Peterson,N.E. (2009). Parental hesitation as afactor in delayed childhood immuniza-tion. Journal of Pediatric Health Care,23(6), 388-393. doi:10.1016/j.pedhc.2008.09.006

MacLaren, J.E., & Cohen, L.L. (2005).Teaching behavioral pain managementto healthcare professionals: A systemat-ic review of research in training pro-grams. Journal of Pain, 6(8), 481-492.

MacLaren, J.E., & Cohen, L.L. (2007).Interventions for paediatric procedure-related pain in primary care. Paediatricsand Child Health, 12(2), 111-116.

continued on page 299

Curry, D., Brown, S.W., & Wrona, S. (2012).Effectiveness of oral sucrose for painmanagement in infants during immu-nizations. Pain Management Nursing,13(3), 139-149.

Dilli, D., Küçük, Z.G., & Dallarthe, Y. (2009).Interventions to reduce pain during vac-cination in infancy. Journal of Pediatrics,154(3), 385-390.

Dodd, D. (2003). Benefits of combination vac-cines: Effective vaccination on a simpli-fied schedule. American Journal ofManaged Care, 9(1), S6-S12.

Gaskell, S., Binns, F., Heyhoe, M., & Jackson,B. (2005). Taking the sting out of needles:Education for staff in primary care.Paediatric Nursing, 17(4), 24-28.

Gildengil, C.A., Rusinak, D., Allred, N.J., Luff,D., Lee, G.M., & Lieu, T.A. (2009).Financial barriers to implementing com-bination vaccines: Perspectives frompediatricians and policy makers. ClinicalPediatrics, 48(5), 539-547.

Gray, L., Lang, C.W., & Porges, S.W. (2012).Warmth is analgesic in healthy new-borns. Pain, 135(5), 960-966.

Harrington, J.W., Logan, S., Harwell, C.,Gardner, J., Swingle, J., McGuire, E., &Santos, R. (2012). Effective analgesiausing physical interventions for infantimmunizations. Pediatrics, 129(5), 815-822. doi:10.1542/peds.2011-1607

Harrison, D., Elia, S., Royle, J., & Manias, E.(2012). Pain management strategiesused during early childhood immunisa-tion in Victoria. Journal of Paediatricsand Child Health, 49, 1-6. doi:10.1111/jpc.12161

Hatfield, L.A., Gusic, M.E., Dyer, A., &Polomano, R.C. (2008). Analgesic prop-erties of oral sucrose during routineimmunizations at 2 and 4 months of age.Pediatrics, 121, e327-e334. doi:10.1542/peds.2006-3719

Hensel, D., Morson, G.L., & Preuss, E.A.(2013). Best practices in newborn injec-tions. American Journal of Maternal andChild Nursing, 38(3), 163-167.


Instructions For Continuing Nursing Education Contact Hours

Evidence-Based Recommendations For Reducing Pediatric Distress During Vaccination

Deadline for Submission: December 31, 2018 PED 1607

To Obtain CNE Contact Hours1. To obtain CNE contact hours, you must read the article and com-

plete the evaluation through the Pediatric Nursing website at www.pediatricnursing.net/ce

2. Evaluations must be completed online by December 31, 2018. Uponcompletion of the evaluation, your CNE certificate for 1.3 contacthour(s) will be mailed to you.

Learning OutcomeAfter completing this learning activity, the learner will be able to identifyand implement age-appropriate and evidence-based coping strategiesbefore, during, and after routine vaccination.

The author(s), editor, editorial board, content reviewers,and education director reported no actual or potential conflictof interest in relation to this continuing nursing educationarticle.

This educational activity is provided by Anthony J.Jannetti, Inc.

Anthony J. Jannetti, Inc. is accredited as a provider ofcontinuing nursing education by the American NursesCredentialing Center’s Commission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by theCalifornia Board of Registered Nursing, provider numberCEP 5387. Licensees in the state of California must retainthis certificate for four years after the CNE activity iscompleted.

This article was reviewed and formatted for contact hourcredit by Rosemarie Marmion, MSN, RN-BC, NE-BC,Anthony J. Jannetti, Inc. Education Director.Fees — Subscriber: FREE Regular: $20


Distress During Vaccinationcontinued from page 274

McMurtry, C.M., McGrath, P.J., Asp, E., &Chambers, C.T. (2007). Parental reas-surance and pediatric procedural pain:A linguistic description. Journal of Pain,8(2), 95-101.

Miller, M.K., Wickliffe, J., Jahnke, S.,Linebarger, J., & Humiston, S.G.(2014). Views on human papillomavirusvaccination: A mixed-methods study ofurban youth. Journal of CommunityHealth, 39, 835-841. doi:10.1007/s10900-014-9858-2

Riddell, R.R., Stevens, B.J., Cohen, L.L.,Flora, D.B., & Greenberg, S. (2007).Predicting maternal and behavioralmeasures of infant pain: The relativecontribution of maternal factors. Pain,133, 138-149. doi:10.1016/j.pain.2007.03.020

Royal Australasian College of Physicians(RACP). (2006a). Guideline statement:Management of procedure-related painin children and adolescents. Journal ofPaediatrics and Child Health, 42, S1-S29.

Royal Australasian College of Physicians(RACP). (2006b). Guideline statement:Management of procedure-related painin neonates. Journal of Paediatrics andChild Health, 42, S31-S39.

Schecter, N.L., Zempsky, W.T., Cohen, L.L.,McGrath, P.J., McMurtry, C.M., & Bright,N.S. (2007). Pain reduction during pedi-atric immunizations: Evidence-basedreview and recommendations. Pedi -atrics, 119, e1184-e1198. doi:10.1542/peds.2006-1107

Shah, V., Taddio, A., & Rieder, M.J. (2009).Effectiveness and tolerability of phar-macologic and combined interventionsfor reducing injection pain during routinechildhood immunizations: Systematicreview and meta-analyses. ClinicalTherapeutics, 31(Suppl. 2), S104-S151.doi:10.1016/J.c1lnthera.2009.08.001

Taddio, A., Appleton, M., Bortolussi, R.,Chambers, C., Dubley, V., Halperin, S.,… Shah, V. (2010). Reducing the painof childhood vaccination: An evidence-based clinical practice guideline.Canadian Medical Association Journal,189(8), E843-E855.

Taddio, A., Chambers, C.T., Halperin, S.A.,Ipp, M., Lockett, D., Rieder, M.J., &Shah, V. (2009). Inadequate pain man-agement during routine childhoodimmunizations: The nerve of it. ClinicalTherapeutics, 31(Suppl. 2), S132-S167.

Taddio, A., Ilersich, A.L., Ipp, M., Kikuta, A., &Shah, V. (2009). Physical interventionsand injection techniques for reducinginjection pain during routine childhoodimmunizations: Systematic review ofrandomized controlled trials and quasi-randomized controlled trials. ClinicalTherapeutics, 31(Suppl. 2), S48-S76.

Uman, L.S., Birnie, K.A., Noel, M., Parker,J.A., Chambers, C.T., McGrath, P.J., &Kisely, S. (2013). Psychological inter-ventions for needle-related proceduralpain and distress in children and ado-lescents. The Cochrane Database ofSystematic Reviews, 10, 1-111. doi:10.1002/14651858.CD005179.pub3

Walco, G.A. (2008). Needle pain in children:Contextual factors. Pediatrics, 122(Suppl. 3), S125-S129. doi:10.1542/peds.2008-1055d

Documents

Learning outcome, instructions for completing the evaluation, and ... - Pediatric Nursing · 2017-06-20 · PEDIATRIC NURSING /November-December 2 016/Vol. 42/No. 6 267 V accinations