Administering pediatric vaccinations

BKCinNOLA · Jun 9, 2011

Hi Marpola,

As the main vaccine administrator in our peds office, I know exactly where you're coming from!

It's important to remember that the crying comes mostly from fear of 'the shot.' Children and teens, especially those with sensory sensitivity or at age 4&5 when they are first beginning to fear bodiy mutilation, build shots up in their head as "this event that is going to be unbearably painful, with a lot of blood, with the possbility that their arm is going to fall off!, and they're going to die!!"

We as nurses (and parents, too), know that 'shots' only last about 2 seconds max, and that they prevent deadly, debilitating diseases, so you really shouldn't ever feel too bad about giving shots.

All that said, here are some tips I've developed:

1. For children over 3 make them feel like they are in control of the situation as much as possible - Let them choose which arm they want to start with, which color bandaid they want after, where they want to sit (on the exam table or in mom/dads lap). Some precocious kids will try to haggle their way out of shots..the number of shots is never an option, sorry!

2. Don't lie - When they first arrive, don't tell them they aren't getting any shots today if they ask and definitely don't let the parents tell them this!, Don't tell them it won't hurt, Don't say it's only one when there's two, etc. 'It will be a quick pinch, but we have super magic bandaids that make everything all better after'

3. Explain everything as its happening..Roll up your sleeve to see your big strong muscle, Cleaning with smelly cold soap (alcohol wipes..P-U!), I'm going to give your arm a hug, I'm going to count to three and it'll be over..

4. If you use the count to three method.. Give the shot on 2! Then inject on 3. Their body will be pumping adrenaline already, but most won't jump because they're expecting the pain on 3. Works like magic..especially with our needle phobic adolescents.

5. Lots of praise when they're done! 'All done!' 'You did it!' 'I'm so proud of you!' 'You were so brave!' **Our lesson we tell kids that get embarassed when they cry: You can't be brave without being scared first. And don't worry, no one likes to get shots. Dr.__ doesn't even like to get shots! It makes them feel better about the whole situation.

6. Bribery - stickers, lollipops, silly bands. We generally give one prize for each shot. No one should be above bribery..

7. Remove other siblings from the room if possible, especially if the infant is getting the shot and there's school age siblings there. Nothing is worse for a scared child than a room full of other scared children.

8. For squirmy, wiggly children: Sit them in Mom/Dad/Guardians lap. The big wigglers can face the parent while the parents give a nice tight bear hug. It feels less like restraining to the child if its the person they trust giving them a big hug.

9. For older children who are generally ok with shots, it still helps if I remind them to relax their shoulder before the vaccine. Explain it'll hurt even less if their muscle is relaxed, then gently press on their shoulder..usually I get a good 4 inches of relaxation even from our big brave football players.

10. For older children/adolescents who are needle phobic we have a backup plan. We use 'Painease' (ethyl chloride) before the shot. It's a topical skin refrigerant that numbs just the injection area. It works in seconds and the anesthetic properties only last 60 seconds. Much more practical than Emla cream.

It's important that YOU are confident (or at least appear confident), and don't get tunnel vision when you walk into the room. Keep talking to the kid: ask about school, summer plans, favorite books/movies. It'll keep the tension in the room to a minimum.

That's all I've got for now! But I'll let you know when I remember more of our tricks of the trade!

Marpola · Jun 9, 2011

Wow thanks BKCNewGrad09, this is wonderful! It’s just what I was looking for!

Please explain what you mean by “Give the shot on 2! Then inject on 3.” What is the difference between “giving” and “injecting?”

Also, what is the best way to administer injections to infants and children who get the vaccine in the vastus lateralis? I’ve noticed they tend to want to kick. Does the parent hold them as in tip # 8, if so how to you reach the thigh muscle if they have their backs to you?

Again thanks so much!

And for anyone else who wants to chime in, feel free. I am truly grateful! :bow:

rnsrgr8t · Jun 9, 2011

The advice you have already gotten is great....I have a few more since I worked in a peds office for 4 + years....

In a 5 year old, if they need 2 shots, I normally would get a coworker to tag team them with me. We would have the child sit on the exam table and lean forward and give their parent a big hug with their arms on the outside. We would each take an arm and do both shots at the same time. Worked a lot quicker and could get it over with at the same time.

WARN kids before you give them the MMR. It REALLY stings (feels different than the other shots). I normally would say "here comes a bee sting!" as I was injecting. I was late on my vaccines and got my second MMR at 18 years of age and remember how much it stings.

The faster you inject the needle and the faster you push in the vaccine into the muscle, the less it hurts. If you have someone that will let you use them as a guinea pig (I let all of our new people practice on me with saline) practice a few times on them trying to inject the needle as fast as possible and they can tell you how it feels. I got to the point where my older patients told me they could not even feel it.

For the babies where you use the thigh muscle.... I had them lay on their backs. I had mom stand at their head and just hold their hands so they could not reach down. Now I have pretty large hands (size 8 gloves) so not everyone could do this. I would reach across the leg closest to me and hold it down with my forearm and with the hand on that arm I would bend their knee so their foot was on the table and hold the leg by their calf. With their leg bent, you really can see their thigh muscle well and they cannot wiggle so much. When it was time to use the leg nearest to me, I would hold it in the same way with the leg bent. They are less likely to kick with the leg they just got a shot in b/c it is a little sore.

Have kids take a deep breath and blow out as you do the shot helps keep them relaxed. If a parent was standing in front of them, "Blow Mom's hair!".

Watch out for the teenage football players...they are the ones most likely to faint on you and the hardest to pick up off the floor . I would always make them sit down on the table and sit for a minute afterward.

I did the 1...2...3 thng to. "I am going to count to 3!!!". 1.... 2 (inject the needle) 3(push the syringe)!.

Remember you do not have to check for blood return on immunizations (all other IM's you do) which makes the injection faster.

DO be careful of siblings in the room. I had a 2 year old hawl off and slap me in the butt while I was giving vaccines to his infant sibling. He was very protective of her and was upset I was making her cry b/c I did not warn him ahead of time. So now, if their are siblings in the room, especially toddlers, I tell them, "I have to give sissy or brother a little owie and they may cry but you can give them a kiss when it is over and make them feel better."

If you can get those small, little circular bandaids, they work a lot better on the infants. The regular size bandaids really stick on the little ones and make them hard and painful to come off and parents are afraid to really pull them off.

Let the older kids pick out their own bandaids and have a lot of colorful ones that they can pick from.

Tetorifice vaccines really make the muscle sore (flu shots can too). The more they move their arms the better so I would tell them "{make windmills with your arms!" and swing their arms in a circle.

Remember be confident and in control and firm but loving and you will be fine!

Remember, 5 minutes of a little pain and tears beats all of the illnesses we are trying to prevent!

Marpola · Jun 9, 2011

Excellent post rnsrgr8t! So many good ideas! I will particularly remember to warn the sibs ahead of time. Just picturing that toddler administering his form of "justice" was enough to send me on the floor laughing. :lol2: We forget how things appear to a child. The circular bandaids are a great idea too, as well as working quickly to avoid pain. I think that's a good idea to have the child breathe deeply. I've heard that you can also ask them to hold up a finger and pretend they are blowing out a birthday candle.

And you're right — the benefits far outweigh the temporary minor pain.

Thank you very much for your advice!

rnsrgr8t · Jun 9, 2011

You are very welcome!!!! Good Luck! You will be great!

BKCinNOLA · Jun 10, 2011

rnsrgr8t answered all your questions about my post! and more! I'll definitely be taking some of those tips myself! :)

The only two kids I've ever had faint on me were big tough football players. So it's also important to tell anyone of driving age: 1. Ride in the passenger seat on your way home or 2. If you drove here on your own, wait in the waiting room for 15 minutes after your shots. Set a timer and let them know when it's ok to go. It's better that they pass out in the waiting room, than while driving home.

We usually only give injections in the vastus lateralis to non-walking infants. As soon as they're walking around independently we 'graduate' them to their deltoids (unless, of course, they have teeny tiny deltoids).

Marpola · Jun 10, 2011

You're right BKCNewGrad09, rnsrgr8t did answer my questions very well. I particularly like your idea about the Painease. I've never heard of that before, but it sounds like it would be the best way to handle pain-sensitive patients.

Thanks again to both of you! These are things you don't learn in the text books. :yelclap: