Preparing Kids (and Parents!) for COVID Vaccines

Source: American Academy of PediatricsxSELF, used with permission

Co-Authored by Drs. Rachel Zoffness PhD & Samina Ali MD*

A New Era: Vaccines and Needles

We have finally, thankfully entered a new era: the era of the COVID-19 vaccine. While research indicates that vaccines are both effective and critical for ending the pandemic (Thompson et al, 2021), vaccine-hesitancy and fear slow our progress (Rosenbaum, 2021).

And the fear isn’t just of the vaccine: It’s of needle pain, too. In fact, over 60% of children (Taddio et al, 2012) and almost one-quarter of adults fear needles (McLenon & Rogers, 2019). These untreated fears can lead to a lifetime of needle phobias, anxiety, and avoidance of important medical procedures like vaccine injections (McMurtry et al, 2015). In the era of life-saving COVID-19 vaccines, it’s never been more important to address needle phobia and fear of pain so that we — and our children — can be protected. But how?

Research shows there are strategies that children, parents, and healthcare providers can use to minimize the pain and fear associated with injections — and it doesn’t require medication or even a degree in psychology.

The Science of Pain

Before we talk about needles, let’s first talk about pain science.

For decades, pain was incorrectly framed as a purely biomedical problem — an issue due exclusively to bodily damage or system dysfunction. However, science reveals that this is incorrect and that pain is actually constructed by the brain (Martucci & Mackey, 2018). Evidence of this is a condition called phantom limb pain, wherein a person loses a limb but continues to feel terrible pain in the missing body part. If pain lived exclusively in the body, no limb should mean no pain! This tells us that the brain plays a critical role in the experience of pain.

The second important fact is that pain is constantly regulated by thoughts and emotions. Neuroscience reveals that negative, fearful thoughts — “I hate needles, this is going to be terrible!” — amplify pain volume, while positive, calming thoughts — “No big deal, I’ve had 10 injections before and I handled all of them” — can turn pain volume down (Melzack, 2001). Attentional processes, or what you’re focusing on, also change pain: Focusing on pain amplifies it while distracting attention away from pain can minimize it.

Emotions also inform and adjust the pain we feel. Negative emotions like stress, sadness, fear, and anxiety turn pain volume up via the limbic system — our brain’s emotion center — while positive emotions like joy, happiness, calm, and feeling safe turn pain volume down (Martucci & Mackey, 2018). Context, or environment, also significantly impacts the pain experience, which is why children’s hospitals are often festooned with colorful murals and stuffed animals: Joyful, calming visual and contextual cues can completely change your experience of pain.

Addressing Needle Fears: 10 Tips and Tools

As we head to vaccine centers with our children in the coming days and months, here are 10 tried-and-true strategies rooted in science and research to help lessen needle fear, distress, and pain. They can also work for you!

1. Model Calm: Children look up to their parents and healthcare providers as role models for how to react to stressors like injections. If you show calm confidence in the face of a vaccination, children are more likely to react calmly, too. Show her — in addition to telling her! — that she’s going to be fine, even if you have to fake it ‘til you make it. If you panic, she’ll panic, and fear only makes the pain worse.
2. Hold: No one should ever forcefully hold a baby or child down for a medical procedure, including vaccines. Instead, parents can hold their children in various supportive positions to help them feel safe and soothed during procedures, such as sitting on their parent's lap while being hugged. Babies can be calmed by swaddling them with blankets. Older children and teens may prefer to sit up and watch the vaccine being administered rather than lying down. This can reduce anxiety, help them feel more in control, and turn down pain volume (Taddio et al, 2009).
3. Stay: Caregivers should be asked if they want to stay with their child during vaccines and painful procedures. If parents choose to stay, use soothing words like “I’m here for you,” and “You got this.” Draw attention to how well they’re coping rather than the pain by saying, “You’re doing so well!” instead of apologizing or talking about pain (e.g., “I know it hurts, I’m sorry.”). Excessive reassurance, criticism, or apologies increase distress, whereas humor and distraction tend to decrease distress (Schechter et al, 2007). If a parent is so scared of needles that they’d prefer to leave the room rather than pass this fear onto their child, this is understandable —anxiety is indeed contagious.
4. Sweeten: Sugar reduces evidence of distress in young infants and babies (Harrison et al, 2016), and can be given in concentrated drops during procedures such as blood tests, putting in an IV, and injections. Sugar may lessen pain by triggering the release of our body’s natural pain killers, called endogenous opioids, which turn down pain volume. Breastfeeding is also shown to ease pain via multiple mechanisms, including physical touch, soothing, skin-to-skin contact, warmth, rocking, the mother’s sound and smell, and the release of endogenous opioids in breast milk (Stevens et al, 2016). Sucking on a pacifier can also help, and sugar drops plus a pacifier can be combined for maximum effect.
5. Explain: Most children 4 years and older appreciate knowing what’s coming and why. Use simple terms to help children understand what to expect, including why the vaccine is important. Preparing children in advance can help reduce anxiety, confusion, and even pain (Schechter et al, 2007). Plan to talk with kids ahead of time about the vaccine using age-appropriate language. For younger children, explain that they’re getting “medicine” in their arm that will keep them healthy. Older children and teens may appreciate the amazing science of the COVID-19 vaccine. Let them know the injection will involve a poke, pinch, or temporary discomfort. Then briefly talk through what you’ll do together to help manage any pain.
6. Apply: Numbing creams such as Maxilene, LMX, or EMLA work well to lessen pain, and can be used 30-60 minutes before needle pokes to numb the skin (Lander et al, 2006). Numbing cream should be combined with techniques that lessen anxiety and stress for the best overall effects. If you want to use numbing cream before the COVID-19 vaccine, consult online resources or ask your healthcare provider where and how to apply it. After the vaccine, lingering pain (if any) can be managed using Ibuprofen (e.g. Advil, Motrin), acetaminophen (e.g. Tylenol, Tempra), or other pain medicines. Make sure to confirm when and how to use these medications with your doctor.
7. Distract: Distraction is a great pain management technique that can be used by any child, parent, or healthcare provider to pull a child’s attention away from scary medical procedures. Use simple distractions like blowing bubbles, talking about non-procedure-related subjects (e.g. sports, an upcoming birthday party, a favorite TV show), or humor to draw attention away from the injection. Technology-based distractions like screens can also be helpful (Gates et al, 2020). Families can bring a phone, iPad, or another device to access games, music, videos, or even virtual reality.
8. Breathe and Imagine: Belly-breathing, also known as diaphragmatic breathing, can help lessen pain; as can using imagery, or imagining calming images. These techniques turn off the body’s fight-or-flight stress response to reduce muscle tension, decrease anxiety and fear, and lower pain volume. Children 3 and up can easily learn to take slow, deep breaths before and during painful procedures. One trick for teaching belly breathing is to hold out your hand and have the child pretend your extended fingers are candles on a birthday cake. Then, ask the child to take a deep breath and “blow the candles out” (Taddio et al, 2015). To assist children with imagery, have them close their eyes and imagine a time they were happy and relaxed: a camping trip in nature, an amusement park, or another positive memory.
9. Celebrate: Be positive and supportive before, during, and after the vaccine. Use positive reinforcement to reward all bravery and coping: plan with your child in advance a small treat s/he will receive after the vaccine. Make sure to verbally celebrate everything your child did well, focusing on the positive things s/he did in the moment: taking deep breaths, holding your hand, staying still. Talk about people who were helpful and things that made the injection easier to bear, such as using numbing cream and imagery. The way children remember this procedure will impact how they feel about future procedures, so take the time to help them develop confidence-inspiring memories.
10. Plan: Don’t be afraid to ask for help if you or your child are extremely afraid of needles. Plan to talk to your doctor, a psychologist, or a child life specialist before your vaccination appointment to develop a coping plan. Coping plans help families prepare effective coping tools in advance that can reduce stress and pain. If this isn’t possible, your healthcare team should still be able to work with you on the day of the vaccine to make the procedure less scary and stressful. Caregivers should always feel empowered to ask for help and request the best possible care!

*Dr. Samina Ali, MD is a Professor of Pediatrics and Emergency Medicine and Faculty of Medicine and Dentistry at the University of Alberta. She is one of the world’s foremost experts on pediatric procedural pain.