Monday, October 26, 2009

Doctors question ethics of needles for children - National Post

With Canada on the brink of one of its largest-ever vaccination drives, a group of academics and doctors is urging health-care workers to make flu and other shots less painful for children, suggesting it is actually "unethical " for them to ignore the sting of injections.

Many doctors and parents believe a needle is nothing to fret about, with the hurt lasting only a moment and leaving no long-term effects, the researchers acknowledge in a series of medical-journal papers just published.

Using one of several possible pain-reduction techniques, however, could help avert needle phobias that affect as much as 10% of the population, last years and undermine vaccination campaigns, they argue.

Those methods -- from anesthetic cream applied to the skin to simply giving babies sugar water -- are seldom employed now, the panel says in the journal Clinical Therapeutics.

"The attitude is, 'It's only pain -- what's the big deal?' " said Anna Taddio, a pharmacy professor at the University of Toronto and lead author of the papers. "But it actually is when you start figuring out what all the costs of it are. It means someone is not going to donate blood ... and it means that person doesn't go to see the doctor, doesn't go to see the dentist because they don't want to be poked," she said. "They're probably sicker as a group of people."

The issue is becoming more pressing, given that Canadian children are receiving a constantly expanding range of vaccines --as many as 20 shots by age five -- while uptake on immunization is dropping, the journal articles argue.

Not everyone is convinced of the need for widespread action, though. Pain in immunization is undoubtedly a serious issue for a "subset" of children who could benefit from pain-reduction methods, but they are likely the exception, said Dr. Peter Nieman, a Calgary pediatrician. "For the majority of kids I've seen, it's a trade-off," he said. "On the one hand, nobody in their right mind would say, 'I love needles,' but on the other hand, the pain you put up with is a small price to pay for the benefit you get."

Nevertheless, Prof. Taddio's group, including pharmacists, physicians and pain researchers, is developing a formal practice guideline around vaccine-pain reduction that it hopes the Canadian Pediatric Society will adopt for its members soon.

There is also a movement to have pain reported as one of the adverse side effects of vaccine injections, which might encourage pharmaceutical companies to produce vaccines that hurt less, Prof. Taddio said. Some formulations are already less painful than others, a function of the chemicals used and how they interact with human tissue.

As a physician and pharmacologist in the emergency department of a London, Ont., hospital, Dr. Michael Rieder says he sees the impact of pain-induced needle fear "all the time," with older children and even teenagers recoiling at the approach of a hypodermic, whether it is to draw blood or inject local anesthetic.

"One of the biggest problems in pediatric acute care is fear of needles," he said. "If you have to draw blood and the child is struggling and fighting because they're afraid of a needle, it's not such an easy thing to do."

The group's review of evidence cites studies that suggest 90% of toddlers and 50% of school-age children experience severe distress during vaccination, with some evidence that early bad experiences can condition bodies to be more sensitive to pain in future.

About one in 10 people is estimated to have full-blown needle phobia, and 25% of adults to have significant fears, prompting them to avoid dental visits, fail to donate blood and neglect insulin injections, the researchers say.

In one study of 12,000 people, only 12% agreed to undergo a free flu vaccine, and virtually all of them chose a nasal spray instead of a needle, many of them citing the pain of injection for their decision.

In fact, recent polls suggest that only a third of Canadians plan to get the H1N1 vaccine, and Prof. Taddio believes memories of childhood immunization pain are likely a reason why some will pass on the shot.

To reduce needle pain, apply topical anesthetic creams; comfort babies by having them breast-feed or suck on sugar water during the shot; and simply distract the child. Doctors and others should also give needles without aspirating, a process designed to ensure they are not injecting vaccine into a blood vessel, Prof. Taddio said. Aspiration prolongs the pain and is not necessary, she said.



Clinical Therapeutics, Vol. 31 (2009), pp. S47-S47.


Clinical Therapeutics, Vol. 31 (2009), pp. S48-S76.


Clinical Therapeutics, Vol. 31 (2009), pp. S77-S103.


Clinical Therapeutics, Vol. 31 (2009), pp. S104-S151.


Clinical Therapeutics, Vol. 31 (2009), pp. S152-S167.

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