INTRODUCTION:

Pain is highly unpleasant and very personal sensation that cannot be shared with others. “It can be defined as an unpleasant sensory and emotional experience associated with actual or potential damage or described in terms of such damage” (International Association for the study of pain).¹ Every child has his or her own perception of pain.²

Pain management is the most neglected area in pediatric population. It is estimated that up to 25% of adults have a fear of needles³,with most fears developing in childhood^4. About 10% of the population avoids vaccination and other needle procedures because of needle fears.⁵

Pain is a dynamic experience that is often beneficial by warning of impending or actual injury, thereby preventing or restricting tissue damage. However, barring this aspect, pain has only damaging effects in terms of metabolic and behavioral responses induced by it.⁶

Rapid injection technique refers to rapid intra muscular injection technique without aspiration and reduction in contact time of needle with muscular tissue.⁷

Previous versions of the General Recommendations have recommended aspiration in 1994 (i.e., gently pulling back on the plunger to check for blood before injection) prior to injection, particularly before intramuscular injection. No data exist to document the necessity of this procedure. As per CDC, 2000 (Central Committee for disease control and prevention) general recommendations on immunization does not recommend aspiration before injection.

1) Recommended sites for immunization do not have major blood vessels, hence the risk of accidently injecting the vaccine into a blood vessel is thought to be minimal.

2) Syringes have been given in mass campaigns for IM injections without any reported adverse effects or injury from failure to aspirate. All complications reported in literature of intra arterial injection involved penicillin and other medications and not vaccines.

3) Aspiration can result in wastage of vaccine.

4) Aspiration prolongs the time that the needle is inside the patient, hence increasing the pain experienced by the recipient.

5) Less control is exercised during two handed aspiration using a conventional syringe which may lead to local injury. During a one handed vaccination without aspiration, the vaccinator can use the other hand to control the child.⁷

Aspiration before intramuscular injection and slow injection of vaccines are long-standing practices that have never been subjected to scientific evaluation. Aspiration was initially proposed for safety reasons, to prevent penetration of blood vessels during the injection. Slow injection was recommended to minimize pain from sudden distension of the tissues.⁸Barriers to pain management in children are numerous and include inaccuracies regarding patho-physiological mechanisms of pain with statements such as “children do not feel pain the way adults do”⁹, fears regarding the use of pharmacological agents and deficits in knowledge of methods of pain assessment.^9,10 This caused psychological impact for parents and difficulties in administering immunization by the health workers. This inspired the investigator to look out for an alternate method which would reduce the pain threshold of infant during immunization.

The study was conducted with the objective of to assess and compare the post interventional level of pain among children receiving rapid injection technique and traditional injection technique for DPT vaccination.

MATERIAL AND METHODS:

Research design:

A quantitative research approach, Quasi experimental research in which post test only control group design without randomization was used for the present study.

Setting:

The present study was conducted at immunization unit of Guru Gobind Singh Medical College and Hospital, Faridkot and Civil Hospital, Bathinda.

Sample:

The target population of the present study consists of children who were receiving DPT vaccination in Guru Gobind Singh Medical College and Hospital, Faridkot and Civil Hospital, Bathinda.120 children were selected as study subjects receiving DPT vaccination in Guru Gobind Singh Medical College and Hospital, Faridkot and Civil Hospital, Bathinda based upon the inclusion and exclusion criteria. The proposed sample was selected by convenience sampling technique as the parents of children agreed to participate in the study.

Sample size (120)

Experimental Group (n=60) Control Group (n=60)

The study includes the children who were below 2 years, receiving DPT vaccination, willing to participate in the study and present at the time of data collection. The study excludes the children who were having acute febrile illness, using topical anesthetics / analgesics, allergy to any component of DPT vaccine and using any diversional technique for pain relief. The tool planned for data collection consists of two sections:

Instrumentation:

Part-A consists of socio- Demographic variables (age of children, gender of children, position of child during vaccination, relation with family member holding the child, feeding status and type of vaccine) and Part-B consists of FLACC (Legs, Activity, Cry, Consolability scale) pain scale. The data for pilot study was collected in the month of February 2016. A sample of 12 children i.e. 6 or experimental group and 6 for control group were selected for pilot study by using Convenience sampling technique. Data collection was done from February 3, 2016 to March 2, 2016. Demographic data from 120 parents were collected by investigator with the help of structured interview schedule. Subjects were divided into 2 groups, as experimental and control group. The intervention was performed by health personnel and assessment of pain was done by researcher by using FLACC pain scale for 1-2 minute. The intervention for the present study was rapid injection technique to reduce the level of pain. In experimental group, rapid injection technique is used in which the needle is introduced at 90^ºwith steady pressure and no aspiration is to be performed, drug is rapidly injected over 1-2 seconds, and the needle to be withdrawn rapidly. In control group, traditional injection technique was used in which slow intra muscular injection technique followed by aspiration, slow administration of vaccine and slow withdrawal of needle. Data analysis was done by using descriptive and inferential statistics such as mean, percentage, standard deviation, unpaired t test and chi square test.

RESULTS:

Among 60 Samples (N=120), in control group, majority 35(58.4%) of children had moderate level of pain, 24 (40%) had mild pain and remaining 1(1.6%) had no pain. In experimental group, majority 38 (63.4%) children had mild level of pain, 21(35%) had moderate level of pain and remaining 1(1.6%) had no pain or relaxed. Hence, it was concluded that majority of the children felt mild pain in experimental group and majority of the children felt moderate pain in control group. Table 1 depicts that mean pain score in experimental group was 3.1±0.92 and 3.8±1.2 in control group. On statistical analysis, using unpaired ‘t’ test the calculated value was found to be 17.9 which was higher than table value (1.98) at 0.05 level of significance. Hence it was interpreted that there is statistically significant difference in the post interventional mean pain score between experimental group and control group.

Table 1: Comparision of post interventional mean pain score

Group

Observation

Mean pain score ± S.D

Unpaired ‘ t’ test

Experimental (n=60)

3.1 ± 0.92

17.9**

df = 118

Control (n=60)

3.8 ± 1.2

** - significant at level of 0.05

On statistical analysis, using Chi square test (for comparison post interventional level of pain in experimental and control group) the calculated value was found to be 6.22 which was higher than table value (2.0) at 0.05 level of significance and it was interpreted that there is statistically significant difference in the post interventional level of pain between experimental and control group.

DISCUSSION:

In support of objectives of the study, in experimental group, majority 38(63.4 %) children had mild level of pain, 21(35%) had moderate level of pain and remaining 1(1.6%) had no pain or relaxed. In control group, majority 35(58.4% ) of children had moderate pain, 24( 40%) had mild pain and remaining 1(1.6%) had no pain which were inconsistent with the study conducted by Jacobson RM et al (2001)¹¹ which revealed that 90% of 15-18 month old children and 45% of the 4-6 years old children showed severe distress and pain. The findings were supported by study of Ipp M et al (2007)¹² which revealed that mean modified behavioral pain scores were higher in standard group i.e., 5.6 when compared to pragmatic group i.e., 3.3.⁶ In experimental group, mean pain score was 3.1±0.92 and 3.8±1.2 in control group which were consistent with the study conducted by Ipp M et al (2007) ¹² which revealed that mean modified behavioral pain scores were higher in standard group i.e., 5.6 when compared to pragmatic group i.e., 3.3.¹² On statistical analysis, using unpaired ‘t ’ test the calculated value was found to be 17.9 which was higher than table value (1.98) at 0.05 level of significance. So, there is statistically significant difference in the post interventional mean pain score between experimental and control group.

In experimental group, majority 38(63.4%) children had mild level of pain, 21(35%) had moderate level of pain and 1(1.6%) had no pain whereas in control group majority 35(58.4%) of children had moderate pain, 24 (40%) had mild pain and 1(1.6%) had no pain. On statistical analysis, using Chi square test the calculated value was found to be 6.22 which was higher than table value (2.0) at 0.05 level of significance and it was interpreted that there is statistically significant difference in the post interventional level of pain between experimental and control group. The above objective and findings are supported by the study of Girish G N et al (2014)¹³, found that ’’standard’’ slow technique was significantly more painful than pragmatic rapid technique.¹³ On the basis of above statistical analysis, it was concluded that research hypothesis is not rejected.

LIMITATIONS AND FUTURE PRESPECTIVE:

Limitations of the Study:

Small number of sample subjects leads to limit the generalization of the study.

Short availability of time for data collection limits the area under research.

Study was conducted only on children receiving DPT vaccination.

RECOMMENDATIONS:

On the basis of the findings of the study following recommendations are-

A similar study can be replicated on large sample to generalize the findings.

Randomized controlled trial can be done for similar type of study.

An experimental study can be conducted with control group in order to see the effectiveness of various pain reduction strategies.

Comparision study can be conducted between different pain reduction strategies like brand of vaccine, order of vaccine, tucking, sweetening solutions, stroking of skin before vaccination etc.

Same studies can be conducted for other vaccinations.

ACKNOWLEDGEMENT:

The authors are grateful to the authorities of SINPMS, badal and BFUHS, Faridkot for the facilities.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

REFERENCES:

1. Ipp M, Taddio A, Goldbach M, David S B , Stevens B , Koren G. Effects of age, gender and holding on pain response during infant immunization. Canadian Journal Of Clinical pharmacology. 2004 April 1; 11(1): 11-15.

2. Mcgranth pain in children.Newyork:Guitfortpublications;1990. P. 3

3. Guideline statement: management of procedure-related pain in children and adolescents. J Paediatr Child Health 2006; 42(Suppl1):1–29.

4. Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;41:169-175

5. Taddio A, Chambers CT, Halperin SA. Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther 2009; 31(Suppl 2): 152–67.

6. Anand KJ. Effects of perinatal pain and stress. Prog Brain Res. 2000; 122: 117-29.

7. http:// www.cdc.gov/hip/recs/child schedule. htm

8. Taddio A, Ilersich AL, Ipp M. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi- randomized controlled trials. Clinical therapeutics.2009; 31(Suppl 2):48–76.

9. Hagan JF, Jr., Coleman WL, Foy JM, et al. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001; 108(3):793–797.

10. Abu-Saad HH, Hamers JPH. Decision-making and paediatric pain: a review. Journal of Advanced Nursing. 1997; 26(5):946–952. 11. Jacobson RM, Swan A, Adegbenro A, Ludington SL, Wollan PC, Poland GA et al. Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines. 2001 Mar 21; 19(17-19):2418-27.

11. Ipp M, Taddio A, Sam J, Goldbach M, Parkin P C. Vaccine related pain randomised control trial of 2 injection techniques. Archives of disease in childhood 2007 dec 2; (92): 12 .

12. Girish G N and Ravi M D. Vaccine related pain: comparision of two injection technique. The Indian Journal of Pediatrics. 2014 December; 81:1327-13.

Received on 13.02.2018 Modified on 18.04.2018

Int. J. of Advances in Nur. Management. 2018; 6(2): 87-90.

DOI: 10.5958/2454-2652.2018.00018.5