Evaluation of Methods to
Relieve Parental Perceptions
of Vaccine-Associated Pain
and Anxiety in Children: A
Karlen E. Luthy, DNP, FNP, Renea L. Beckstrand, RN, PhD, CCRN,
& Amy Pulsipher, RN, BS
Introduction: The pain and anxiety associated with vaccina-
tion is a significant reason why parents are reluctant to have
their children vaccinated. Distraction methods and vapocoo-
lant sprays may be use to modify the parent’s perceptions of
their child’s pain and anxiety, thus encouraging parents to re-
turn for the child’s next vaccination.
Methods: A convenience sample of 68 parents with children
ranging in age from 2 to 12 years was selected. The parents
and the child were randomly assigned to three groups: a con-
trol group, a DVD distraction group, or a vapocoolant spray
group. After the child was vaccinated, parents evaluated the
child’s pain and anxiety.
Results: No significant difference in the parents’ perception
of their child’s pain or anxiety was found between the two
treatment groups compared with the control group. Some
parents expressed the desire to be able to choose the type
of distraction method their child received rather than having
them randomly assigned to a group.
Discussion: Although quantitative results were not statisti-
cally significant in this pilot study, parents commented that
the DVD distraction method seemed helpful before and/or
after vaccination, but not during vaccination, and parents ap-
preciated the distraction. Parents, however, would prefer to
choose the intervention rather than being randomly assigned
to a group. The effectiveness of interventions with regard to
parental perceptions of pain or anxiety warrants further
study. J Pediatr Health Care. (2013) 27, 351-358.
Vaccination, pain, distraction, topical spray
The development and widespread use of vaccina-
tions has dramatically improved public health by de-
creasing the rate of infectious diseases and is one of
the most important public health achievements of the
20th century (Attaran, 2008; Luthy, Thorpe, Dymock
McGrath, & McMurtry, 2007). Despite the immeasur-
able benefits of vaccinations, many parents are still re-
luctant to vaccinate their children (Miller, 1993).
Multiple studies have reported that the perceived pain
and anxiety associated with the administration of vac-
cines is a significant reason why parents are reluctant
to vaccinate their children in a timely manner (Abbott
Karlen E. Luthy, Assistant Professor, College of Nursing, Brigham
Young University, Provo, UT.
Renea L. Beckstrand, Associate Professor, College of Nursing,
Brigham Young University, Provo, UT.
Amy Pulsipher, Registered Nurse, College of Nursing, Brigham
Young University, Provo, UT.
Funded by the Brigham Young University College of Nursing
Research and Scholarship Council.
Conflicts of interest: None to report.
Correspondence: Karlen E. Luthy, DNP, FNP, 355 SWKT, Provo,
UT 84602; e-mail: Beth_luthy@byu.edu.
Copyright Q 2013 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
Published online April 26, 2012.
www.jpedhc.org September/October 2013
& Fowler-Kerry, 1995; Luthy, Beckstrand, & Peterson,
2009; Luthy, Sperhac, Faux, & Miner, 2010; Reis &
Holubkov, 1997). Therefore it may be helpful to iden-
tify ways to reduce the parent’s perception of their
child’s pain or anxiety during vaccination (O’Brien,
Taddio, Ipp, Goldbach, & Koren, 2004). The reduction
timely return for future vaccinations.
Pain is experienced during many health care proce-
dures and often results in fearful children, which may
lead to prolonged procedures and dissatisfaction with
care (Cassidy et al., 2001; Farion, Splinter, Newhook,
Gaboury & Splinter, 2008). Currently, distraction is
recommended as one of the most basic yet helpful
interventions to decrease the perception of pain
(Schechter et al., 2007). Distraction methods, including
playing a game are easily and commonly implemented
in hospitals during painful procedures, such as intrave-
(Cassidy et al., 2001; Cohen et al., 2006). In theory, as
children engage in activities that demand attention,
they have a limited capacity to process pain during
uncomfortable hospital procedures (Jeffs, 2007). The
distraction method, however, is most successful when
the distraction activity selected is ‘‘attentionally de-
manding’’ and meaningful to the child (Foster, 2007;
Jeffs, 2007; Vessey, Carlson, & McGill, 1994).
Vapocoolant sprays also have been implemented
to effectively alter the perception of pain during
uncomfortable procedures (Davies & Molloy, 2006;
Mawhorter et al., 2004). Ethyl chloride is a commonly
thetic, cooling the surface of the skin to nearly 0?C
(Davies & Molloy, 2006; Farion et al., 2008; Hsu, 2012;
Reis & Holubkov, 1997; Yoon, Chung, Lee, & Park,
2008). It is believed that the rapid cooling of the skin
may desensitize pain receptors and quickly anesthetize
the surface of the skin (Hijazi, Taylor & Richardson,
ical anesthetics with a delayed onset of action ranging
from 10 minutes to 1 hour, vapocoolant sprays can
anesthetize the skin up to 4 mm in depth after only
a 3- to 7-second application (Farion et al., 2008;
Soueid & Richard, 2007).
the average of 35 vaccines received by the age of 18
years or any other number of medical procedures rou-
tinely performed in hospitals and pediatric offices. Al-
though the effectiveness of interventions to mitigate
pediatric pain and anxiety varies widely depending
on the individual child, pharmacologic and psycholog-
ical methods to control such pain have been investi-
gated. Researchers exploring needle-related pain and
anxiety, in particular, have used various distraction
methods, topical local anesthetics, or a combination
of similar interventions.
Systematic review of psychological interventions
during needle-related procedures supports the use of
distraction in the clinical setting (Uman, Chambers,
McGrath, & Kisely, 2006). Distraction was more effec-
tive than control and comparison groups in reducing
self-reported pain (standardized mean difference of
?0.24, 95% confidence interval [CI] = ?0.45 to ?0.04).
Similar studies using various distraction techniques, in-
cluding movies, music, short stories, and guided imag-
ery, in a variety of settings also yield similar positive
results (Kleiber & Harper, 1999; Schechter et al., 2007).
Although some research supports the use of vapo-
coolant sprays in decreasing vaccine-related pain
(Hijazi et al., 2009; Page & Taylor, 2010), other research
examining the effectiveness of vapocoolant sprays
tween groups (Shah, Taddio & Rieder, 2009). Although
results vary for reasons that include the placebo effect,
tion techniques, the overall body of research available
regarding vapocoolant sprays is small.
We found no published research that specifically
studied parents’ perception of their child’s pain or anx-
iety during vaccination using vapocoolant spray or
while watching a DVD
compared with a con-
trol group. If distrac-
tion using DVD or
a vapocoolant spray
could successfully re-
duce the parent’s per-
ception of the child’s
pain or anxiety during
may be encouraged to
returnfor the next
vaccination in a timely
manner. An increase
in vaccination com-
pliance may have sig-
Therefore the purpose
of this study was to de-
termine if the parent’s
perception of their child’s pain and anxiety was lower
with the distraction method (DVD) or the vapocoolant
spray compared with control subjects (usual care).
1. Does distraction (i.e., use of a DVD) effectively
reduce a parent’s perception of his or her child’s
vaccine-related pain compared with control
If distraction using
reduce the parent’s
perception of the
child’s pain or
parents may be
return for the next
a timely manner.
Volume 27 ? Number 5 Journal of Pediatric Health Care
duce a parent’s perception of his or her child’s
vaccine-related anxiety compared with control
3. Do vapocoolant sprays (e.g., ethyl chloride) ef-
fectively reduce a parent’s perception of his or
her child’s vaccine-related pain compared with
4. Do vapocoolant sprays (e.g., ethyl chloride) ef-
fectively reduce a parent’s perception of his or
her child’s vaccine-related anxiety compared
with control subjects?
After receiving Institutional Review Board approval,
ing in age from 2 to 12 years were informed about the
study and selected as subjects. Parents were included
tions. Children 8 years of age and older were given the
sent then was obtained from parents, while assent was
in the study was voluntary, and no compensation was
provided. To participate in the study, the parent must
parents whose children were diabetic, had poor ex-
tremity circulation, or had a previous allergic reaction
to any topical anesthetic were excluded from the study
(Hsu, 2012). Because stress or anxiety experienced by
one child during vaccination may influence a sibling’s
reaction, parents with more than one child in need of
vaccinations also were excluded.
The study took place at a pediatric office located in the
sicians and two nurse practitioners primarily care for
privately insured families of middle to upper socioeco-
A posttest design was used for this study. A pretest/
posttest design was not selected because response to
pain could change as the child matured between ad-
ministration times of vaccines in a series (Berberich &
cinations in one visit and received one vaccine with an
intervention and another vaccine without an interven-
tion, the pain and anxiety of the first injection could af-
fect the child’s reaction to the second one. Instead,
parents were asked to compare their perceptions of
with this experience.
Use of a DVD and vapocoolant spray (compared
with control, which was usual care) were selected as
interventions by the researchers because of the ease
of administration and nearly immediate effect, thus
improving feasibility. Envelopes containing one of
two intervention groups or the control group (a total
of three groups) were computer randomized prior to
the study. Once participants signed consent, the
health care professional selected the next available en-
velope, and parents and children were assigned to
one of three groups: control, a DVD distraction group,
or a vapocoolant spray group. Subjects in the control
group received no intervention but were given the
vaccination as usual. This process included a prelimi-
nary visit with the office provider, after which a health
care professional came into the room and adminis-
tered the needed vaccination. A bandage was then
placed on the injection site, the child was redressed
if necessary, and the child and parent were escorted
out of the room after the parent completed the
1-page evaluation tool.
After the routine visit with the office provider, sub-
jects in the distraction group watched a DVD movie
(The Lion King) before, during, and after the vaccina-
tion. The movie was viewed on a small portable DVD
player on a counter in the examination room and was
selected because it was the most popular animated
Disney movie at the time this study was completed. A
was redressed if necessary, and the child and parent
were escorted out of the room after the parent com-
pleted the evaluation tool.
pocoolant spraywas administered tosubjects in theva-
pocoolant spray group for 3 to 7 seconds immediately
before the vaccination. A bandage was then placed
on the injection site, the child was redressed if neces-
sary, and the child and parent were escorted out of
the room after the parent completed the evaluation
ception of the child’s pain or anxiety compared with
a previous vaccination experience. Finally, each child
was able to select a toy after vaccination regardless of
their randomized group.
A questionnaire was developed that parents could use
to record their perceptions of their child’s response to
vaccination after use of either of two interventions or
the control procedure. The 11-item, single-page ques-
tionnaire included one visual analog item, one Likert-
type item, one yes/no item, one item asking them to
rate their experience, six demographic questions, and
one open-ended item for comments regarding the
study. The demographic items included the child’s
age, gender, and ethnicity. The parent’s gender was
www.jpedhc.org September/October 2013
not collected. It was assumed that the memory of the
child’s vaccine-related pain and anxiety might have
faded over time. Consequently, parents were asked to
report the length of time since the last vaccination.
The number of scheduled vaccinations also was re-
ported. To evaluate whether the participants had
vaccine-related anxiety that affected their willingness
to return for vaccines in a timely manner, parents
were asked whether or not the child’s vaccination was
on time, and if not, why not.
The visual analog item included a Wong-Baker
FACES Pain Rating Scale ranging in options from 0 =
No Hurt to 5 = Hurts Worst. The WBFS was selected
because of its reliability, validity, and straightforward
approach to pain assessment (Keck, Gerkensmeyer,
Joyce, & Schade, 1996). The questionnaire also in-
cluded a single anxiety item that used a Likert scale of
0 to 5, with higher scores indicating that the child
exhibited more anxiety. Another item asked parents
to rate how the current vaccination experience ranked
compared with the last vaccination experience. The
three options were worse, about the same, and better.
The final dichotomous yes/no item asked parents
if they would choose the same intervention again
(if they received either treatment) for the child’s next
vaccination. For parents randomly assigned to the con-
trol group, the option not applicable was included.
Responses were entered into SPSS (SPSS Inc.,
Chicago, IL). Frequencies and measures of central
tendency and dispersion were calculated for all quan-
titative items. Because the data were normally distrib-
uted, one-way analysis of variance (ANOVA) tests
were conducted to examine whether statistically sig-
nificant differences existed for both perceived pain
or anxiety during vaccination using vapocoolant
spray, a DVD movie, or control (i.e., usual care).
The open-ended comment item was transcribed and
analyzed independently for themes. Final themes
The study had a total of 68 participants. Twenty-seven
participants were randomly assigned to the DVD dis-
to the vapocoolant spray group, and 22 participants
were randomly assigned to the control group.
The ages of the children ranged from 2 years to 12.5
child’s gender; 53% (n = 36) of subjects were girls and
47% (n = 32) were boys. Of the sixty-five parents
(96%) who reported their child’s ethnicity, 97% (n =
63) were White. Time since the child’s previous vacci-
nation was most commonly within the past 1 to 2 years
(37%). However, a few parents (7%) could not remem-
ber when their child’s last vaccination took place. Fi-
nally, parents were questioned regarding the number
of injections the child received during the visit. Most
commonly, parents reported that the child received
two injections (37%). When asked if the child was on
time for his or her current vaccination(s), 67 parents re-
sponded, of whom 63 (94%) were on time for vaccina-
tions (Table 1).
‘‘Hurts Little Bit’’ (n = 22; 33%). Only one parent se-
lected zero or ‘‘No Hurt’’ (2%) to describe his/her per-
vaccination (Table 2). A one-way ANOVA was used to
test for differences in parents’ perceptions of their
child’s pain among three groups: DVD distraction, va-
pocoolant spray, or control (usual care). No significant
differences in perceived pain scores were found across
the three groups (F (2, 64) = .222, p = .801; Table 3).
When asked to rate their child’s anxiety following the
vaccination, the most frequently chosen response by
parents was ‘‘some anxiety’’ (n = 18; 27%). A few par-
ents reported the child experienced ‘‘no anxiety’’ (9%)
during vaccination (Table 4). A one-way ANOVA also
TABLE 1. Participant demographics
(standard deviation)n (%)
Age of children (yr)
Gender of child
Ethnicity of child
Time since previous vaccination
< 6 mo
> 2 yr
I don’t know
No. injections received
Scheduled vaccination on time
Volume 27 ? Number 5Journal of Pediatric Health Care
was used to test for differences in the parents’ percep-
tion of their child’s anxiety among three groups: DVD
distraction, vapocoolant spray, or control (usual care).
No significant differences in perceived anxiety scores
were found across the three groups (F (2, 65) = .151,
p = .860; Table 5).
Comparison With Previous Vaccination
When asked to compare this vaccination experience
with the previous experience, most parents (n = 38;
59%) claimed their child’s current vaccination experi-
ence was about the same as their previous experience.
However, some parents reported the child’s vaccina-
tion experience was better (n = 21; 32%), and a few
claimed the child’s vaccination experience was worse
(n = 6; 9%) compared with their previous vaccination
experience (Table 6).
Preference for Same Treatment on Future
Parents also were asked to report whether they would
like the same intervention during vaccination at future
visits; 65 parents (96%) responded. Of those who re-
sponded, 38 (58.5%) parents chose ‘‘yes,’’ while 19
dren were in the DVD distraction group, six children
were in the control group, and seven children received
the vapocoolant spray.
In the open-ended comment section, parents were in-
vited to share any comments regarding the study.
Twenty-eight parents (41%) wrote a response. Two
major themes were identified: (a) the DVD distraction
method was helpful before and/or after the vaccina-
tion, but not during, and (b) parents wished they
could have chosen which intervention their child re-
Six parents claimed the DVD distraction method
was helpful before and/or after the vaccination, but
not during the vaccination. For some children, the
DVD distraction method was perceived as being espe-
cially helpful in relieving anxiety prior to the vaccina-
tion. As stated by one parent, the ‘‘movie worked to
help wait for shots.’’ Although the DVD distraction
method relieved anxiety prior to vaccination for
some children, for others the distraction method
was most helpful immediately after the vaccination.
As one parent stated, ‘‘Even though the movie didn’t
decrease her anxiety before the shots, it helped dis-
tract her after the shots and she quit crying sooner.’’
For some parents, the DVD distraction was helpful
in reducing pain. As stated by one parent, ‘‘It dis-
tracted him about the pain right after. Overall, I would
say [the movie was] worth it.’’
Interestingly, seven parents stated they appreciated
the intervention to reduce anxiety or pain associated
with the child’s vaccination. However, they would pre-
randomly assigned to a group. The reasons for choos-
ing the child’s intervention were mostly justified by
unique personality differences or specific needs of the
child. For example, one child had an unfavorable re-
sponse to the vapocoolant spray. As the parent of this
child stated, ‘‘[she has] bad eczema on her arms [and]
tervention based upon their child’s personality. As
stated by one parent, ‘‘Distraction with video would
TABLE 2. Parent’s perception of pain
Hurts a little bit
Hurts a little more
Hurts even more
Hurts a whole lot
TABLE 3. Analysis of variance for parent’s
perception of child’s pain
TABLE 4. Parent’s perception of anxiety
Lots of anxiety
TABLE 5. Analysis of variance for parent’s
perception of child’s anxiety
www.jpedhc.org September/October 2013
[have worked] well forourchild better than spray.’’An-
DVD distraction group, stated, ‘‘My son is not into
movies so I think that is why it did not help.’’ Even par-
ents whose children were randomly assigned to the
anxiety and pain reduction intervention. One parent
expressed, ‘‘. I would love to try a movie or spray
Although no statistically significant quantitative results
were found with regard to the parents’ reports of their
child’s pain or anxiety between intervention groups
compared with the control group, the interventions
seemed to have had a marginal effect for a few chil-
dren. Whereas ideally an intervention would com-
pletely eliminate vaccine-associated pain, it is much
more realistic to expect a mild to moderate reduction
in pain during vaccination, such as was perceived by
the majority of parents in this study. Likewise, no sta-
tistically significant reduction in anxiety was found
between intervention groups. However, more than
half of the parents selected ‘‘a little anxiety’’ or
Although the majority of parents claimed the child’s
vaccination experience with intervention was about
the same as without an intervention, almost one third
ply be due to the fact that the child had matured since
his or her last vaccination. Indeed, several of the chil-
dren were 1 to 2 years older than they were at the
time of their previous vaccination. In addition, parents
were required to compare the child’s pain and anxiety
to a previous vaccination. For some parents, this re-
quest involved recalling the child’s vaccine-induced
pain and anxiety from more than 5 years ago. Certainly
the parent’s ability to recall the child’s previous re-
sponse to a vaccine could have had a confounding ef-
fect on the results.
It is interesting to note that one of the main themes
of the open-ended comments was appreciation for an
intervention to relieve vaccine-associated pain. Even
though no statistically significant difference in reduc-
ing pain and anxiety was found between groups,
more than half of parents reported they would like
the same intervention during vaccination in the fu-
ture. Although the quantitative and open-ended com-
ment resultsseem contradictory,
difference between results could be resolved with
a larger sample size. Also worth mentioning is the
fact that parents seemed to prefer any intervention
rather than no intervention at all; however, they
wanted to choose the child’s pain- and anxiety-
reducing intervention rather than being randomly as-
signed to a group.
In children as young as 3 years old, experiences with
pain can affect future perceptions of painful proce-
dures and response to painful stimuli (Paway &
Garten, 2010). Because vaccinations occur at regular
intervals during child-
painful vaccination ex-
periences may exhibit
increasing anxiety and
perception of vaccine-
associated pain before
and during subsequent
tration. As a result,
some parents may pro-
crastinate in schedul-
ing the child’s
pain associated with
the injections. It is im-
care professionals as-
sess thelevel of
a child’s anxiety regarding vaccinations and, when ap-
propriate, offer a choice of anxiety- or pain-reducing
intervention to parents. Because parents are most fa-
miliar with the child’s unique personality and specific
needs,they aremore likely tochoose aneffectiveinter-
comment, that parents believed the DVD distraction
process. For several children, the DVD distraction
method was able to take the child’s mind off the vacci-
nation experience before administration and then
ministration of the vaccination. Although further re-
search still needs to be completed, implementing
distraction using a DVD in the clinical setting may be
useful to decrease anxiety prior to vaccination, espe-
cially ifthechildwill bewaiting forsome time intheof-
fice before receiving the injection.
TABLE 6. Parent’s overall experience
compared with last vaccination
parental responsen (%)
About the same
to prefer any
wanted to choose
the child’s pain-
to a group.
Volume 27 ? Number 5 Journal of Pediatric Health Care
LIMITATIONS OF THE STUDY
The sample was small, primarily White, and from one
state, so it may not represent the entire population of
parents in the United States, thus the findings cannot
be generalized to other populations. A limitation to
this study was that it was underpowered. Although it
would have been useful, an initial power analysis was
not undertaken to determine our sample size for this
tion efforts to a 12-month period, which resulted in 68
participants. A post hoc power analysis indicated that
to obtain significant results for the one way ANOVA at
a = .05 with 80% power and a medium effect size of
.25, a total sample size of 165 (or 55 per group) would
have been needed. Another limitation was that parents
were not asked what treatments (such as a pain-
reducing medication) or behaviors (such as promise
of a reward) they had either given or offered the child
before coming for vaccinations. If children were pre-
medicated with an oral pain medication or offered are-
ward for ‘‘good behavior’’ during vaccination, results
may have been affected.
Evaluating pain perception in children is a complex
process and thus presents additional limitations be-
cause of the presence of many variables. For example,
our study solely evaluated the parent’s perception of
the child’s pain, although this measurement may have
altered results because some parents may not have
been able to differentiate between subtle variations of
the child’s pain and anxiety (i.e., ‘‘Hurts Little Bit’’ and
‘‘Hurts Little More’’). Also, it is possible that the older
children, who were capable of self-reporting pain and
anxiety, may have perceived their own pain and anxi-
ety differently than their parents, although in this study
only parent perception of the child’s pain and anxiety
was measured. Furthermore, some variables were not
controlled, such as age and maturity of the child, the
member previous vaccinations, or the interventions in-
stituted by parents before arriving at the clinic (i.e.,
administering a pain-reducing medication), which
likely would affect their levels of anxiety regarding
vaccination-associated pain. Moreover, the level of
restraint used during injections differed between
children. Although physical restraint during injections
also may influence the perception of pain and anxiety,
the level of restraint required for each child’s
vaccination was not recorded.
A replication of this pilot study with a larger sample is
needed to determine if statistically significance differ-
ences exist between treatment groups. While the re-
searchers opted to exclude interventions that took an
extended amount of time to take effect, such as EMLA
cream, other quick and inexpensive methods to alter
amined, such as placing anexternal thermomechanical
stimulation device on the limb of the injection site.
Thermomechanical stimulation devices, such as Buzzy
(MMJ Labs, Atlanta, GA), simultaneously utilize several
mechanisms for pain relief: the gate control theory, de-
scending noxious inhibitory control, and distraction
(Baxter, Cohen, McElvery, Lawson, & von Baeyer,
2011; Baxter, Leong, & Mathew, 2009). However, no
studies are available for review addressing the anxiety
among children regarding the device itself.
Many parents also stated that the child’s anxiety was
reduced before and after the vaccination was adminis-
tered if the child was watching a DVD movie. Because
this intervention is perceived by parents as reducing
the child’s anxiety,futureresearchshouldbeconducted
specifically exploring a DVD distraction method’s effect
the DVD distraction method could prove to effectively
reduce anxiety for pediatric patients in need of vaccina-
Parents expressed the desire to choose the child’s in-
the child’s pain- and anxiety-reduction intervention.
The perception of intervention effectiveness may be
positively influenced if the parent feels empowered to
make choices according to the child’s personality and
Ideally, parents who purposefully delay childhood
vaccinations because of vaccine-related pain and anxi-
ety should be studied regarding pain- and anxiety-
relieving interventions. However, in this pilot study,
parents were not asked to reveal the reason their child
was late for vaccinations until they were already en-
rolled as a participant. Therefore it is recommended
that replication studies require parents to identify
themselves as delaying vaccinations because of worry
regarding the child’s pain or anxiety prior to enroll-
ment. Only parents who delay childhood vaccinations
because of negative pain and anxiety perceptions
should be eligible for participation.
Furthermore, some of the pilot study questions did
not yield helpful results. although it was anticipated
a correlation could be identified between the parent’s
perception of the child’s vaccine-related pain and anx-
iety and time since last vaccination, number of injec-
tions due, and description of why the parents were
not on time for vaccinations, the data collected were
not useful in this regard. As a result, we recommend
that these items be removed from the questionnaire in
If distraction with a DVD movie or a vapocoolant spray
successfully alters aparent’s perceptionof thepain and
anxiety experienced during vaccinations, timely return
for future vaccinations may be fostered. Although no Download full-text
statistically significant results were found of the chil-
dren randomly assigned to one of three groups, many
parents still expressed
the desire to have the
same intervention on
ferred the ability to
choose the pain- and
Therefore it may be
helpful to evaluate the
child’s level of anxiety
regarding vaccinations and offer a variety of interven-
tions from which parents can choose. Further research
needs to be conducted to determine whether a differ-
ence in a parent’s perception of their child’s pain and
anxiety occurs when the pain- or anxiety-reducing in-
tervention can be selected.
Abbott, K., & Fowler-Kerry, S. (1995). The use of a topical refrigerant
anesthetic to reduce injection pain in children. Journal of Pain
and Symptom Management, 10(8), 5841-5901.
Attaran, A. (2008). A legislative failure of epidemic proportions.
CMAJ: Canadian Medical Association Journal, 179(1), 9-10.
Baxter, A. L., Cohen, L. L., McElvery, H. L., Lawson, M. L., & von
venipuncture pain in a pediatric emergency department. Pedi-
atric Emergency Care, 27(12), 1151-1156.
Baxter, A. L., Leong, T., & Mathew, B. (2009). External thermome-
chanical stimulation versus vapocoolant for adult venipuncture
pain. Clinical Journal of Pain, 25(8), 705-710.
Berberich, F. R., & Landman, Z. (2009). Reducing immunization dis-
comfort in 4-to 6-year-old children: A randomized clinical trial.
Pediatrics, 124(2), e203-e209.
Cassidy, K. L., Reid, G. J., McGrath, P. J., Smith, D. J., Brown, T. L.,
& Finley, G. A. (2001). A randomized double-blind, placebo-
controlled trial of the EMLA patch for the reduction of pain
associated with intramuscular injection in four to six-year-old
children. Acta Paediatrica, 90(11), 1329-1336.
Cohen, L. L., Bernard, R. S., McClellan, C. B., Piazza-Waggoner,
C., Taylor, B. K., & MacLaren, J. E. (2006). Topical anesthesia
versus distraction for infants’ immunization distress: Evalua-
tion with 6-month follow-up. Children’s Health Care, 35(2),
Davies, E. H., & Molloy, A. (2006). Comparisonof ethyl chloride spray
with topical anaesthetic in children experiencing venipuncture.
Paediatric Nursing, 18(3), 39-43.
Farion, K. J., Splinter, K. L., Newhook, K., Gaboury, I., & Splinter,
W. M. (2008). The effect of vapocoolantspray on pain due to in-
travenouscannulation inchildren: A randomized controlledtrial.
Canadian Medical Association Journal, 179(1), 31-36.
Foster, R. L. (2007). State-of-the-art pain assessment and manage-
pocoolant spray on pain with intravenous cannulation in patients
in emergency departments: Randomised double blind placebo
controlled trial. BMJ (Clinical Research Ed.), 338, b215.
Hsu, D. C. (2012). Topical anesthetics in children. Retrieved from
UpToDate website: http://www.uptodateonline.com
Jeffs, D. A. (2007). A pilot study of distraction for adolescents during
Keck, J. F., Gerkensmeyer, J. E., Joyce, B. A., & Schade, J. G.
(1996). Reliability and validity of the faces and word descriptor
scales to measure procedural pain. Journal of Pediatric Nurs-
ing, 11(6), 368-374.
Kleiber,C., & Harper,D. C.(1999).Effectsofdistraction on children’s
pain and distress during medical procedures: A meta-analysis.
Nursing Research, 48, 44-49.
Luthy, K. E., Beckstrand, R. L., & Peterson, N. E. (2009). Parental
hesitation as a factor in delayed childhood immunization.
Journal of Pediatric Health Care, 23(6), 388-393.
Luthy, K. E., Sperhac, A. M., Faux, S. A., & Miner, J. K. (2010). Im-
proving immunization rates in the clinic and in the community.
Contemporary Pediatrics, 27(9), 54-60.
Luthy, K. E., Thorpe, A., Dymock, L. C., & Connely, S. (2010). Eval-
uation of an intervention program to increase immunization
compliance among school children. Journal of School Nursing,
Mawhorter, S., Daugherty, L., Ford, A., Hughes, R., Metzger, D., &
Easley, K. (2004). Topical vapocoolant quickly and effectively
reduces vaccine-associated pain: Results of a randomized,
single-blinded, placebo-controlled study. Journal of Travel
Medicine, 11, 267-272.
Miller, A. M. (1993). Health care reform: Clarifying the concepts.
Journal of Community Health Nursing, 10(4), 199-211.
O’Brien, L., Taddio, A., Ipp, M., Goldbach, M., & Koren, G. (2004).
Topical 4% amethocaine gel reduces the pain of subcutan-
eous measles-mumps-rubella vaccination. Pediatrics, 114(6),
Page,D.E.,& Taylor,D.M. (2010).Vapocoolant sprayvssubcutane-
ous lidocaine injection for reducing the pain of intravenous can-
nulation: A randomized, controlled, clinical trial. British Journal
of Anaesthesia, 105(4), 519-525.
Paway, D., & Garten, L. (2010). Pain management in children. In A.
Kopf & N. B. Patel (Ed.), Guide to pain management in low-
resource settings (pp. 255-268). Retrieved from http://www.
Reis, E. C., & Holubkov, R. (1997). Vapocoolant spray is equally
effective as EMLA cream in reducing immunization pain in
school-aged children. Pediatrics, 100(6), e5.
Schechter, N. L., Zempsky, W. T., Cohen, L. L., McGrath, P. J., &
McMurtry, C. M. (2007). Pain reduction during pediatric im-
munizations: Evidence-based review and recommendations.
Pediatrics, 119(5), e1184-e1198.
Shah, V., Taddio, A., & Rieder, M. J. (2009). Effectiveness and toler-
ability of pharmacologic and combined interventions for reduc-
ing injection pain during routine childhood immunizations:
Systematic review and meta-analyses. Clinical Therapeutics,
Soueid, A., & Richard, B. (2007). Ethyl chloride as a cryoanalgesic in
pediatrics for venipuncture. Pediatric Emergency Care, 23(6),
chological interventions for needle-related procedural pain and
distress in children and adolescents. Cochrane Database of Syst-
ematic Reviews, 4(CD005179).
Vessey, J. A., Carlson, K. L., & McGill, J. (1994). Use of distraction
with children during an acute pain experience. Nursing Re-
search, 43(6), 369-372.
Yoon, W. Y., Chung, S. P., Lee, H. S., & Park, Y. S. (2008). Analge-
sic pretreatment for antibiotic skin test: Vapocoolant spray vs
ice cube. American Journal of Emergency Medicine, 26(1),
. it may be helpful
to evaluate the
child’s level of
offer a variety of
which parents can
Volume 27 ? Number 5Journal of Pediatric Health Care