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Injections for vaccinations, the most common source of iatrogenic pain in childhood,1 are administered at mul - tiple times to almost all Canadian children throughout infancy, childhood and adolescence.2 The pain associated with such injections is a source of distress for children, their parents and those administering the injections. If not addressed, this pain can lead to preprocedural anxiety in the future, fear of needles and nonadherence with vaccination schedules.3 It is estimated that up to 25% of adults have a fear of needles,4 with most fears developing in childhood.5 About 10% of the population avoids vaccination and other needle procedures because of needle fears.3
Conversely, minimizing pain during childhood vaccination can help to prevent distress, development of needle fears and subsequent health care avoidance behaviours such as nonadherence with vaccination schedules. More positive experiences during vaccine injections also maintain and promote trust in health care providers.3
In light of the prevalence of pain during vaccine injections and the potential for substantial adverse sequelae, we iden - tified a need for a national guidance document to address this important public health issue. Although the topic was covered in a previous narrative review1 and a national guideline,4 neither of those documents was based on the requisite systematic approach and rigorous guideline development process. Moreover, additional data have been published since the appearance of the previous documents.
Our objective was to develop a clinical practice guideline, based on systematic reviews of the literature, as interpreted by experts, to assist clinicians in managing procedure-related pain and distress among children undergoing vaccine injections. The scope was limited to acute (immediate) pain and distress at the time of vaccine injection in children 0 to 18 years of age. We did not consider the management of delayed-onset pain occurring in the hours or days after the injection. The term "distress" is often used to refer to the combination of pain and anxiety or fear experienced by children before and during painful medical procedures. For the purposes of this guideline, we considered distress and pain together, referring to the combination as "pain."
Methods
We convened an interdisciplinary expert panel, the Help ELiminate Pain in KIDS (HELPinKIDS) Team, to develop the guideline. Individual panel members, with the required expertise in areas of vaccination...