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Needle Distress and Anxiety Related to COVID-19 Vaccine among Children: An under-recognized Challenge Contributing to Vaccine Hesitancy

According to the recent state-level data report published by the American Academy of Paediatrics (AAP), the pediatric population accounted for only less than 0.26% of all coronavirus disease-2019 (COVID-19) deaths, while eight states did not report any child deaths.1 As COVID-19 continues to disrupt normal life with its continuous waves of infection, the development of vaccines seems to be the most effective preventive measure to curb the spread of the infection. While several vaccines have been authorized for emergency use among adults, some have recently been approved for use in the pediatric population. Approval, however, is only the first step and not the ultimate solution. Several hurdles need to be overcome, with the most commonly reported being a pain, needle distress, and associated anxiety with the vaccinations, especially among children. In the past, needle phobia has been a proven cause for poor adherence to the vaccination schedules among children and parents.2 Although children are not severely affected with COVID-19 so far, according to the AAP, children represent 14% of the total cases in the USA, whereas Health Canada reports around 19% of cases that are attributed to individuals below 19 years.3 Despite the prevalent high vaccination roll-outs and the low mortality among children, the pediatric population draws maximum attention as only those above 12 years are eligible for the jabs. However, recently in late October 2021, Pfizer-BioNTech has received authorization for emergency use (EUA) among those aged 5-11 years by the Food and Drug Administration (FDA).

It is important to understand that although immunization is currently the best option to combat this pandemic, there are certain hurdles and challenges in its administration and further consequences, especially among children. One of the main reasons is the children’s response towards vaccination, including the attitude of parents and caregivers. Needle-related distress affects approximately 3.5% to 10% of the entire population, where around 63% of children aged between 6-17 years experience needle fear.4 When research was conducted in a large sample of children being vaccinated, the self-reported fear of needles was observed to decrease with age, and needle phobia was rated as strong among 68% of children aged 6-8 years, 65% of children aged 9-12 years and 51% of children aged 13-17 years, respectively.4, 5 Most of the vaccines are available as intravenous or intramuscular formulations, and thus distress and avoidance behaviour towards vaccination are routine manifestations of needle-related fear and phobia. Despite knowing the benefits of being vaccinated, the thought of vaccination in children tends to automatically trigger pain and anxiety associated with the needle prick. A study by Kennedy et al. reported that 44.2% of the parents are primarily bothered about the pain posed to their children through vaccination.6 Pain might sound like a trivial reason to be non-compliant with a proposed immunization schedule that could save a child’s life. However, this can be backed up by scientific evidence, which has proposed that as many as 24% and 63% of parents and children respectively are traumatized with the fear of needles, and it is one of the root causes for poor compliance to immunization among 7% of the parents and 8% of the children.5

The World Health Organization (WHO) put together the immunization stress-related response (ISSR) for the most common symptoms observed with needle use among children.7 Consequently, York University has come up with ways to aid parents in handling distress during or post-vaccination among children.8 Children are observed to become calmer during the immunization with the encouraging statements ‘you can do this’ and ‘it will be over soon’ from the parents. In order to handle the consequence of pain caused by needle pricks in a much better manner, various techniques have been devised. The offer to gently rub the site of injection before administration, parent- and clinician-led distraction using videos and music, the use of topic anesthetics such as a 5% cream, patch of lidocaine-prilocaine or the use of a sweet-tasting solution containing sucrose are some of the ways to handle needle-related distress and anxiety among children.9, 10 Scientists in the pharmaceutical sector have directed significant efforts to develop new formulations of the vaccines and the use of new routes to alleviate the issues of pain and needle distress among children. Furthermore, novel approaches like dry powder injections, micro-needles and nano-patches are promising routes under clinical trials for the painless delivery of vaccines in children.11 These contemporary avenues of vaccine delivery are not only cost-effective but are also safe and easy to administer to the pediatric population. The propensity to further the practice of immunization in the future depends on how quickly and successfully the scientists can develop alternative routes and formulations that are easier to administer in a child-friendly manner. The development of such a painless delivery system will be a powerful and successful tool to ensure compliance with the proposed vaccination schedule. Also, concerning the demand for human resources, less trained staff will be required to administer these painless vaccines during epidemics, pandemics, and emergencies like COVID-19.

Vaccine hesitancy due to fear for needles among children remains a challenge. It is essential to involve daycare, kinder garden, and school boards to improve the knowledge towards the importance of vaccination in combating the COVID-19 pandemic. For children below 12 years of age, parents are the sole decision-makers for providing consent towards vaccination. It is parents’ responsibility to let their children know about the significance of receiving the vaccine, which could potentially reduce vaccine hesitancy, especially among children.12 It is also the healthcare workers’ responsibility to educate and train the parents to make the vaccination process easier for the children. There are currently no gold standard questionnaires to quantify needle fear among children. However, a new innovative tool called the CARD system (Comfort, Ask, Relax and Distract) developed by the University of Toronto helps identify the type of needle fear and address how to deal with it.13 Some of the strategies that could potentially overcome this issue would include preparing information leaflets and educational videos both in English as well as in the local vernacular languages to address major concerns and the myths surrounding the COVID-19 vaccines, both in the minds of parents as well as children. Usage of flyers and large billboards could draw attention and highlight the importance of vaccination among children. Since schools and educational institutions have begun using social media platforms as the new norms of learning, teachers and educational facilitators, need to be trained regarding the significance of being vaccinated against COVID-19. In this technically advanced world, social, digital and print media are powerful tools that could be utilized in this aspect of advancing vaccination rates among children who are usually scared of needle pricks. Lastly, it is also essential to properly train all the healthcare professionals in administering the COVID-19 vaccines, especially to children, in a skilled manner to alleviate as much pain and needle distress as possible.

About the author: Sai Krishna Gudi is a Ph.D. student at the College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Canada. Alongside, he is also working as a Jr. Epidemiologist at the Manitoba Health, Government of Manitoba. Sophia M George is an assistant professor, Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences, NITTE University (Deemed), Mangalore, India. Tarannum T is a MPH graduate from the University of Alberta and currently working as an Epidemiologist at the Fraser Health Authority, British Colombia, Canada. Komal Krishna Tiwari is a researcher with the Physiotherapy and Rehabilitation Sciences background and worked among various settings including research and practice in Winnipeg, Canada.

Follow Dr. Gudi on Twitter @SaiKGudi

REFERENCES

  1. American Academy of Pediatrics. Children and COVID-19: State level data report. Accessed January 05, 2022. Available at: https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
  2. McLenon J, Rogers MAM. The fear of needles: A systematic review and meta-analysis. J Adv Nurs 2019;75(1):30-42.
  3. Bonfield, J. Why a COVID-19 vaccine isn’t available for children yet. Accessed January 05, 2022. Available at: https://www.cp24.com/news/why-a-covid-19-vaccine-isn-t-available-for-children-yet-1.5509995?cache=wpwecmoua%3FclipId%3D89925
  4. Orenius T, LicPsych, Säilä H, Mikola K, Ristolainen L. Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors. SAGE Open Nurs 2018;4:2377960818759442.
  5. Taddio A, Ipp M, Thivakaran S, et al. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine 2012;30(32):4807-4812.
  6. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics 2011;127 Suppl 1:S92-S99.
  7. World Health Organization‎. Immunization stress-related response: a manual for program managers and health professionals to prevent, identify and respond to stress-related responses following immunization. Accessed January 05, 2022. Available at: https://apps.who.int/iris/handle/10665/330277.
  8. Annayar. YorkU pain research finds what you say in the first minute after a vaccine can be key in reducing a child’s future distress. Accessed January 05, 2022. Available at: https://news.yorku.ca/2021/07/13/yorku-pain-research-finds-what-you-say-in-the-first-minute-after-a-vaccine-can-be-key-in-reducing-a-childs-future-distress/
  9. Halpert C, Meier S, Naus M. Reducing immunization injection pain in infants. BCMJ 2015;57:189.
  10. Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary). CMAJ 2010;182(18):1989-1995.
  11. Garg N, Aggarwal A. Advances Towards Painless Vaccination and Newer Modes of Vaccine Delivery. Indian J Pediatr 2018;85(2):132-138.
  12. Allen, B. Don’t assume your child wants a COVID-19 vaccine, parents and public health experts warn. Accessed January 05, 2022. Available at: https://www.cbc.ca/news/canada/saskatchewan/child-vaccine-covid-19-parents-assume-1.6040198.
  13. Immunize Canada. CARD for Kids and Adolescents. Accessed January 05, 2022. Available at: https://immunize.ca/card-kids-and-adolescents.
Discussion
  1. This is really fantastic of you to shine a light on needle fear as a contributing factor to vaccine hesitancy. Amy Baxter MD is a leader in this research – and even testified before US policymakers about the public health implications of ignoring needle fear. (Dr. Baxter even quotes Dr. Taddio!) https://youtu.be/UXNTGFOlw-g
    Her company’s Buzzy solution is the only needle intervention proven to reduce both needle pain and fear. https://paincarelabs.com/research/

  2. We found a dose response with the number of same day injections during the critical 4-6 year age range and the degree of subsequent preadolescent needle fear. In pediatric PTSD to natural disasters, the age range before abstract thought but after development of verbal memory is critical (i.e. 3-7 years). Parental behavior and presence of pain influence whether subsequent trauma reactions develop. Interventions increasing parental confidence, pain management, and lowering the numbers of same-day booster injections should be studied to reduce needle phobia. In addition, devices that reduce needle fear/anxiety have been used routinely in some practices since 2013. Patients for whom these interventions were used could be compared to patients who did not use these interventions to see retrospectively if preadolescent needle fear is reduced.

  3. I like that you said that it is important to act as support for your child for them to be comfortable. After moving to our current area, my wife stated to me last night that she wants our son to have a vaccination to ensure that he is protected from various illnesses, and she asked if I had any ideas about what the best option is to do for safety purposes. Thanks to your informative article, I’ll be sure to schedule vaccinations for our son.

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