Jun 17, 2019, By: Mary Ives
Childhood immunizations provide enormous health benefits and are mainly accomplished without difficulty. However, many children struggle with strong fear or even outright phobia of getting a needle. In 2006, a British Columbia study identified practice gaps for public health nurses responding to children who strongly resist needle injection (Ives, 2007; Ives & Melrose, 2010). In 2012, the British Columbia Centre for Disease Control (BCCDC) appended practice guidelines entitled “Reducing Immunization Pain” to the provincial immunization manual. Let’s review the nurse’s critical role in these complex situations and avoid drift from best practice.
- Every childhood immunization encounter is an opportunity to build resilience.
- Although each situation with needle-resistant children is unique, predictable patterns occur.
- Focus on tuning in to the child’s need for a felt sense of enough safety to proceed.
The BCCDC appendix might be more appropriately titled “Managing Immunization Pain and Building Resilience.” We know from research in adverse childhood experiences (ACEs) that resilience offsets harmful neural impacts of adverse life events. Resilience is the ability to cope with and recover from adversity. Resilience prevents autoimmune, cardiovascular, and other diseases associated with ACE-related premature death in adults. When a child resists needle injection, nurses can welcome an opportunity to contribute to the child’s resilience experience.
Pain is subjective. While minimizing pain is important, needle injection tends toward the less painful end of a spectrum. Fear, rather than actual pain, generates resistance. Elimination of mild to moderate pain can actually rob a child of an important mastery experience and may even communicate an unintended message of disempowerment.
At the very least, we must do no harm. Ensure that you, the immunizer, are calm enough to structure the situation and come alongside to guide the child. Focus on pacing that resonates with the child’s capacity to proceed. Let go of any outcome except to scaffold as the child struggles with this learning opportunity. Scaffolding provides temporary support and requires precise attunement to the learner’s state. This “tuning in” is an element of compassion and is not to be confused with pity or indulgence. Pity implies the person is undeserving of an unfair fate. Indulgence suggests an extravagant overcompensation. Neither attitude fosters ability to manage life’s inevitable doses of pain and suffering with some equanimity. Appropriate scaffolding is known to be highly correlated with secure attachment and maximizes learning via careful tailoring to support learner success. Doing too much or too little disrupts learning.
Facilitate a calm, receptive environment that encourages openness to new ideas. Do not barrage with information. A five- to seven-second pause before speaking can leave space for internal processing. The goal is to help the child adjust perception from that of an insurmountable problem to one where he or she feels safe enough to turn toward and gently work through the source of fear.
In highly charged situations, emotional messages have more influence than facts. Empathy with the child’s present experience helps to establish connection. Stay alert and curious about what is happening in yourself and others so you can make decisions based on emerging needs and without being unduly influenced by notions of “good” or “bad.” Provide structure and keep moving forward. Parents, often surprised by their child’s resistance, seek trust in your ability to manage the event competently.
Responding to common behaviours in children
Although each situation is unique, patterns of behaviour recur. Here are some common child behaviours with suggested clinical responses:
- Child presents crying and clinging to parent.
Child states: “I don’t want a needle!”
- Use empathy: “You look unhappy. I’m guessing you’d rather be anywhere than here.” When we feel truly understood, we are better able to cope.
Child wants younger, less anxious sibling to go first.
- Use empathy: “I hear how much you don’t want this.” Grant wishes in fantasy: “I wish we could put the medicine in some ice cream instead of a needle.” Acknowledging how much someone wishes things could be different communicates understanding.
Child asks, “Can I see the needle?”
- Maintain structure: Start with the most anxious (usually the eldest) even if the parent thinks otherwise. Watching someone else go first, no matter how calmly, does not help the anxious child feel understood.
Child states, “I can’t do it!”
- Maintain structure: Explain you can show it after the procedure. The needle is a primary source of fear, and viewing it beforehand is unhelpful because the child’s perception is skewed by anxiety.
Child continues to resist. Parent continues to insist. Nurse sees no movement toward cooperation from child.
- Use empathy: “This is really hard for you. On the one hand, you’d like to get it over with; on the other hand, it’s scary.” Offer hope: “This is difficult; yet with help, you can handle it.”
- Maintain structure and provide closure: Describe what you see, and make a decision to defer. “I see that you (child) are not ready to go ahead right now. Sometimes it takes more than one try.” Offer a rest or another appointment. Celebrate effort: “You tried your best. That’s a good start and enough for today. Would you like to choose a sticker to celebrate your hard work?” The parent usually appreciates the nurse taking responsibility for managing the process. Occasionally, a parent insists another nurse be recruited to “just give the needle.” Give information: Policy restricts use of coercive force. It is the responsibility of the immunization provider to stop the procedure when necessary (Appendix D, BCCDC Immunization Manual, p. 6).
Help for parents
Patterns also recur with caregivers who may:
- Express a fear that their young child will remember the experience and subconsciously blame or even “hate” the parent.
Not inform the child as to the purpose of the visit through fear of the child’s resistance.
- Use empathy and give information: “You sound torn. Most likely your child will remember your supportive presence during a difficult experience.”
Tell the child, “It won’t hurt.”
- Offer support without parental role intrusion: Ask the child if they know why they are here. Ask the parent how they would describe it to the child. Help the parent inform the child, for example, “You are here for your kindergarten booster.” Don’t wait for the child to agree that immunization is a good idea. Move forward using empathy and structure.
Admonish the child not to cry.
- Give information: Honesty fosters trust. Explain, “It may hurt a bit; at the same time, I believe you’ll handle it. I will not surprise you before you are ready.”
Threaten the child: “No needle, no birthday party!”
- Give information: Calmly assert: “Here it is okay for anyone to cry, especially when getting a needle.”
Inadequately hold the child.
- Support the parent: Use empathy, state a neutral fact or principle, and offer hope. For example: “You must be frustrated. Immunizations are not emergencies. I think we can come up with something we can all live with.”
Chastise the nurse to the child: “The mean nurse did that to you.”
- Structure the situation: Secure restraint minimizes risk of injury. The goal of restraint is not to overpower but to help the child hold still during the brief procedure. Give clear direction to the parent on how to hold the child. At the same time, do not over-rely on the parent. Maintain a firm grasp on the target limb and administer dose efficiently. Parent might insist on being absent for actual immunization. Preferably, someone with whom the child is familiar can remain present so as to reduce any sense of abandonment/betrayal.
- Support the parent: This is a situation where two people may need empathy at the same time. Pause. Give yourself a quick dose of self-empathy before you respond. For example, silently say to yourself, “Ouch! I’m working to be helpful. Okay… breathe… it’s nothing personal.” Address the parent: “Sounds like you have mixed feelings about this. A parent’s job can be difficult. You decided to protect your child, yet it was hard to see him struggle.”
Childhood immunizations are opportunities to promote resilience and positively influence long-term health. When one feels truly understood, supported with respectful pacing and bounded choices, and simply appreciated for one’s effort—these are experiences that embed resilience.
British Columbia Centre for Disease Control. (2012, June). Chapter 2: Immunization Appendix D—Reducing immunization injection pain. BCCDC communicable disease control manual. Vancouver, BC: Author.
Ives, M. (2007). Model empathy and respect when immunizing children who fear needles. Canadian Nurse, 103(4), 6–7.
Ives, M., & Melrose, S. (2010). Immunizing children who fear and resist needles: is it a problem for nurses? Nursing Forum, 45(1), 29–39.
Mary Ives, RN, BSN, MHS lives in Chilliwack BC and currently practices in the Nurse Family Partnership program with Fraser Health.