Dr. Stefan Friedrichsdorf: Helping kids with vaccine pain and fear

[0:00:19]

STEFAN FRIEDRICHSDORF: Hi, my name is Dr. Stefan Friedrichsdorf, I’m a professor of pediatrics here at the UCSF University of California, San Francisco, and I am the medical director of the Stad Center for Pediatric Pain, Palliative Care and Integrative Medicine. And as the title and the name implies, my body of research and interest is preventing pain and suffering for children.

[0:00:53]

STEFAN FRIEDRICHSDORF: When you ask every single child—What are you most afraid of seeing a doctor right now? Every single kid is going to tell you they’re afraid of needles, of pokes, of being held down. So, we have looked at the data, and based on what many clinicians, pharmacists, child life specialists have been taught for decades now, we basically package this as a comfort promise, and we really want to offer those four things to every child every time. Because what’s happening most of the time in most places here in the United States is like, oh, this is offered for some children some of the time. All right, let’s go through it. Number one: always offer numbing cream. So, you can just buy over the counter 4% lidocaine cream. You can order this online for a few dollars, and you want to apply the numbing cream at least 30 minutes before the needle procedure. It can be on longer. That doesn’t matter, but it should be at least for 30 minutes. Number two: for babies younger than 12 months, always offer a drop of sugar water, sucrose, or allow breastfeeding if this is possible. And the sugar water, the breastfeeding, works basically as a pain blocker. It stops the pain information reaching the brain the same way as if I have a piece of dark chocolate tonight—it helps me to release endorphins, happy hormones in my brain—and reduce the amount of pain and stress reaching my brain. Number three: never, ever, ever, ever hold down a child. We were all taught the wrong way, that the best way is to hold down kids and then do the vaccination and do the blood draw, and we now know this is a terrible mistake. So once children are old enough to sit upright to six months or older, you really want to sit them upright and give them choices. They may want to sit on their parents or grandparents’ lap. They may want to sit next to them. Teenagers may just want to sit upright on their own, but they would know what to do. And number four: offer age-appropriate distraction. Age-appropriate distraction means that, as I just mentioned, teenagers may choose to be on their phone listening to music or being with an app. For smaller children and school kids, we like blowing bubbles or blowing pinwheels or using a book—Find Waldo, or something like this. And for small kids, babies, and toddlers, they are very fascinated by distracting toys with spinning wheels or something like that. And we have found if we offer those four things to every child every time, the vast majority of children do not experience pain and anxiety with needles, and some say they were bothered a little, but it’s really, really significantly down.

[0:04:02]

STEFAN FRIEDRICHSDORF: If your doctor’s office does not provide the numbing cream, you want to buy the numbing cream yourself and apply it at home at least 30 minutes before, so just check in with your clinician’s office where to apply the numbing cream. For older children a year or older, it’s usually up here on the arm. They might need two vaccinations, so maybe have to do the other arm. Usually for babies or children younger than one year, it’s like, up on the leg, on the thigh. So just make sure that you know where to put the numbing cream. And talk to your kids about this. We’re not lying if they’re asking, “Do I get a shot?” To say, like, “Well, you will get a very brief vaccination at the very end, and this time, we’re going really differently. Yeah, you’re going to sit on my lap, if you like, or what do you want to sit next to me? We’re going to put the numbing cream—the magic cream on.” It helps, and parents are welcome to use our website or other websites for this information to really make sure to care for our language. I’m a dad of three kids. I never was taught what to do, right? And we just now have learned that research has shown like, do not count to three. So, this idea of counting to one, two, three, and then put the needle in that makes it even worse. Yeah, so that’s not a good idea. And it’s also not a good idea to say like, “Oh, I’m so sorry. I’m so so sorry, or it’ll be over soon, or it’ll be okay. It’ll be okay.” All of this actually makes the very much, much larger.

So, we really want to encourage parents like myself to encourage them to use bravery language and and things they can do to help to relieve the stress of and pain of the procedure, like deep breathing distraction, ask them about pets or school or music or interests—some like a very much distraction. And right after the needle poke, whether it’s a blood draw or vaccination, it’s really helpful to reframe the pain. We want to shape the memory for next time. We want the kids to remember this well. So, praise them—either the parent or the caregiver or the clinician—no matter what, I’m so proud of you. You did so well, and either the kid actually did not flinch, I was really completely distracted, and I said like, You did amazing. Do you remember how you were not bothered at all? Or even if this is a child who’s quite anxious and has been held down in the past and and maybe all those modalities still make them that they’re crying for very brief moments. Then you say, like, remember how you were bothered for only a brief moment? And then afterwards, you got this nice sticker from the nurse. Do you remember that? But just saying this, the kids will remember this much more positively, so they have much less anxiety when they come back.

[0:06:49]

STEFAN FRIEDRICHSDORF: If we go back in time, 50 years, 100 years, 150 years, if I talk to my grandmother, six of her 12 siblings died. So, three generations ago, babies died. And if you actually see, why do most kids survive right now? There are two answers. Number one is hand washing. So, since doctors actually washing their hands, it really has gotten down on numbers of people dying from infections. Number two, it’s vaccinations. Without vaccines, children would be at risk of serious illness, disability, or even death from diseases such as measles or whooping cough or infection of the brain, and meningitis due to haemophilus influenza type B. So, a vaccine as a medical product. I personally, as a pediatrician, have taken care of five children who died from measles because they were not vaccinated, and that is preventable in each and every time of these tragic cases.

[0:07:59]

STEFAN FRIEDRICHSDORF: So, if you look at the statistics, you find that somewhere between 92 and 79% of the children with Medicaid or uninsured children are vaccinated. Slightly more 96% with private insurance. If you actually look and ask the parents, why are kids not vaccinated? Of course, a huge study has shown that being afraid of needles is actually the number one reason why kids are not getting vaccinated, and as I said, because the parents can’t watch their baby being held down and pinned down and getting one or two or three needles, because they’re also themselves are very afraid, or the children themselves don’t want to do this. So, needle fear is the primary reason for immunization and non-compliance. We now know that one out of four adults are afraid of needles. And if we ask, when did you become afraid of needles? Well, it was probably when they were held down as children and they developed all this anxiety, and when it was like all done in the wrong way, so we can do better. And taking pain and anxiety is not only the right thing to do—it also improves medical care and proves access to medicine later on in life.