![]() We included studies published as a full report or short report and published academic theses. The review included individuals of all ages undergoing vaccination in any setting or if not undergoing vaccination, the closest related skin-breaking procedure or context (eg, venipuncture) and randomized or quasi-randomized study designs. Relevant citations were screened and included as previously described. The search strategy was developed with the assistance of an academic librarian and was executed in EMBASE, Medline, PsycINFO, CINAHL, and ProQuest Dissertations & Theses Global. 3 Briefly, both the Grading of Assessments, Recommendations, Development and Evaluation (GRADE) 6 and Cochrane 7 methodologies guided the review. 4 ,5Ī universal approach was used to carry out several systematic reviews on the same topic the methodological details are provided elsewhere. 4 Similarly, we also separately report on the effects of combined interventions that include physical interventions (eg, non-nutritive sucking and sweet-tasting substances together) and the effectiveness of muscle tension in individuals with high levels of needle fear and a history of fainting. Breastfeeding, which combines physical (positioning and non-nutritive sucking) and pharmacological (sweet-tasting substances) elements, is included in a separate manuscript in this series. This manuscript reports the results for the effects of the following procedural and physical interventions: (1) aspiration during intramuscular (IM) vaccine injection, (2) order of injection for sequential vaccine injections, (3) simultaneous versus sequential injection of multiple vaccines, (4) positioning of the individual undergoing vaccination, (5) anatomic location for the vaccine injection, (6) non-nutritive sucking during vaccination, (7) tactile stimulation (manual and vibration) during vaccination, (8) warming the vaccine, and (9) muscle tension (for individuals with a history of fainting). The current systematic review was therefore undertaken to update and expand the knowledge synthesis on this topic. In addition, the original guideline excluded research in adults, leaving a gap in best practices for this population. 1 Since the original guideline was developed, additional research has been undertaken that has the potential to impact previous conclusions. 2 These interventions were subsequently incorporated in a clinical practice guideline about childhood vaccination pain management. In a previous knowledge synthesis on this topic, we found support for several different procedural and physical interventions. But for the costs of training clinicians, the majority of procedural and physical interventions offer the advantage of being time and resource cost neutral when compared with other approaches, and hence can be applied across clinical settings. 1 These interventions can be broadly divided into pharmacological, psychological, procedural, and physical approaches. Numerous interventions have been evaluated to combat the pain from vaccine injections. Vaccine injections are the most frequent painful medical procedure performed worldwide. Muscle tension was beneficial in selected indices of fainting in adolescents and adults. There was no benefit of warming the vaccine in adults. An external vibrating device and cold reduced pain in children (n=145): SMD −1.23 (95% CI: −1.58, −0.87). Manual tactile stimulation did not reduce pain across the lifespan. Self-reported fear was reduced for children positioned upright (n=107): SMD −0.39 (95% CI: −0.77, −0.01). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD −0.65 (95% CI: −1.08, −0.22). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD −1.25 (95% CI: −2.05, −0.46). Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. There was no benefit of simultaneous injections in children. ![]() Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD −0.56 (95% CI: −0.87, −0.25). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD −0.69 (95% CI: −0.98, −0.4). Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) −0.82 (95% confidence interval : −1.18, −0.46).
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