No pain , much to gain ! !

No pain, much to gain!! Ranganath K. R.1, M. Prabhu S.2*, T. Kumar P.3, Govindaraj M.4 DOI: https://doi.org/10.17511/ijpr.2020.i07.01 1 Ranganath K. R., Associate Professor, Department of Paediatrics, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India. 2* Sameeta M. Prabhu, Post-Graduate, Department of Paediatrics, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India. 3 Pavan T. Kumar, Post-Graduate, Department of Paediatrics, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India. 4 M. Govindaraj, Professor and HOD, Department of Paediatrics, Dr. B R Ambedkar Medical College, Bengaluru, Karnataka, India.


Introduction
Immunization has been called the greatest public health achievement of the 20th century by the Centers for Disease Control and Prevention (CDC) [1]. Currently, children have very minimal risk of severe complications of tuberculosis, paralysis from polio, cervical cancer from human papillomavirus, mental retardation, and profound hearing loss from Haemophilus influenza, meningitis, etc due to the implementation of routine immunization programs.
Vaccinations not only protect a child from diseases, but they also keep the community safe by eliminating or reducing these diseases that can spread from one to the other in a population.
Because of this community protection, individuals who cannot be vaccinated due to certain contraindications and persons who fail to elicit an adequate immune response to the vaccine are protected indirectly as they are not exposed to these diseases.
In recent years, many individuals are uncertain about vaccinations, due to fear of side effects and unable to recognize the enormous health and economic benefits that vaccines provide. Many parents delay vaccinations or decide against vaccinating their children. This increases the risk of contracting vaccine-preventable diseases and disrupting herd immunity, and also reduces the trust in the capacities of health care systems to protect people.
Vaccine hesitancy is related to a range of both psychological and demographic determinants, such as attitudes toward vaccinations, social norms, and trust in science. For parents, vaccinating their children could mean that parents have to experience their child's discomfort side effects. For the child, a major concern is the pain and discomfort associated with the vaccine.
Hence, there is a need to alleviate these fears of both parent/guardian as well as child to encourage routine immunization. Pain management is an integral part of this. The present study aims to study the effects of regular use of local anesthetics in routine immunization with regards to the patient, the parent/guardian, and the medical personnel. Case (local anesthetic i.e Lidocaine aerosol applied) and control (no local anesthetics applied). There was no significant difference in gender distribution between the two groups.   Comparison between two groups. There was a significant difference in pain scores between the two groups.    In the Local Anaesthesia group, the Median pain score in the IM group was 6, in the ID group was 6 and in the SC group was 5. In the No Local anesthesia group, the Median pain score in the IM group was 8, in the ID group was 8 and in the SC group was 8.

Results
There was a significant difference in pain scores between the two groups among those who received IM and ID injections, but no significant difference in pain scores was observed for the SC route.

Discussions
Immunizations in children, especially the associated pain, pose difficulties and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Some children experience intense anxiety regarding vaccinations, a reaction that may result in non-adherence to the recommended vaccination schedule.
It is integral to provide a suitable environment for the child, before the administration of the vaccine to reduce the associated anxiety. Certain steps that can be taken are choosing an appropriate site of injection, appropriate length of the needle, parental reassurance, distraction techniques, and sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children [8].
There is adequate evidence supporting the effectiveness of topical anesthetics in preventing pain in children and adults.9,10 They also have a good safety margin and are effective for infants and children [11]. There is no interference with the immune response to the vaccines [9,10].
A study by Taddio et al, states that despite an abundance of data that demonstrate the efficacy of local anesthetics for decreasing immunization pain, their adoption in practice has not been determined [12]. Lower in the EMLA (topical anesthetic mixture of Lidocaine (2.5%) and Prilocaine (2.5%) in a cream base) group than in the placebo group. The VAS (visual analog scale) scores at the time of the injection were significantly lower in the EMLA group compared with the placebo group [14].
Lidocaine is a local anesthetic that can be used before immunization. A comparative study by Zhu J et al showed topical lidocaine anesthesia had the same postoperative pain relief and the least adverse events as local and general lidocaine anesthesia [15].
Another study showed that vapor coolant spray significantly reduces immediate injection pain compared with distraction alone, and is equally effective as, less expensive, and faster-acting than EMLA cream [16].
The current study shows the efficacy of the topical Lidocaine in significantly reducing immediate injection-associated pain and there are no significant associated adverse effects for the same. This was very advantageous to abate all the anxiety of the child, the parent, and the health provider.
However, it was found more effective in some individuals than others, with probable contributing factors such as type of vaccine, the route, age, temperament, and parental factors. Hence a further sub-analysis is required under each factor individually.
The pain was assessed using the MBPS, which may not be a very accurate measure of pain in all age groups. This requires the use of other scales such as the Numeric Rating Scale (NRS), visual analog scale, etc to confirm the same.
A further detailed study regarding the variation of onset of action, duration, efficacy, etc of the aerosol for different skin types, ages, climates, etc also needs to be done. In addition, the present study was conducted on a relatively small number of children. All of these limitations warrant further research.

Conclusions
Vaccinations can be one of the most painful procedures for infants and children, resulting in anxiety, which in turn results in decreased adherence to the vaccination schedule. The pediatrician has to develop effective pain-relieving strategies with vaccinations. The present study presented that, along with simple strategies, the use of a local anesthetic is a costefficient and effective pain-management technique. However, the study had a limited number of children (especially those who received the subcutaneous injection), requiring further studies.
Hence, the application of local anesthetic can be effectively incorporated as a routine pain-relieving intervention within routine vaccination appointments. This will be a positive step in not only relieving the child but also the medical personnel involved; preventing any inadvertent mistakes.
What does the study add to the existing knowledge The use of an aerosol containing Lidocaine, rather than topical gels or creams (such as EMLA), has many advantages.

Authors contributions
Dr. Sameeta Mercy Prabhu: Study concept and design, acquisition, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript for important intellectual content and final approval, agrees to be accountable for all aspects of the study.