Needle anxiety – Immunisation

Introduction

'Needle anxiety' refers to an overwhelming fear of medical procedures involving needles or injections, which can manifest in both psychological and physical symptoms, including avoidance behaviour and significant distress.

Needle anxiety can impact on a child’s ability to complete a range of injection-related medical procedures however the scope of the Perth Children's Hospital (PCH) needle anxiety pathway is limited to the successful administration of vaccinations.

Minimising pain during vaccinations can help to prevent distress, the development of needle fears and subsequent health care avoidance. Positive experiences during vaccination(s), help to maintain and promote trust in health care providers.

Pre-referral investigation

• Nil

Pre-referral management

• Consider referral for a Mental Health Care Plan especially if there are features of anxiety or other mental health concerns in addition to medical procedural anxiety.
• Many instances of needle anxiety are most appropriately managed in the primary care setting. This may require multiple appointments or longer appointments to allow adequate time for patients and caregivers to express their concerns and to have these addressed.

Some strategies to attempt prior to referral for specialist needle anxiety pathway are outlined below.

Prior to immunisation

• It is important that the family prepares the child before the appointment, including age-appropriate information, to assist them to make choices about their support and comfort needs i.e. being offered the choice of which arm can reduce anxiety.
• Reduce waiting times and consider distraction for any waiting periods.

During immunisation

• Incorporate pain relieving strategies such as tactile stimulation; topical anaesthetics (i.e. numbing cream) and/or injecting the most painful vaccine last.
• Consider positioning and comfort. Being upright and comfortably held by a parent can reduce anxiety; being positioned away from the needle being drawn.
• Consider distraction. Changing the focus of attention changes the way the body processes pain and anxiety.

Following immunisation

• Focusing on the positive and praising good coping skills following a vaccination can create a positive memory and help for future expectations.

See the useful resources section below for links to materials that can help guide these conversations and procedures.

When to refer

The family must be aware of the referral and willing to engage with the service.

• When patients have experienced multiple unsuccessful attempts at vaccine administration within community-based immunisation centres despite employing strategies outlined above and referred to in the useful resources section below.

Referrals requesting services that are not directly related to the administration of vaccines, for example phlebotomy, will not be accepted.

Families are likely to face significant wait times to access our service, which risks further delaying their child’s protection through immunisation. Please continue conversations with families after referral and inform us if the family successfully proceed with vaccination prior to a clinic appointment becoming available.

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
• Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals go to the PCH Referral Office via fax: (08) 6456 0097 or email

Essential information to include in referral

• The child’s vaccine status and vaccines due according to the WA Immunisation Schedule
• Previous attempts at vaccination in the community
• Relevant medical history, including neurodevelopmental and mental health comorbidities
• Previous treatment for needle anxiety

Useful resources

The following resources may assist you in your approach to help these families:

1. Use of social stories: step by step procedure guides
2. Tips for navigating conversations around needle anxiety | EPIC – My child is afraid of needles
3. Learning How to Manage Pain During Medical Procedures – YouTube | The ‘being the boss of your brain’ video can be helpful for the child and parent to watch when planning their visit. This is a great general resource for kids and adults as it is helpful to explore different ways we can learn to be the boss when our brain is setting us down a scary or overly protective pathway.
4. Meg Foundation has some general strategies that are useful. Lots of older children will complete the ‘poke plan’ and bring it to their appointment.
5. Consider the use of numbing cream. This should be applied to the deltoid–upper area of the arm and covered with a dressing one hour before the immunisation. For further guidance see the video: How to apply Emla Cream
6. Buzzy bee taking the sting out of shots – Buzzy4Shots Australia and New Zealand
7. The Melbourne Vaccine Education Centre (MVEC) has a number of educational resources for supporting skills development in administering immunisations.

References

1. Orenius T, LicPsych, Säilä H, Mikola K, Ristolainen L. Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioural, and Contextual Factors. SAGE Open Nurs. 2018 Mar 14;4:2377960818759442. doi: 10.1177/2377960818759442. PMID: 33415191; PMCID: PMC7774419
2. Taddio, A, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ. 2010 December DOI: https://doi.org/10.1503/cmaj.092048
   
   

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