#548 - Reducing Vaccination Pain, Falls Prevention PS, Taking More Call

From the Literature

1)  Reducing Pain From Childhood Vaccinations

Anticipated pain from vaccinations can be a barrier to successful immunization not only for the cognizant children themselves, but for the needle-fearing parent. A 2010 systematic review recommended the following techniques for reducing pain from childhood vaccinations: breastfeeding, sugar solution, choosing the least painful brand of vaccine if available, and topical anesthesia all work best (A recommendations). Injecting rapidly without aspiration for intramuscular vaccinations, injecting the most painful vaccine last, rubbing the skin at the planned injection site with moderate intensity in a child over 4 years, clinician or parent led distracting techniques, child-led distracting techniques (age over 3 years), deep breathing or blowing (age over 3 years), and using combined psychological interventions (behavioral and cognitive) in children over 3 years were all also effective (B recommendations). There was good evidence to AVOID placing the child supine for vaccination or telling the child “It won’t hurt.”

A new study looks at the effect of a cold, vibrating instrument placed 0.5 cm superior to the injection site for 1 minute prior to vaccination and 15 seconds after vaccination in six-month-olds. Eighty infants were randomized to the instrument or to no intervention. Pain was assessed by the researchers using observation (the Modified Pain Behavior Scale, MBPS) and crying duration. The children were placed on a vaccination bed in a quiet room with their parent (presumably in a supine position, since they were all injected in the vastus lateralis muscle), were vaccinated by the same person and with the same vaccine.

Pain intensity (by MPBS) was less in the intervention group (6.1 ± 1.8 vs. 7.0 ± 2.1, p = 0.032, effect size 0.48, on a 10-point scale). Crying duration was much less in the intervention group (18.6 seconds less, p = 0.0001, effect size 0.86). As a reminder, effect sizes are generic measures of magnitude; for this effect size, 0.2 is small, 0.5 is moderate, and 0.8 is a large effect.

John’s Comments: 

Pain during vaccinations can really cause an issue in our clinics by tying up nurses attempting to give a vaccine to a reluctant, scared child. So, an intervention like this would be a welcome routine addition. This study would have been more convincing with an active placebo – maybe one that made noise and looked similar but didn’t vibrate and was room temperature. However, there are several studies on this technique with different age groups that are finding consistent results. It doesn’t appear to be harmful at all, so it may be worth a try. A commercial form of this device is available online under the brand “Buzzy.” You can see Buzzy in action. Caveat emptor.

References:

• Taddio A, Appleton M, Bortolussi R, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary). CMAJ. 2010;182(18):1989-1995. Link
• Unesi Z, Amouzeshi Z, Jamavar J, Mahmoudzadeh Zarandi F. The Effect of a Combination of Vibration and External Cold on Pain Caused during Vaccine Injection in Infants: A Randomized Clinical Trial. Int J Clin Pract. 2024;2024:7170927. Link

From the USPSTF

2)  Preventing Falls In Older Adults – PS

In our April 5 Take 3, we shared that falls are among the most common and preventable causes of morbidity and mortality for older adults and increase substantially after age 65.   In 2018, 28% of community-dwelling adults > 65 reported at least 1 fall in the past year and 10% reported a fall-related injury.  Most fall-related deaths occur in adults 85 years or older; this group also has the fastest-growing rate of death from falls.  This data provides a sense of urgency to identify those at greatest risk and implement effective methods to prevent falls in this age group.   

The US Preventive Services Task Force (USPSTF) recently updated their 2018 recommendations for fall prevention for community dwelling adults > 65 who are at increased risk.  Recommendations include:

• recommends exercise interventions to prevent falls (Grade B) and
• recommends that clinicians individualize the decision to offer multifactorial interventions to prevent falls, recognizing the existing evidence for the net benefit of routinely offering multifactorial interventions to prevent falls is small.  When determining whether this service is appropriate for an individual, patients and clinicians should consider the balance of benefits and harms based on the circumstances of prior falls, presence of comorbid conditions, and the patient’s values and preferences (Grade C).

The review noted that effective exercise interventions include supervised individual physical therapy and group exercise classes and that it is difficult to identify specific components of exercise that are particularly effective. The most commonly studied exercise components were gait, balance, and functional training, followed by strength and resistance training, flexibility, and endurance training. The most common frequency and duration for exercise interventions was 2 to 3 sessions per week for 12 months, although duration of exercise interventions ranged from 2 to 30 months.

Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment.  The initial assessment could include a multidisciplinary comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health.  Intervention components vary based on the initial assessment and could include group or individual exercise, psychological interventions (eg, cognitive behavioral therapy), nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists (eg, ophthalmologist, neurologist, or cardiologist).

The following interventions were reviewed by the USPSTF but lack sufficient evidence to assess their benefits and harms in preventing falls in community-dwelling older adults when offered alone and not in the context of a multifactorial intervention: environmental modification, medication management, psychological interventions, education interventions, and combination interventions (exercise plus environment interventions or exercise plus education interventions).

Mark’s Comments:

An accompanying editorial to the Task Force recommendation noted that in general,  functional exercises that focus on movements performed in daily activities and balance appear to be more effective for fall prevention than walking or resistance training alone.  However, we know that counseling a patient to exercise more is rarely enough to change behavior.  Less than half of community-dwelling adults > 65 meet physical activity guidelines.  Therefore, although evidence suggests it is important for primary care clinicians to recommend exercise, the major challenge is transforming this recommendation into action.  Encouraging participation in community-funded exercise programs adds the element of socialization and accountability, which is preferred when possible.  And remember to take advantage of your time during Medicare Annual Wellness visits to screen, counsel and educate your patients to minimize their fall risk.  The algorithm at the last reference below might be helpful in this regard.

References:

•  Nicholson WK, et al.  Interventions to Prevent Falls in Community-Dwelling Older Adults.  US Preventive Task Force Recommendation Statement.  JAMA 2024.  Published online June 4.  Link
• Reuben D and Gantz D.  Editorial - Preventing Falls in Older Persons:  Steps in the Right Direction.  JAMA 2024.  Published online June 4.  Link
• CDC STEADI (Stopping Elderly Accidents, Death, and Injuries) Older Adult Fall Prevention Resources:  Link
• CDC STEADI Falls Prevention Algorithm:  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  We Need to Take More Call

“You just call on me …. when you need a hand.  We all need somebody to lean on.”  Bill Withers, Rock and Roll Hall of Fame inductee, from the song “Lean on Me”

Asking for help is not something that comes naturally or easily for me, nor for many others.  And yet, I’m always glad to help when a colleague reaches out to me, and touched when someone connects “just to check in.”  While there was a time in my career when I may have been bothered and perhaps even felt a bit defensive by such an outreach (professional posturing = “I’m fine!”), those days are past for me.  The emotional load we carry is simply too great for any of us to try to process it alone. 

At the same time, I’m a lot more likely to both reach out for help and look forward to those “check-ins” when a trusting relationship exists.  How is that trust developed?  Through regular brief connections (“touches”) by text or e-mail and also pre-scheduled times to meet in order to share life together.  Unlike ongoing friendships from our youth, our “adult relationships” take regular and intentional action in order for them to effectively form, be sustained, and grow, because at this stage in our careers and lives we don’t usually have a lot of “hang out together” time.  Yet these newer relationships are essential, as these are often the people who know us best now, not simply as an older version of a person they knew from the past.         

So it was a true gift this past week to have the opportunity to check in via video with a  valued colleague I’ve known for the past 8 years who lives elsewhere, and with whom I hadn’t spoken for 3 months.  While our original intention when we scheduled the meeting weeks ago was to “catch up and look ahead,” we ended up talking about a decision I was struggling with that he had a unique perspective on.  Had we not had this regular time scheduled, I likely would not have reached out to him to serve as a sounding board.       

While it would be my desire that colleagues would feel comfortable calling on me when they need a hand (or an ear) and that I would be totally comfortable doing the same with them, we know that familiarity and shared experience make such an outreach much more likely.  This happens by our being intentional about connecting not only when we need support or encouragement, but also when we simply want to communicate “I’ve been thinking about you and wondering how you are, so let’s connect soon” and scheduling that time without feeling like we are imposing or bothering each other. 

That’s the entire purpose of PeerRx – to both regularly remind us of the importance of sharing the journey together, and then help encourage and equip us to do so.  For that reason, I’m glad to take more “call.”  That kind of call is never an imposition.  Rather, it is life-giving for all involved.  As Bill Withers reminds us “… it won't be long till I'm gonna need somebody to lean on …,” so let’s be sure to prepare by proactively and regularly scheduling time with our inner circle of trusted colleagues, including our PeerRx partner.  And as a bonus, there will be no post-call brain fog …. 

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org