Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.
Fear of needles may play a larger role than clinicians think in vaccine compliance, both in the childhood years and beyond.
Although the blame for deciding against vaccination may fall on parents who question the safety of vaccines, new research suggests there might be another reason for skipping shots-fear.
Children often are afraid of shots, which are not only necessary but also frequent in a child’s early years. This fear, and frequency, can lead to long-term fears of shots, according to the new report.
The study, led by Amy Baxter, MD, a clinical associate professor at Medical College of Georgia, found that children who received multiple injections at a time between the ages of 4 and 6 were more likely to be afraid of injections even as teenagers.1 Published in Vaccine, Baxter’s report suggests that a fear of shots develops around age 5 years and can have a negative impact on vaccine compliance.
The research was supported by the National Institutes of health and data was collected at a private practive in Atlanta, and other studies have echoed the results. A 2012 study in Vaccine revealed that two-thirds of children and a quarter of parents in a poll of nearly 2000 were afraid of needles.2 This resulted in noncompliance with vaccine in 8% of the children polled and in 7% of parents, according to investigators.
Baxter’s study assessed injection fears on a scale of 1 to 100, with 100 being the highest level of fear. She discovered that between ages 4 and 6, fear of injections correlated to the number of injections given at a singular visit, and that fear increased as the number of injections increased. Children were not assessed for fear in the school years, however, but later at age 10 to 12. The total number of shots wasn’t really the issue, she notes, but the number of injections given at a single visit. Specifically, by age 10 to 12, children associated multiple shots in their at 1 visit with increased fear, but only for injections given in the preschool years. In her study, Baxter notes that needle fears seemed to increase when 3 or more shots were given at a single visit in those early school years.
“Our study shows that vaccination practice at the preschool visits has consequences that last at least 8 years in a dose response manner-1 injection multiple times, no fear; 2 injections several times, 9% fearful; 3 injections on 1 day, 26% were fearful; and 4 or 5 injections on a single day, 50% of those kids were in the highest fear quartile as preteens,” Baxter says. “There are probably many ways to solve this problem-pain relief, microneedles, combination vaccines-but we need to acknowledge that inducing persistent needle fear is our problem, not the children's weakness.”
Baxter says this indicates that the ages of 4 to 6 years are a crucial time to address injection fears in order to prevent a lasting fear of needles.
“Preschoolers are at a vulnerable period for developing phobias. Four-year-olds are developmentally more prone to fear, are very sensitive to their parents' anxiety, and are concrete thinkers for whom good and bad are binary. Doctor good, pain bad,” Baxter says. “They remember traumatic events, and tell themselves stories to make sense of the world. If a good place where they're supposed to be safe turns painful, they have to be held down, and their parent is upset, it makes sense that from their perspective it is a traumatic childhood event. To avoid causing a phobia, reduce the trauma.”
Baxter suggests not holding children down for shots, and letting them sit in a parent’s lap. Hers and other studies show that multiple injections at once may cause more fear. Clinicians can use distractions, pain relief, or fewer injections to lessen the child’s trauma.
“The longer children have to solidify a traumatic experience, the better they remember it,” she adds. “Get them out of the room quickly, have a treat, change the situation. Do quick distraction training with parents in the waiting room; they'll convey less anxiety if they have a job during injections.”
Baxter notes that injection fears have tripled over the last few decades, and suggests a correlation to the fact that the number of vaccines recommended by the Centers for Disease Control and Prevention (CDC) tripled in that same period. There are already strong recommendations across pediatric practice against alternate vaccine schedules, with the American Academy of Pediatrics (AAP) specifically warning against alternate schedules last summer.3 In that warning, AAP noted that 93% of pediatricians report being asked to deliver vaccines on an alternative schedule each month, and that 74% usually comply with parents’ requests.
“Only one vaccine schedule has been shown to be safe and effective,” AAP states in its recommendation. “Any deviation from the recommended schedule may jeopardize benefit and increase the risk of harm.”
Although Baxter says she fully supports the CDC vaccination schedule, she also shares concerns about the long-term effects of unaddressed injection fears. Baxter says pediatricians don’t necessarily have to change the CDC schedule at all, noting that staggering booster injections is still in compliance with the CDC’s recommendations. "Fortunately, we determined that the existing infant and toddler schedule is not associated with increased needle fear. This is one more finding against an alternate schedule when children are the most vulnerable," Baxter says. They do, however, need to find a way to make early vaccines less traumatic in order to reduce the development of later fears and possible noncompliance.
“Needle fear is a logical consequence of the current way we give boosters, and has health consequences,” Baxter says. “Needle fear impacts patients' health choices for life, their likelihood to immunize their own children, and it's iatrogenic. We need to take it seriously.”
There are other considerations to scheduling vaccines, as well, Baxter notes. “Optimizing booster and flu vaccinations requires legislative and payer shifts, and sometimes school district entrance requirements. Ideally flu vaccinations could be done elsewhere to reduce the association of healthcare and anxiety. Ideally, combination vaccines would be approved by all payers,” Baxter says. “We're not in an ideal world, but there are some evidence-based factors to consider if we were. Children at age 4 are the most susceptible to fear; pain is worse when the most painful vaccine is given first. Obviously, you want to err on the side of getting them vaccinated if the family is unreliable.”
Baxter also points out that as children age, they are better able to deal with injections, and any alternative spacing-within CDC recommendations-could be adjusted as children age and are better able to handle their fears.
“What I most hope is that by changing how we give preschoolers injections, we can mitigate the consequences of our patients leaving our practices with needle fear, Baxter says.
“In the most recent US vaccine-preventable death data, there were 40 deaths from pediatric infectious diseases. There were 101 pediatric deaths from flu, and only 26% had been immunized. The CDC estimates 3000 to 12,000 people a year die because they're not vaccinated against the flu,” Baxter notes. “By insisting on giving 4- to 6-year boosters on the same day, we're saving at most 20 lives a year, and causing needle fear in half these kids. If only 20% of those who don't get HPV or flu shots avoid it because of needle fear, that's still 2900 deaths a year. When you throw in that 7% of adults say they won't vaccinate their kids because of their own needle fear, the fact that 63% of kids are now afraid of needles should be a public health emergency.”
1. Baxter AL Cohen LL, Burton M, Mohammed A, Lawson ML. The number of injected same-day preschool vaccines relates to preadolescent needle fear and HPV uptake. Vaccine. 2017; 35(33);4213-4219.
2. Taddio A, Ipp M, Thivakaran S, et al. Survey of the prevalence of immunization noncompliance due to needle fears in children and adults. Vaccine. 2012;30(32):4807-4812.
3. Meissner HC. Do not stretch the immunization schedule. AAP News. Available at: http://www.aappublications.org/news/2017/07/27/IDSnapshot072717. Published July 27, 2017. Accessed January 24, 2018.