Tuesday, March 15, 2011

Injections: Does hurting children now, hurt their health care decisions later

For a long time I ran a large multi-specialty group medical practice in a relatively small town. One of our most active divisions was pediatrics.

Ruby was a nurse in the department for almost 30 years and she had seen probably half the community's children grow into fine healthy adults.

But one day I ran into Ruby at the local Walmart about the time that a group of small children rounded the corner. I also stopped to visit with the nice lady.

The children, though, turned, ran, and cried to their mother.

Ruby commented to me that this was a common but unfortunate occurrence for her.

She was the "shot lady."

Hypodermic injections are one of the earliest memories that children have about health care. In fact, if you ask a young child about the necessity to go to the doctor, the child (and many adults as well) will respond, "I don't need a shot."

Physicians, nurses, and mothers over the years have devised a whole host of tricks to encourage children to get the needle.

Bribery is a favorite of mine: "we'll go get ice cream," "we'll stop on the way home and ...", or the most recent experience for an 18 year old in my office -- "we'll stop at Nordstrom's and get your makeup done."

Threats seem to work for some children. It usually is a threat about "worse pain" than the actual injection. If children are old enough to reason even a little, then the fear of being beat with a belt is usually enough to motivate one for the measles shot.

But it doesn't always work that way. A couple of years ago a father threatened to whip a 14 year old in my office if she didn't submit to an injection.

(Just for the record, I'm opposed to corporal punishment.)

Some nurses and parents are particularly good at trickery. Either there is a ruse on coming to the doctor in the first place ("mommy is here to see the doctor" only to find out that "little Johnny is getting a flu shot"), or my absolute favorite: "this won't hurt a bit."

Well, it never hurts me.

Sometimes health care workers can't bring themselves to completely lie about the pain, so they'll compare it to something more familiar and hopefully more palatable.

Like a bee sting.

That one always makes me calm down.

"Yes, it will feel like a small furry creature is inserting a stinger into your skin and blasting poison away."

You're calm now, aren't you?

Brute force is sometimes an option, particularly if it's a young child.

There is a device for young children called a "papoose board" which is a politically correct way of saying "straight jacket."

Children are strapped in the device which has various holes and openings that allow physician or nurse access to desirable locations -- like those for an injection.

This isn't effective when children get above three or four. They are just too strong and our staff and parents are too weak.

Attempts are sometimes made with this modality and usually everyone ends up in positions that would rival team wrestling at the Dallas Sportatorium.

Negotiation is sometimes employed, with very mixed results (usually followed by one of the items listed above.)

You see with injections there's really no "compromise." So negotiation is doomed from the beginning.

You can't end up only "injecting the needle a little bit" or using a "very small needle" or avoiding the injection altogether -- which is the only solution that most children will agree with.

But in the end, most children are traumatized in some way by the experience. I'm not saying that they shouldn't be receiving injections, rather I'm just saying most children leave with short-lived tears and long-term fear of physicians and going to the doctor.

So the question is does this affect their desire to go the physician later in life for regular, and possibly preventative health care?

Particularly if the primal image of your first health care experience is clouded with pain.

Do you put off the flu shot? The breast exam? The prostate exam? Just your annual physical because of some underlying deep seated sub-cortical negative early experience.

I think many patients do.

Going to the doctor is often a painful experience. Some things just hurt.

But I do believe that anything that physicians and nurses can do to mitigate the pain has a positive effect on that person's future health care decisions.

I like to compare it to swimming. As a scuba diver and water lover I think it's essential for children to learn to swim.

Aside from the obvious reason that it helps to avoid drowning, it also opens up a wonderful world of water sport experiences that otherwise might be avoided.

Children who are taught to not to fear the water, but learn how to interact with it in a positive manner -- playing, floating, blowing bubbles -- usually learn to swim quickly.

Their fear is gone and what comes with it is a learning that water can be safe.

Health care is no different for children.

If they are taught that physicians and nurses shouldn't be feared, then the overall calm atmosphere raises the pain threshold for the children.

Anxiety is the biggest cause for most pain. Children, and even adults, have "fear of pain."

Teaching patients and especially children that pain does occur with procedures but you are there to help them with it can go a long way to prevent an adverse outcome.

Of course, some children are just too small to be able to understand, or they carry with them feelings and fears from other providers into the office. In that case it's, of course, more difficult.

In our office it  is important to me that children have the least pain possible and the most positive experience. If we can find a less painful solution, we try to do that. If it's impossible, then we explain the procedure, and the pain, and we work with that patient to make it as comfortable as possible.

I would love to hear from parents and providers on their ideas and solutions to creating positive interactions with children and painful procedures. I'm sure I have a lot to learn.

And I don't want children to run away crying when they see me at Walmart!

- Posted using BlogPress from my iPad

Location:Dallas, Texas


  1. As an allergist, this is less of an issue in our office than you might expect. When I start a child on weekly allergy injections (which really do use a smaller needle), there is often weeping and gnashing of the teeth at the prospect. I tell the parents to be very matter of fact about getting shots, no bribery whatsoever (on a weekly basis, it escalates quickly) and after a shot or two, the child realizes it's no big deal and becomes desensitized to the process of getting a shot as well as to the allergen itself. A child who continues to throw a fit every time they get a shot virtually always has other behavioral comorbidities, shall we say.
    The saddest part for me is parents who because of their own bad memories of allergy testing and shots neglect their children's need to do the same. And you'd be amazed at how many adults won't do allergy shots because of THEIR fear of needles.

  2. I love to ask you some questions on blogging. Please let me know if you have a few spare email minutes.

    -Jaclyn Gadbaw, MD (Family Med Resident)

  3. Sue, great points! You probably have more experience giving shots than anyone I know.

  4. Jaclyn, happy to help you with any blogging questions. Just send me an email or post yours and I'll be in touch,