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PMCID: PMC5296633 DOI: 10.5409/wjcp.v6.i1.81


AIM: To increase evidence-based pain prevention strategy use during routine vaccinations in a pediatric primary care clinic using quality improvement methodology.

METHODS: Specific intervention strategies (i.e., comfort positioning, nonnutritive sucking and sucrose analgesia, distraction) were identified, selected and introduced in three waves, using a Plan-Do-Study-Act framework. System-wide change was measured from baseline to post-intervention by: (1) percent of vaccination visits during which an evidence-based pain prevention strategy was reported as being used; and (2) caregiver satisfaction ratings following the visit. Additionally, self-reported staff and caregiver attitudes and beliefs about pain prevention were measured at baseline and 1-year post-intervention to assess for possible long-term cultural shifts.

RESULTS: Significant improvements were noted post-intervention. Use of at least one pain prevention strategy was documented at 99% of patient visits and 94% of caregivers were satisfied or very satisfied with the pain prevention care received. Parents/caregivers reported greater satisfaction with the specific pain prevention strategy used [t(143) = 2.50, P ≤ 0.05], as well as greater agreement that the pain prevention strategies used helped their children's pain [t(180) = 2.17, P ≤ 0.05] and that they would be willing to use the same strategy again in the future [t(179) = 3.26, P ≤ 0.001] as compared to baseline. Staff and caregivers also demonstrated a shift in attitudes from baseline to 1-year post-intervention. Specifically, staff reported greater agreement that the pain felt from vaccinations can result in harmful effects [2.47 vs 3.10; t(70) = -2.11, P ≤ 0.05], less agreement that pain from vaccinations is "just part of the process" [3.94 vs 3.23; t(70) = 2.61, P ≤ 0.05], and less agreement that parents expect their children to experience pain during vaccinations [4.81 vs 4.38; t(69) = 2.24, P ≤ 0.05]. Parents/caregivers reported more favorable attitudes about pain prevention strategies for vaccinations across a variety of areas, including safety, cost, time, and effectiveness, as well as less concern about the pain their children experience with vaccination [4.08 vs 3.26; t(557) = 6.38, P ≤ 0.001], less need for additional pain prevention strategies [3.33 vs 2.81; t(476) = 4.51, P ≤ 0.001], and greater agreement that their doctors' office currently offers pain prevention for vaccinations [3.40 vs 3.75; t(433) = -2.39, P ≤ 0.05].

CONCLUSION: Quality improvement methodology can be used to help close the gap in implementing pain prevention strategies during routine vaccination procedures for children.

Journal Title

World J Clin Pediatr





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MeSH Keywords

Vaccination; Pain/prevention & control; Quality Improvement; Child; Child, Preschool; Infant


Comfort positioning; Distraction; Immunization; Non-nutritive sucking; Pain management; Pain prevention; Pediatrics; Primary care; Quality improvement; Sucrose analgesia; Vaccination


This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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