Tag: pain relief

Flumist Is Not Just a Last Resort

The return of FluMist has hit a slight snag.

Most folks will remember that on February 12, 2017, at a meeting of the Advisory Committee on Immunization Practices (ACIP), members voted to once again recommended FluMist Quadrivalent to prevent the flu. So it will be available for this year’s flu season.

Many parents and pediatricians welcomed the news, as it meant that many kids could avoid getting a shot and could get the nasal spray flu vaccine instead.

Why did flu vaccine rates drop in younger school age kids when Flumist wasn't available?
Why did flu vaccine rates drop in younger school age kids when Flumist wasn’t available?

It was especially good news for those kids who skipped getting a flu vaccine because they didn’t want to get a shot when Flumist wasn’t available.

Flumist as a Last Resort?

So what’s the problem?

“The Academy recommends pediatricians give children inactivated influenza vaccine in the upcoming season and use live attenuated vaccine only as a last resort.”

American Academy of Pediatrics

Members of the AAP Committee on Infectious Diseases (COID) are concerned that FluMist, even after it has been changed to address previous issues, may not work as well as a standard flu shot.

“Influenza is unpredictable from year to year, so we really want to immunize as many kids as we can against the flu with what we think will be the most effective product. That’s why we’re recommending the flu shot this coming season.”

Henry H. Bernstein, D.O., M.H.C.M., FAAP

While many of us were surprised by the “last resort” phrasing from the AAP, maybe we shouldn’t have been.

In addition to being an ex officio member of the AAP Committee on Infectious Diseases (COID), Henry H. Bernstein was one of only two members of the ACIP who voted against bringing FluMist back, going against the opinion of twelve other members who voted in favor of FluMist.

Dr. Henry H. Bernstein is also the “leading voice on AAP’s annual policy statement on preventing flu in children with flu vaccines.”

“The data reviewed showed that receiving the nasal spray vaccine is better than not getting any vaccine at all,” said Flor Munoz, MD, FAAP, member of the AAP Committee on Infectious Diseases. “If you get the nasal spray vaccine, just be aware that, depending on the performance of the new vaccine formulation, there might be a chance you will not be fully protected against H1N1 strains of flu. The efficacy of this new formulation has not yet been determined.”

It is important to note that the AAP is not saying that Flumist won’t work though.

“The effectiveness of this new formulation of LAIV4 has not been confirmed, since A/H1N1 virus has not widely circulated recently.”

AAP influenza immunization recommendations revised for 2018-’19 season

They are basically saying that if the reformulated version of Flumist doesn’t work as it is predicted to work, then your kids might not be protected. They are concerned that we haven’t seen the new version of Flumist work in real world studies against the H1N1 strain of the flu.

Flumist Is Not Just a Last Resort

Fortunately, the AAP has somewhat rephrased their message about Flumist (LAIV4). While they still recommend that the inactivated influenza vaccine (flu shots) be the primary choice for children, they now say that:

“LAIV4 may be offered for children who would not otherwise receive an influenza vaccine (and for whom it is appropriate by age and health status).”

AAP influenza immunization recommendations revised for 2018-’19 season

Importantly though, parents and pediatricians should note that the recommendations of the Advisory Committee on Immunization Practices (ACIP) for the 2018–19 flu season very clearly make no preferential recommendation for the use of any influenza vaccine product over another.

“Following two seasons (2016–17 and 2017–18) during which ACIP recommended that LAIV4 not be used, for the 2018–19 season, vaccination providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, RIV4, or LAIV4). LAIV4 is an option for those for whom it is appropriate.”

Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season

And the ACIP and CDC aren’t the only ones who disagree with the AAP’s decision.

“So I think the AAP was wrong, frankly, to say that FluMist should only be used as a last-resort vaccine for influenza. Rather, they should have gone along with what the ACIP said, which was that these vaccines can now be used interchangeably for persons aged 2-49 years.”

Paul Offit, MD on FluMist: Reasonable Vaccine Option or ‘Last Resort’ for the Upcoming Flu Season?

So what should you do?

If it is going to be a battle getting your kids a flu shot and you might you might have even skipped it the last few years because Flumist wasn’t available, then your choice is very clear.

Get vaccinated with Flumist, as long as your child is at least two years old and otherwise meets the requirements.

And don’t feel bad or worried that your decision is leaving your child unprotected. Remember that Flumist is recommended by the ACIP and CDC and has been used continuously in most other countries (under the name Fluenz).

Your next battle might simply be finding Flumist. Because of the AAP’s “last resort” comment, some pediatricians didn’t even bother ordering any doses.

More on the Latest Flumist Recommendations

Kids Getting Shots – Are You Prepared?

Most kids have a favorite cartoon or show that they like to watch.

When I was a kid, it was Sesame Street and Mister Rogers’ Neighborhood.

Are You Prepared for Your Kids Getting Shots?

Although we often complain about kids overdoing it with screen time, there are some circumstances when a little screen time might be a good thing.

A little distraction helped Elmo get his shot.
A little distraction helped Elmo get his shot.

For example, if your kids are nervous about an upcoming visit to their pediatrician when they will get shots, having things explained by a well known character will almost certainly be helpful.

How else can you prepare your kids?

Remember to be honest. Don’t lie and say that they aren’t getting a shot or that it won’t hurt at all, only to have their pediatrician tell them that they need a vaccination during the visit.

Going to the Doctor.Books on going to the doctors can also be helpful. Many include a section or story on getting vaccines.

Going To The Doctor by T. Berry Brazelton, MD has always been a favorite of mine, but there are many others:

  • Leo Gets a Checkup
  • The Berenstain Bears Go to the Doctor
  • Corduroy Goes to the Doctor
  • Nicky Goes to the Doctor
  • Daniel Visits the Doctor
  • Froggy Goes to the Doctor
  • My Friend the Doctor
  • The Big Blue House Call

And have your kids play with a Doc McStuffins medical kit.

Vaccines are safe and necessary and you can help to make sure your kids are ready to get them at their next appointment.

More on Preparing Kids When Getting Shots

How to Breastfeed Your Child During Vaccinations

Can you breastfeed while your child is getting their vaccines?

Sure.

How to Breastfeed Your Child During Vaccinations

While the smallpox vaccine and yellow fever vaccine are contraindicated for moms who are breastfeeding, there are no contraindications on vaccinating kids while they are breastfeeding.

Why breastfeed while your kids are getting their vaccines?

While some moms just breastfeed immediately afterwards,  others understand that breastfeeding at the same time as the shots are being given can help decrease any pain associated with getting those vaccines even more.

“If you are breastfeeding, feed your baby before, during and after immunization. The physical closeness and familiar taste of breast milk will calm your baby. Breastfeeding during immunization is safe for babies, even newborns. There is no evidence that babies will choke or associate their mothers with pain.”

Tips For Parents For A Positive Immunization Experience

Will it make it harder for health professionals to hold your child while the shots are being given? Not usually, especially if you help hold your child.

But how can infants get the oral Rotavirus vaccine if they are breastfeeding?

In general, infants should get the least painful vaccine first. And oral vaccines are typically given before shots. So they can get their Rotavirus vaccine before you begin breastfeeding and get prepared for the rest of their vaccines.

The Be Sweet to Babies videos can help you see the benefits of breastfeeding while your kids get their vaccines.
The Be Sweet to Babies videos can help you see the benefits of breastfeeding while your kids get their vaccines.

And while it might depend on the age and size of your child, in general, to breastfeed your child while they are getting their vaccinations, once everything is prepared and ready, you should:

  • hold your child on your lap, understanding that until age three years, most shots will be given in your child’s thighs, although toddlers can sometimes get them in their arms
  • once you have your child well positioned, have a good latch and have started nursing, make sure your child’s arm or leg remains exposed (wherever the shot will be going) and help hold your child securely so that they don’t move while getting their vaccines. For example, you might hold an arm or leg with your free hand and anchor their legs between your thighs or your other hand if possible
  • continue nursing after your child has gotten their vaccines, keeping in mind that you may have to switch positions if they are getting multiple shots

Also understand that it might not always be a good idea to nurse while getting vaccines. Is your baby a distracted eater? Is it going to be hard to hold your child while they are nursing and getting their shots? Does your health care provider not have experience giving vaccines to a child while they are breastfeeding? Does your health care provider have a lot of experience giving vaccines, and they think that giving them while you are nursing will just make the whole process take a lot longer?

“Breastfeeding moms may wish to breastfeed baby during vaccination or immediately after to lessen pain and stress.”

AAP on How can I comfort my baby during vaccinations?

In general though, especially as it is recommended by the WHO and the AAP, consider breastfeeding your child while they are getting their vaccines.

More On Breastfeeding Your Child During Vaccinations

Can I Give My Kids Tylenol When They Have Their Vaccines?

Many parents ask about acetaminophen (Tylenol) when kids get their vaccines.

Is it okay to give kids Tylenol when they get their shots?

The Tylenol and Vaccines Controversy

As you can probably guess, there is no real controversy about Tylenol and vaccines.

Instead, what we are talking about are the myths surrounding Tylenol and vaccines that anti-vaccine folks have created, including that:

  • giving Tylenol right before a child gets their shots somehow increases the risk that they will have side effects
  • giving Tylenol right after a child gets their shots somehow masks the symptoms of serious vaccine damage
  • giving Tylenol after the MMR vaccine is associated with developing autism

Fortunately, most parents understand that like other anti-vaccine misinformation, none of these statements are true.

Why do some folks believe it?

Well, there have been studies warning people about giving Tylenol before vaccines. It had nothing to do with side effects though. They suggested that a vaccine might be less effective if the child got Tylenol before his vaccines. It is important to note that they never really found that the vaccines didn’t work as well, as all of the kids in the study still had protective levels of antibodies, they were just a little lower than kids who didn’t get Tylenol.

Other studies have found the same effect if Tylenol was given after a child got his vaccines. Although interestingly, other studies have found that giving Tylenol after vaccines does not affect antibody titers.

“Antibody titres to diphtheria and tetanus toxoids and pertussis bacteria of the placebo (n = 25) and acetaminophen (n = 34) groups did not differ significantly from each other. It is concluded that acetaminophen in a single dose schedule is ineffective in decreasing post-vaccination fever and other symptoms.”

Uhari et al on Effect of prophylactic acetaminophen administration on reaction to DTP vaccination

Giving Tylenol after the MMR vaccine is not associated with autism.
Giving Tylenol after the MMR vaccine is not associated with autism.

The only thing that this had to do with side effects though, is that the kids who got Tylenol had a little less fever.

Could giving Tylenol mask something like encephalitis, which some anti-vaccine folks think can be vaccine induced?

Nope. It typically can’t even keep someone from getting a febrile seizure.

What about the association of MMR, Tylenol and autism? Although one study did suggest that to be true, the study, a parental survey, was found to be “fatally flawed.”

Can I Give My Kids Tylenol When They Have Their Vaccines?

So, can you give your kids Tylenol when they get their vaccines?

The better question is, should you give your kids Tylenol either before or after they get their vaccines?

Have some Tylenol or Motrin on hand after your kids get their vaccinations, just in case they need a dose.
Have some Tylenol or Motrin on hand after your kids get their vaccinations, just in case they need a dose. Photo by Vincent Iannelli, MD

Notwithstanding the very small chance that giving Tylenol might cause decreased immunogenicity (lower antibody production) if you give it before your kids get their vaccines, since there is a good chance that they won’t have any pain or fever and won’t even need any Tylenol, then why give it?

Skip the “just in case” dose and wait and see if they even need it.

What about afterwards?

If your kids have pain or fever and are uncomfortable, then you should likely give them something for pain or fever control, such as an age appropriate dose of either acetaminophen or ibuprofen. Will that cause lower antibody production? Maybe. Will that mean that their vaccines won’t work. That’s doubtful. It certainly won’t lead to increased side effects though, unless they a reaction to the dose of Tylenol itself.

Should you give a pain or fever reducer after a vaccine “just in case?” Again, there is a good chance that your kids might not need it, so it is likely better to wait and see if they do, instead of giving a dose automatically after their shots.

There is even some evidence that giving acetaminophen or ibuprofen before vaccines, or as a routine dose right after, especially with booster shots, doesn’t really prevent side effects that well anyway. They work better if given on an as needed basis instead, and these kinds of doses are less likely to be associated with decreased antibody production.

What to Know About Tylenol and Vaccines

Giving a pain or fever reducer either before or after your child’s vaccinations likely won’t affect how it works, but since it often isn’t necessary, it is likely best to only given one, like Tylenol or Motrin, if it is really needed.

More on Tylenol and Vaccines

Which Vaccines can be Given SQ?

When most folks think about getting a vaccine, they typically picture someone getting a shot.

It is important to remember that not all vaccines are shots though.

And even for those vaccines that are given as shots, not all of them are given intramuscularly (IM).

Some vaccines are also given orally, nasally, and subcutaneously.

Which Vaccines can be Given SQ?

Vaccines that are given by subcutaneous injection include:

  • MMR
  • ProQuad (MMR/V combination of MMR and chickenpox vaccines)
  • Pneumovax* (Pneumococcal vaccine)
  • IPV* (polio vaccine)
  • Varivax (chickenpox vaccine)
  • Zoster (shingles vaccine)

*The Pneumovax and IPV vaccines can be given either IM or Subcutaneously (SQ). And there are some other exceptions too. Kids with hemophilia can get the hepatitis A and B vaccines SQ, instead of IM.

Where to Give SQ Injections?

After asking how many shots they are going to get, kids often ask where they are going to get them?

While infants get their subcutaneous injections in the fatty tissue over their anterolateral thigh muscle, toddlers and older children get them in the fatty tissue over their anterolateral thigh muscle or triceps.

Older children get SQ injections in the the upper-outer triceps area.
Older children get SQ injections in the the upper-outer triceps area.

Be sure to use the correct needle size, length and gauge (typically 5/8″ and 23-25 gauge), and insert the needle with a quick thrust at a 45° angle to the skin (rapid injection technique), pinching up on the SQ tissue to avoid hitting the muscle, and instead injecting in the subcutaneous tissue between the skin and muscle.

Also keep in mind that it is not necessary to aspirate after injecting the needle and that multiple injections in the same extremity should be separated by at least one inch.

What to Know About SQ Vaccines

It is important to know which vaccines need to be given subcutaneously (SQ) and both how and where to give these shots.

More on SQ Vaccines

 

Which Vaccines Can Be Given IM?

When most folks think about getting a vaccine, they typically picture someone getting a shot.

It is important to remember that not all vaccines are shots though.

And even for those vaccines that are given as shots, not all of them are given intramuscularly (IM).

Some vaccines are also given orally, nasally, and subcutaneously.

Which Vaccines Can Be Given IM?

Vaccines that are given by intramuscular injection include:

  • DTaP, Pediarix, Pentacel, Kinrix, Quadracel (DTaP containing vaccines)
  • hepatitis A
  • hepatitis B
  • Hib containing vaccines (Hib, Pentacel, Comvax, Kinrix, Quadracel)
  • Gardasil9 (HPV vaccines)
  • flu shots
  • Menactra, Menveo, Bexsero, Trunembra (Meningococcal vaccines)
  • Prevnar13, Pneumovax* (Pneumococcal vaccines)
  • IPV* (polio vaccine)
  • Boostrix, Adacel (Tdap vaccines)

*The Pneumovax and IPV vaccines can be given either IM or Subcutaneously (SQ).

There are exceptions though. Kids with hemophilia can get IPV and the hepatitis A and B vaccines SQ, instead of IM.

Where to Give IM Injections?

The upper arm is the best place to give shots to older kids.
The upper arm is the best place to give shots to older kids.

After asking how many shots they are going to get, kids often ask where they are going to get them.

While newborns, infants, and younger toddlers get their IM injections in their anterolateral thigh muscle, older children typically get them in their anterolateral thigh muscle or in the deltoid muscle of their arm.

Be sure to use the correct needle size, length and gauge, and insert the needle with a quick thrust at a 90° angle to the skin (rapid injection technique). Keep in mind that it is not necessary to aspirate after injecting the needle and that multiple injections in the same extremity should be separated by at least one inch.

What to Know About IM Vaccines

It is important to know which vaccines need to be given intramuscularly (IM) and both how and where to give these shots.

More on IM Vaccines

Vaccines and Hemophilia

Kids with hemophilia bleed.

The Medical and Scientific Advisory Council of the National Hemophilia Foundation recommends "that patients with bleeding disorders continue to follow the American Academy of Pediatrics’ and CDC’s vaccine recommendation route and schedule for their age."
The Medical and Scientific Advisory Council of the National Hemophilia Foundation recommends “that patients with bleeding disorders continue to follow the American Academy of Pediatrics’ and CDC’s vaccine recommendation route and schedule for their age.”

They bleed into their joints, into their skin (hematoma), and from their mouth and gums. They can bleed after surgery and even after getting their vaccinations.

Vaccines and Hemophilia

Having hemophilia is certainly not a contraindication to getting vaccinated though.

“Your child should get regular immunizations with necessary precautions to prevent bleeding from the injection sites.”

Hemophilia FAQs

There are some precautions that are recommended before giving vaccines to a child with hemophilia, including:

  • using a 23-gauge or smaller caliber fine-gauge needle – consider a 25- or 27-gauge needle
  • when possible, giving the vaccine SQ instead of IM – for example, although the IPV (polio), hepatitis A, and hepatitis B vaccines are usually given IM, studies have shown that they can be given SQ to kids with hemophilia
  • applying firm pressure, without rubbing, after the vaccine is given for at least two minutes and up to 5 to 10 minutes
  • giving acetaminophen for pain relief, if necessary, instead of ibuprofen
  • warning about the risk of a hematoma developing at the injection site

Most importantly, if the child with hemophilia is already getting routine prophylaxis to prevent bleeding, schedule their vaccines around the same time to decrease the risk of bleeding.

Your child’s hematologist will likely give you specific instructions to provide to your pediatrician regarding immunization precautions.

What to Know About Vaccines and Hemophilia

Kids with hemophilia should get all of their vaccines on schedule, but precautions should be taken to decrease the chance of bleeding after getting an immunization.

More About Vaccines and Hemophilia