Childhood vaccinations

Case scenario

Ann books in her son Anthony, aged 5, for his flu vaccine and tells you he is slightly anxious about vaccinations. You assure Ann that you will use distraction techniques and support her in holding Anthony comfortably to reduce vaccination fear and pain. Ann asks if she should give her son paracetamol immediately before the appointment or apply a local anaesthetic to numb the area. You advise Ann that prophylactic paracetamol before influenza vaccination is not recommended, and unless Anthony has needle phobia, the evidence does not support the application of a local anaesthetic. On the day of the booking, Ann arrives with Anthony, who appears a little worried.

Introduction

It is estimated that, globally, vaccines save 2–3 million children’s lives each year. ¹ Australian pharmacists have long played a role in the advocacy of childhood vaccination, and in recent years jurisdictional regulations have been amended enabling pharmacists to administer some vaccines to children. The types of vaccines that can be administered by pharmacists to children differ across states and territories; however, there is a trend to increase the number of these vaccines to improve vaccination accessibility and promote public health.

This article covers key pharmacist considerations when providing counselling and education, and when advocating for and administering vaccinations to children. These can be considered in addition to any relevant legislative and ethical obligations applicable to the administration of vaccines to children in the pharmacist’s practising state or territory.

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The National Immunisation Program for childhood vaccination

All pharmacists should be familiar with the current National Immunisation Program (NIP) Schedule.² The current schedule is readily accessible on the Department of Health and Aged Care website.

The NIP lists the series of routine immunisations given at specific times from birth, which are free to the patient (who has or is eligible for a Medicare card).²

Under the current NIP (as of July 2023) a child will receive, at minimum, 15 routine vaccines before their fourth birthday (see Table 1). Aboriginal and Torres Strait Islander children will receive additional vaccines under the NIP (e.g. meningococcal B), with some of these varying depending on the jurisdiction in which they live.² Children with specified medical risk conditions will also receive additional vaccines. Please see the current and full NIP for information regarding these.

All Australian children aged 6 months to under 5 years can receive the annual influenza vaccine under the current NIP, as can Aboriginal and Torres Strait Islander children, and children with specified medical conditions aged 5 years or older. The annual influenza vaccine is still recommended however (but not NIP funded) for all other children aged 5 years or older.²

Additionally to the NIP, since January 2022, children aged 5 years or older have been recommended to receive the COVID-19 vaccine.³ This vaccine is also recommended for children aged 6 months to under 5 years who have severe immunocompromise, disability or health conditions that increase the risk of severe infection.³ Full and current information regarding recommendations on the COVID vaccine can be found here.

Key points to understand about childhood vaccination

The age at which vaccines are dosed is based on the best available evidence on the immunogenicity of the vaccine at different ages, and the likelihood of exposure to the vaccine-preventable disease itself.⁴

For example, the first vaccine administered is the hepatitis B vaccine, which is dosed at birth and then again when the child is 6 weeks, 4 months and 6 months of age.² The rationale for administering the hepatitis B vaccine at birth is that the mother may be a carrier and transmit the infection to her child during the birthing process, so vaccination reduces the risk of vertical transmission to the newborn.⁵

Continuing to use the hepatitis B vaccine as an example, the four separately timed vaccine doses are called a ‘primary series’. Like most other vaccines, it needs to be administered multiple times as separate doses for the development of an adequate and long-lasting antibody response.⁶

When compared to live vaccines (e.g. measles, mumps, rubella, varicella, rotavirus), inactivated or subunit vaccines (toxoid, recombinant, polysaccharide, conjugate) generally require more doses in the primary series, and later boosters, to enable ongoing protection.⁶

As shown in the NIP schedule, children can receive multiple vaccines at the same visit. For example, when a child is 2 months old, they are vaccinated against eight different diseases in the form of three separate vaccines (seven inactive strains and one live attenuated).²

In general, with some exceptions, inactivated vaccines can be given at any time with respect to the administration of all other vaccines. However, to optimise immunogenicity, live vaccines should be given at the same time (same visit) as other live vaccines (e.g. measles, mumps, rubella are all live vaccines and given at once), or they must be given at least 4 weeks apart.⁷

Immunogenicity and protection wane against natural infection when vaccines are not spaced appropriately. Pharmacists play a key role in educating parents and caregivers on the importance of adhering to the NIP schedule and can provide education and increase understanding regarding the complexities of the dosing regimens and timings.

Childhood vaccination: some practical considerations

In addition to considering and abiding by any relevant legislative and ethical obligations (depending on the state or territory you practise in), the following are some points to consider when administering vaccinations to children.

Vaccine administration

Most vaccines are given intramuscularly (IM), others are given subcutaneously, orally (e.g. rotavirus) or intradermally. There are two anatomical sites that are routinely used to administer IM vaccines to children. The vastus lateralis muscle in the anterolateral thigh for children younger than 12 months of age, and the deltoid muscle of the upper arm for children aged 12 months or older.⁹

Positioning children for vaccination

To reduce the fear and pain that is commonly associated with childhood vaccinations, the pharmacist vaccinator should position the child comfortably while keeping the limbs still without excessive restraint.⁸

The most common ways of positioning a young child are in the cuddle or straddle position, with the assistance of a parent or carer.⁹ Research shows that having a parent present for the vaccination reduces pain, distress and fear for the child.^{8, 10} When a child is to be administered a vaccine, their parent or guardian must be present in the immunisation service area.¹¹ 

In the cuddle position for infants younger than 12 months, the child sits sideways on their carer’s lap and is slightly reclined. The infant’s arm is then tucked against the carer’s chest, while the carer holds the infant’s outside arm with one hand and the infant’s outside leg against their own thigh with the other. The thigh to be vaccinated is exposed, secured and accessible for the vaccinator.⁹

In the cuddle position for a child aged 12 months or older, the child sits sideways on their carer’s lap, and the child’s legs are held between the carer’s legs. The child’s arm that is not being vaccinated is wrapped under the carer’s armpit (in a cuddle).

The arm to be vaccinated is exposed and accessible for the vaccinator. This arm is held close to the child’s body by the carer and is secured by the carer at the elbow.⁹In the straddle position, the older child sits on their carer’s lap, facing them, with one leg on either side of their carer. The carer hugs the child and restrains the arm to be vaccinated by holding the child’s elbow.⁹

Table 1 – National Immunisation Program (NIP) Schedule: summary of recommendations for childhood vaccination (as of 1 July 2023)

The older child may sit comfortably and independently in a chair. A carer can also stand against the chair (on the opposite side to the arm that is being vaccinated) to provide physical and emotional support for the child.

Distraction techniques

The pharmacist can use distraction techniques to steer the child’s attention away from the source of pain and reduce distress. Evidence-based distraction techniques for children aged 5–12 years include^9,12,13:

• Talking – e.g. have a conversation about something unrelated to the vaccination, such as their pet, favourite hobby, etc.
• Breathing interventions – e.g. blowing bubbles, blowing the pain away, blowing into a pinwheel.
• Visual interventions – e.g. videos on a smart phone or other device.
• Tactile interventions – e.g. rubbing the skin directly above the site to be vaccinated or combined cooling and vibration. Other options include devices such as Buzzy, a vibrating device shaped like a bumble bee with optional ‘cooling’ wings which is fitted above the administration site, and the ShotBlocker,which has several blunt contact points that are pressed onto the skin around the administration area.
• Music – e.g. play child-friendly music.

Pharmacological interventions

• Analgesics: The Australian Immunisation Handbook does not recommend the routine use of prophylactic paracetamol or ibuprofen – before or at the time of vaccination – to reduce the risk of pain or fever.9The only exception to this is the meningococcal B vaccine when administered to infants younger than 2 years (where prophylactic paracetamol is recommended).⁹
• Topical anaesthetics: The Australian Immunisation Handbook does not recommend the routine use of topical anaesthetics prior to vaccination, except when children have needle fears or phobias.⁹ Research shows that application of a topical anaesthetic such as a mixture of lignocaine and prilocaine (e.g. Emla, Numit) applied at least 30–60 minutes under occlusion prior to vaccination reduces, but does not eliminate, an infants’ expression of pain.¹⁴ Topical lignocaine/prilocaine should not be used in children younger than 12 months of age due to the risk of methaemoglobinaemia, a blood disorder.^15,16
• Skin cooling: A rapid-acting alternative to topical anaesthetics is vapocoolants, or cold sprays. Vapocoolants should be applied 15 seconds prior to vaccination. While vapocoolants have been shown to reduce vaccination-related pain in adults, their effectiveness in children is mixed.¹⁷ A reason for this is that children often interpret extreme cold as pain. The extreme cold also draws the child’s attention to the vaccination that is about to happen.¹⁸

Common adverse effects

As vaccines evoke an immune response, the following are common adverse effects of vaccines, and are usually mild and self-limiting¹⁹:

• Pain, redness or swelling at the site of injection
• Fever (see below)
• Headache
• Fatigue.

The child’s caregiver should be informed of the potential adverse effects, and how to manage them, including those that are uncommon or rare but may be serious. If adverse effects persist, or a serious, uncommon or rare adverse effect occurs, they should seek appropriate medical attention.¹⁹

Pharmacists should report all adverse events following immunisation that are not common for that vaccine, or that appear to be getting worse, to their relevant state or territory contacts.¹⁹ Information regarding this process can be found in the Australian Immunisation Handbook.

Vaccine-associated anaphylaxis is very rare across all age groups. However, to ensure access to life-saving treatment, including adrenaline, in the event of anaphylaxis, children must wait with their caregiver under supervision for 15 minutes immediately following vaccination, before leaving the pharmacy.^11,19

Post-vaccination fever

Post-vaccination fever (body temperature greater than 38 °C) is common, affecting approximately 66% of children.20It generally occurs within 24 hours and lasts 1–2 days.²¹ While post-vaccination fever may be a concern for parents, it is probably helpful (as it speeds up the body’s immune response), and is generally benign and self-limiting. Caregivers can manage the child’s fever by increasing fluid intake, removing extra layers of clothing, and by giving paracetamol if necessary. For children aged up to 12 years, 15 mg/kg per dose of paracetamol can be given every 4–6 hours (maximum of 4 times in 24 hours), up to a maximum dose of 60 mg/kg/day (not to exceed 4 g daily).¹⁹ Never recommend aspirin to children under the age of 16 years for analgesia or fever, due to the risk of Reye’s syndrome.²²

There is contention in the literature, with some research concluding that while paracetamol and ibuprofen reduce post-vaccination fever, they may also reduce the antibody response generated against the vaccine antigen.²⁰,²³ Although the clinical implications of this are unclear, theoretically it may reduce the protection that the child is afforded against the natural infection.

Interestingly, recent studies show that paracetamol and ibuprofen do not uniformly lower the antibody response against all types of vaccine antigens. For example, paracetamol reduces the antibody responses against the multivalent pneumococcal vaccine, while ibuprofen does not. Similarly, ibuprofen reduces the antibody response mounted against the tetanus and pertussis vaccine.²⁴

Knowledge to practice

All pharmacists should be knowledgeable about the NIP schedule and advocate for timely childhood vaccination. Pharmacist vaccinators can position children comfortably and employ distraction techniques to reduce pain and vaccination fear. Pharmacists should educate caregivers about any potential adverse effects of vaccines, and what to do if they occur. To improve vaccination  outcomes, pharmacists should discourage prophylactic analgesics (excluding paracetamol prior to the meningococcal B vaccine) and encourage the judicious use of paracetamol for post-vaccination fever.

Conclusion

Pharmacists play a key role in improving childhood vaccination uptake, through vaccine advocacy, education and, where appropriate, administration of vaccines. When children are not up to date with their immunisation schedule, pharmacists should encourage childhood vaccination with their relevant immunisation provider. Where jurisdictional regulations allow, the pharmacist can administer the appropriate vaccines to children, improving vaccination uptake in this vulnerable population.

Key points

• Pharmacists should be aware of the NIP schedule, be prepared to educate parents and caregivers on this, and be able to readily access accurate information.
• For young children, the cuddle and straddle positions are commonly used to position the child comfortably. A caregiver must be present when a child is vaccinated.^9,11
• The pharmacist can use simple distraction techniques to steer the child’s attention away from the source of vaccination pain and reduce distress.
• Evidence does not support the routine use of prophylactic paracetamol or ibuprofen before or at the time of vaccination; however, paracetamol can be used if the child develops a fever following vaccination.^9,23
• Topical anaesthetics are not routinely recommended for childhood vaccinations but may assist in reducing pain for children with needle phobias.⁹

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References

1. United Nations International Children’s Emergency Fund (UNICEF). Immunization programme. 2018. At: www.unicef.org/immunization/
2. Department of Health and Aged Care. National Immunisation Program Schedule. 2023. At: www.health.gov.au/health-topics/immunisation/when-to-get-vaccinated/national-immunisation-program-schedule
3. Department of Health and Aged Care. Clinical recommendations for COVID-19 vaccines: 2023 At: www.health.gov.au/our-work/covid-19-vaccines/advice-for-providers/clinical-guidance/clinical-recommendations
4. Department of Health and Aged Care. Catch-up vaccination, Australian Immunisation handbook. 2023. At: https://immunisationhandbook.health.gov.au/contents/catch-up-vaccination
5. Department of Health and Aged Care. Hepatitis B, Australian Immunisation handbook. Australian Government Department of Health and Aged care. 2023. At: https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/hepatitis-b
6. Knights K, Darroch S, Rowland A, et al. Pharmacology for Health Professionals ebook. 6th ed: Elsevier Health Sciences 2023.
7. Australian Government Department of Health. Preparing for vaccination, Australian Immunisation Handbook. At: https://immunisationhandbook.health.gov.au/vaccination-procedures/preparing-for-vaccination
8. Taddio A, Shah V, McMurtry CM, et al. Procedural and physical interventions for vaccine injections: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clinical J Pain 2015;31(Suppl 10):S20.
9. Australian Government Department of Health. Administration of vaccines, Australian Immunisation Handbook. At: https://immunisationhandbook.health.gov.au/vaccination-procedures/administration-of-vaccines
10. Melbourne Vaccine Education Centre. Administration of vaccines. 2022. At: https://mvec.mcri.edu.au/references/administration-of-injected-vaccines-correct-technique/
11. Pharmaceutical Society of Australia. Practice guidelines for pharmacists providing immunisation services. 2023. At: https://my.psa.org.au/s/asknowledgelistpage?categories=%7B%22categoryMap%22%3A%7B%22Clinical_Category%22%3A%5B%22Immunisation__c%22%5D%7D%7D
12. Yilmaz G, Alemdar DK. Using Buzzy, Shotblocker, and Bubble Blowing in a pediatric emergency department to reduce the pain and fear caused by intramuscular injection: a randomized controlled trial. J Emerg Nurs 2019;45(5):502–11.
13. The Royal Children’s Hospital Melbourne. Kids Health Information: Vaccination and needle phobia. 2022. At: www.rch.org.au/kidsinfo/fact_sheets/Vaccination_and_needle_phobia/
14. Olsson Duse B, Sporrong Y, Bartocci M, et al. Efficacy of topical lidocaine‐prilocaine (EMLA®) for management of infant pain during pneumococcal vaccination: a randomized controlled trial. Paediatric and Neonatal Pain 2022;4(2):53­–60.
15. Kuiper-Prins E, Kerkhof GF, Reijnen CGM, et al. A 12-day-old boy with methemoglobinemia after circumcision with local anesthesia (lidocaine/prilocaine). Drug Safety – Case Reports 2016;3(1):12.
16. Lillieborg S, Otterbom I, Ahlen K, et al. Topical anaesthesia in neonates, infants and children. Br J Anaesth 2004;92(3):450–1.
17. Hall LM, Ediriweera Y, Banks J, et al. Cooling to reduce the pain associated with vaccination: a systematic review. Vaccine 2020;38(51):8082–9.
18. 18. Cohen LL, MacLaren JE, DeMore M, et al. A randomized controlled trial of vapocoolant for pediatric immunization distress relief. Clin J Pain 2009;25(6):490–4.
19. Australian Government Department of Health. After vaccination, Australian Immunisation Handbook. At: https://immunisationhandbook.health.gov.au/contents/vaccination-procedures/after-vaccination
20. Prymula R, Siegrist C-A, Chlibek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet 2009;374(9698):1339–50.
21. Ahn SH, Zhiang J, Kim H, et al. Postvaccination fever response rates in children derived using the fever coach mobile app: a retrospective observational study. JMIR Mhealth Uhealth 2019;7(4):e12223.
22. Rossi S, ed. Aspirin (Analgesic). Australian medicines handbook; [updated 2023 Jan]. At: https://amhonline.amh.net.au/chapters/analgesics/drugs-pain-relief/non-opioid-analgesics/aspirin-analgesic
23. Koufoglou E, Kourlaba G, Michos A. Effect of prophylactic administration of antipyretics on the immune response to pneumococcal conjugate vaccines in children: a systematic review. Pneumonia 2021;13(1):7.
24. Wysocki J, Center KJ, Brzostek J, et al. A randomized study of fever prophylaxis and the immunogenicity of routine pediatric vaccinations. Vaccine 2017;35(15):1926­–35.