Re: Needle and dread: Is it just a little poke? Paediatr Child Health 2007;12(2):101–2

To the Editor, Ms McMurty's well-written article surprised me somewhat because I am now removed from observing injections of paediatric (human) patients, especially since my youngest is in her teen years. I had anticipated that the pain of routine immunization or other injections would be managed as I have managed it for years in clinical practice. Clearly, injections hurt. Veterinary patients react honestly, immediately and often quite effectively in terms of stopping the pain (ie, scratching, biting and flying off the table). While in veterinary college in the mid 1980s, I visited a dentist in Hamilton, Ontario, who advised that he would be using a distraction technique while injecting local anesthetic. I advised that I was not nervous and that the distraction would certainly not be necessary. He persisted, or rather his assistant persisted and she proceeded to gently but firmly tap the inside of my wrist while the injection was being undertaken. Frankly I was stunned. While fully cognizant of both the procedure and the rationale for it, I did not feel the pain of the injection at all. I resolved to use such a technique in clinical practice, modifying what any large animal practitioner or farmer knows – if you slap the cow's hip a couple of times and slip the needle in on the second or third slap when treating with antibiotics, you would not have a lightning fast kick to the abdomen or to other areas. These sorts of friendly slaps on the hip are not uncommon in dairy practice. I practised distraction techniques early on with my daughter who was born in my graduating year (1986), firmly but not painfully squeezing her arm or leg while her immunizations were administered by the nurse or physician. Later in small animal practice, large pats were administered to large dogs, small pats or puffs of air to small dogs and whatever worked for the less predictable felines – sometimes a gentle shaking of the scruff or squeezing of the paws. Often the immunization experience was topped off with an edible treat. Canine patients raised under my care veered toward the building on their daily walks, not away in terror as my dog had done in my youth. Cats, admittedly, still largely found the clinical setting less than satisfactory, but they rarely noticed that their injections were being administered. If controlled studies had been performed, I believe behaviours, overall, would be much more acceptable. On one occasion, as a small animal practitioner not equipped with appropriate equine anesthetic medications, I removed a substantial New Year's dose of porcupine quills from the face of a friend's horse with only firm large pats administered while the hemostat held a few quills. Perhaps pain experienced by the practitioner helps the learning process. Pity I never thought to ask the dentist whether he had ever been injured while administering injections. Children deserve this sort of consideration. Needles hurt. For your patients as with mine, it is tough to explain why it is good for them. Gentle distraction techniques do not require medications or take up any additional time; they are simply a modification to longstanding habits.

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