Afraid of shots

[flutterbee]

When difficult child had her physical in December we were told that she needs a tetanus booster. difficult child had a meltdown and the pediatrician doctor said that she could wait, but that she will need it before school starts or shortly thereafter.

A couple of weeks ago she came downstairs late at night (something about both my kids and them not wanting to talk til sometime after 1am...sigh) sobbing over having to get this shot. Apparently a friend of hers was supposed to get a couple of boosters the day before and it reminded difficult child that her day is near. This particular event lasted for well over an hour. And she wasn't even getting the shot anytime soon.

She is absolutely phobic. It doesn't help that in the past we haven't had a doctor/nurses that were particularly sympathetic and it's just made it worse. difficult child also has zero pain tolerance. And I do mean zero. The tetanus booster causes a pretty sore arm for a day or two (I got mine in February of this year and felt like I had been punched hard in the arm for a couple of days - and I have a decent pain tolerance).

So...any ideas on what to do? She becomes so frantic I've actually thought about asking the pediatrician doctor for some kind of sedation...an anti-anxiety or something. There is absolutely no talking to her when she is in this state as she is in full blown panic. I told difficult child that we could ice her arm before to numb it a bit. Is that a bad idea?

by the way, this doctor is very empathic and I really like her, but it's pretty obvious that she doesn't have a whole lot of experience with kids that can go from zero to meltdown in 5 seconds flat.

 

[smallworld]

Heather, I know exactly what you're going through. difficult child 1 is phobic about shots, blood draws, and even dental cleanings. He will be receiving general anesthesia in August at the children's hospital in our city to have an MRI, overdue blood tests, three overdue immunizations and a dental cleaning because at this point we can't get these procedures done any other way.

Some thoughts for you before you have to go to these lengths. There is a prescription cream called Emla that numbs the arm. My girls use it for blood draws and say it works very well. You could also ask for the anti-anxiety medication Ativan to give before the shot. Our psychiatrist prefers Ativan for medical procedures because it is shorter-acting than some of the others like Klonopin and Xanax. Finally, is there a nurse at your pediatrician's office who has more experience dealing with anxious children? We have some wonderful nurses at our pediatrician's office who have been able to talk my girls (but not difficult child 1) into being less anxious about various medical procedures.

Good luck . . . I so know how you feel.

 

[kris]

<span style='font-size: 11pt'> <span style='font-family: Georgia'> <span style="color: #003333"> two suggestions....first you can ask the doctor for a mild sedative & second there is a topical ointment that can be applied ~~~ has to be applied in advance i think but check with-your pharmacist ~~~ that i hear works well.

given that she's 12 i have to ask...has she had her hep B series. here they have to have it before starting sixth grade.....and those puppies HURT!

kris </span> </span> </span>

 

[Marguerite]

Your daughter needs to feel reassured. An unpleasant experience when she's already afraid is only going to make things even harder next time. But on the other hand, if you can make this easier for her than she anticipates, then next time may be less traumatic.

Talk to the doctor. Make it clear that a solution has to be found or the problems will get worse and the doctor is going to find later experiences much more traumatic (for the doctor, too).

Also shop around for a pathology collection place (for future reference) which will be tolerant and supportive. I didn't know to insist last time difficult child 3 had to have blood taken, and as a result the experience was far worse than it needed to be, simply because the pathology technician was in too much of a hurry to use the EMLA cream I asked for. Believe me, that wasted far more time than if she'd used the cream and we'd waited (she could have done other patients while the EMLA did its magic). We did eventually convince the technician, but too late for difficult child 3.

Tell the doctor that if difficult child needs sedating, it must be considered. Something to calm her at the very least. I don't know if EMLA is going to be much help - the tetanus shot stings like h*** for a number of reasons and EMLA only works on the skin surface (a contact thing). ANY injection into the muscle is forcing that volume of liquid into interstitial tissue which hasn't got space to accommodate it. Remember from school science - liquid is incompressible. So something has to give - and it's your body tissue that gets pushed aside to make room for the shot fluid. The site feels bruised for good reason - it is, in a way. It stings the most while the injection is actually being given and for a few seconds afterward, then the fluid is finally in the body and your body begins the job of slowly absorbing it. But the tissue where it was injected has been insulted and is going to let you know about it until it recovers (a few days).
Whatever you do, she is probably going to have a sore spot at the injection site.

Several things can be done, though, to minimise the pain at time of injection, and afterwards. You need your doctor well and truly on side for this. You also need your daughter as still and relaxed as possible - tense muscles will make this worse.
The trick - inject it s-l-o-w-l-y. The slower you inject it, the less the insult to body tissues because the tissues begin to distribute the fluid moderately quickly. The other trick - use a LARGER diameter needle. I know it sounds crazy, but it's effective. I know, from personal experience, because the only antibiotic treatment I can have now (short of going into hospital on a drip) is an intramuscular injection of antibiotic, 12 mls in volume. Nasty. For the non-metric, one ml is the volume of a cube, 1 cm per side. Imagine 12 such cubes, packed into your gluteus maximus. According to my calculator, 12 mls is the equivalent to two cubic inches in volume. I've had about a dozen or more of these shots with varying degrees of pain (the tissues of my rear end were not designed to have two cubic inches of fluid forced into them). And what has worked best is when the nurse used a larger bore needle (size 21 preferably, certainly nothing smaller than a 23 - that's the gauge of the needle) and took several minutes to steadily inject it.
A tetanus shot is a much smaller volume. It shouldn't take as long. But for this to work, the best thing needed is for difficult child's muscles (the ones receiving the shot) to be as relaxed and still as possible. No squirming permitted, because if you move, it hurts a lot more. So if she's sedated thoroughly, PLUS the doctor uses a large needle and injects very slowly, there should be little or no after-pain.

My regular nurse didn't know the trick of using the large needle. She would inject slowly but with the smallest needle she could manage, on the mistaken belief that it's the hole in your skin that hurts. Yes, it does hurt a little, but the worst pain of i.m. is the fluid packing in where it's not welcome. And if you use a narrow needle, the fluid will squirt out under a much greater pressure (Pascall effect, I think it is). To demonstrate, play with some straws. Suck up a mouthful of liquid and squirt it out through a straw. Then find a much narrower straw and do it again - you will find the stream goes further. Whereas if you just spit the liquid, you can't get the same pressure.

An i.m. shot in the rear end also is supposed to hurt less than the arm - fewer nerve endings. You shouldn't need the round part of the , the best place is higher up, just inside the top of the pelvic hip bone but slightly more to the back. This way she is less likely to lie on it in bed, or sit on it, so it shouldn't hurt as much afterwards. It also means less affronted dignity (in terms of exposed private areas).

The remaining problem - a reaction to the tetanus shot - can't really be avoided, if it's going to happen. It is after all a stimulus to the immune system, she may feel feverish, aching like flu and generally miserable for a few days. All you can do with this is treat the symptoms. It doesn't always happen, she could be fine. Just keep plenty of analgesics on hand and be prepared to coddle her a bit if she feels lousy.

There must be many other situations where these things have to be considered - kids with poor understanding of what is going on, for example, coupled with being big and strong enough to fight off the doctor. Or a patient with advanced Alzheimer's. How do they cope?

Try to organise something well ahead of time with the doctor, and if it's going to be handled gently, reassure difficult child that you're doing everything you can (and so is the doctor) to make it easy on her. Never say it won't hurt, just that you're doing everything you can think of so it will be as gentle as possible.

My last shot - it actually didn't hurt, apart from the first split-second of the jab. And afterwards - I really couldn't feel where the nurse injected it. I was absolutely amazed. And it was because she followed those two rules - use a larger needle, and inject very, very slowly.

husband has to have regular injections too, he went through a lot of pain and bruising until his doctor discovered the trick of using the larger needle. Plus, husband's injections are in oil, not saline, which is much nastier to try to inject because of its viscosity.

You're not being foolish in wanting to make sure this is handled as gently as possible. A doctor neighbour of mine always makes sure her own children get EMLA cream before a blood draw. She knows enough to make sure she gets the care she asks for. After talking to her, I know better too.

Marg

 

[smallworld]

Marg and Heather, we have our pediatrician or psychiatrist write a prescription for Emla to have at home. We put it on about 45 minutes before the appointment time, and the girls wear it to the doctor's office. Then there's no waiting time once we get there.

 

[Marguerite]

I think that's the best way to handle the EMLA situation. I know my neighbour the doctor always provides her own. My problem is - I can't carry it in my handbag all the time, and too often the doctor orders the blood tests while were "on the mainland" and away from home. We currently have no doctor in the village. So wherever we go - we go prepared with books, games etc to sit and wait, unless we can organise things better (like with advance warning). It's at least an hour's round trip to go home and then back to the doctor or pathology place.

I love EMLA cream. I wish they'd had it when I was a kid.

Marg

 

[gcvmom]

My difficult child 1 has a huge needle phobia and we've dealt with some of the same things you are dealing with. In the past, vaccinations and blood draws were VERY traumatic and dramatic -- screaming, kicking, running away, needing to be restrained -- and he would become dizzy, vomit and break out in a sweat afterwards. Horrible to experience for all involved (pediatrician didn't believe me once and he got a foot in his groin for his doubt).

As for the pain, you can get an rx for Emla cream, as others have said here -- I think there are some other brands as well, it's basically got lidocaine in it. You apply it at least 20 min before the poke and cover it with some plastic wrap (so it doesn't get on clothing, etc.). Works GREAT.

The anxiety can be dealt with in a number of ways, including medications and therapy. We've used both and the combination has worked well for difficult child 1.

We also use rewards (small) and we talk about how easy the procedure is going to be, and afterwards difficult child 1 gets lavish praise for how well he managed himself. Distraction during the procedure works to a point -- sometimes difficult child 1 uses my iPod, some kids can try to look away or have someone hold their head so they're not tempted to look. But these things won't eliminate the fear. That's something difficult child has to do, and therapy with the support of medications has been our best approach.

We got an rx for Ativan for my difficult child and that helped take the edge off his fear, but he still got panicky. So then we added guided mental imagery with slow, deep breathing to help him relax, and that worked pretty well, but not consistently. The most recent tool in our anxiety arsenal is an rx for Lexapro for difficult child 1, and that has made the biggest difference for him. I was able to cut the Ativan dose in half for his last blood draw (he gets them freqently), and he handled the procedure WONDERFULLY. I'm going to try skipping the Ativan next time to see if he can just use his CBT coping skills and get through it again without any drama.

It takes a lot of time and patience to devise a system that works for your difficult child, but it can be done! Good luck to you!

 

[smallworld]

Emla is the brand name. Lidocaine and Prilocaine Cream is the generic name. Both are available by prescription.

 

[DazedandConfused]

Get the Emla cream. I don't know what I would have done with out it when Daughter was undergoing Chemo for Leukemia. She had a port in her chest and I can't even imagine how much it would have hurt to have been poked there with the big gauge gaue needles they used. Daughter didn't even flinch when they stuck the needle in her with Emla to get some blood drawn.

On another note:

I had a HUGE needle phobia when I was a kid that lasted until I was in my twenties and was persuaded by a co-worker to be a blood donor. I was able to get over most of it doing that for years.

Anyway, my Dad was in the oil business and there was talk of our family moving to Saudi Aradia when I was a kid. What did I get freaked about? The shots! I still remember the extreme anxiety I felt over that. I was so relieved when it was decided we would stay in the states. Yay! No shots!.

I remember as a teenager holding on to my Mom and hiding my face crying when I had to get some blood drawn. The old bag of a nurse was such a crab and let her disgust with me be known. So, I know what your difficult child is going through.

 

[WNC Gal]

Our pediatrician's office also uses a little device called a "shot blocker" it looks like a circular plastic board with lots of little pricklies on it - basically they gently press it down on the area with the blocker and inject in the center - the nerves are "tricked" by the sensations of the larger gently prickling disc and they don't seem to notice the shot itself as much.

But, my littlest child always has a hard time with shots and basically ends up screaming her head off while about three of us hold her down and get it over with - so sad - and that is with EMLA cream too!

I may ask about a sedative next time too! And perhaps getting some Motrin on board prior to the shot to help with the pain afterwards.

Would icing the area be effective?

 

[Marguerite]

That shot blocker sounds great - it would work, too. For blood draws and very small shots, as well as larger things like putting in a drip, EMLA and the related products are great. They can't do much for the bruise effect for an injection, though, except maybe by making it easier for the child to sit still enough and relaxed enough so the tissues can cope with a slower injection.

The suggested distractions are also good - difficult child 3 uses our iPod as a distraction, but for him it's not enough when it comes to blood draws. He's due for a tetanus shot soon, too - he's cooperative, he just gets so panicky and anxious that he throws up and the anxiety clamps his veins down (problem, for blood draw). I'm going to talk to the doctor about sedation/relaxation first, before we do the shot. Without sedation, I know he won't sit still long enough without tensing his muscles, so he will have pain afterwards, for sure. Maybe if I have him playing his Nintendo DS while they do the shot? It might be distraction enough for him. Wouldn't work for a blood draw with him, though. I'm also going to ask about that shot blocker, see if we can get our own.

Marg