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Keywords:

  • analgesia;
  • children;
  • immunisation;
  • infant;
  • pain management;
  • pain

Abstract

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information

Aim

The study aims to identify pain management practices used during scheduled childhood immunisation.

Methods

A survey of members of the Australian Nurses Federation (Victorian Branch) Immunisation Nurses Special Interest Group. Questions included frequency of use of pain reduction strategies during immunisations for infants, toddlers and children, injection techniques and existence of an articulated pain management policy.

Results

The survey was emailed to 274 Immunisation Nurses Special Interest Group members with registered email addresses, and 125 (46%) completed the survey. Nineteen respondents (15.2%) stated their main place of employment had a pain management policy during immunisations and 20 (16.0%) respondents were not sure. Distraction strategies were frequently used during immunisation for all age groups, with 95 (76.0%) replying that distraction was used often or always. Breastfeeding during immunisation for infants younger than 6 months was used occasionally (n = 54, 44.6%), often (n = 11, 9.1%) or never (n = 55, 45.5%) and was used even less frequently for infants aged 6–12 months. Sucrose or other sweet solutions were almost never used for infants prior to, or during, immunisation. As a reward, lollies were frequently given to children after immunisations. Topical anaesthetics were almost never used in any age groups. Over half the respondents used a rapid injection technique; 55 (44.7%) used a slow technique and four respondents aspirated the needle before injections.

Conclusions

Many distraction strategies were used during and following immunisation but sweet solutions, breastfeeding or topical anaesthetics were rarely used. Use of these strategies where feasible, should be facilitated in diverse settings where immunisations take place.


What is already known on this topic

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information
  1. Early childhood immunisation causes considerable anxiety and distress for infants and children as well as their parents.
  2. Effective pain reduction strategies during immunisation include breastfeeding and sweet solutions for infants, topical anaesthetic agents and distraction.
  3. Despite evidence of benefit during immunisation, these strategies are rarely used during early childhood immunisation in Canada.

What this paper adds

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information
  1. Sweet solutions, breastfeeding and topical anaesthetics are infrequently used by Victorian immunisation nurses during immunisation.
  2. Many different distraction strategies are frequently used during immunisation of infants, toddlers and children.
  3. Injection technique varies; over half of immunisation nurses use a rapid injection technique but the majority do not aspirate the needle prior to injecting.

Scheduled childhood immunisations have reduced global morbidity and mortality and are vital for ongoing community protection against life-threatening infectious diseases.[1] However, immunisations are painful and cause anxiety and distress for many infants, children and their parents.[2, 3] Subsequent risks include fears of needle pain, parental non-adherence with immunisation schedules and avoidance of medical care.[3] It is therefore important that pain and distress is effectively reduced during immunisations.

Breastfeeding[4-6] and sweet solutions[7] reduce pain during immunisation for infants up to 12 months of age and sucrose is recommended in the National Health and Medical Research Council's Australian Immunisation Handbook.[8] Evidence also supports topical anaesthetics,[2, 9] and distraction, especially for pre-school and school-aged children.[10] However, these strategies are not consistently used during immunisation in Canada,[11, 12] (Kavanagh, pers. comm., 2010) or Australia (Whitelaw & Downes, pers. comm., 2009), highlighting a gap between published evidence, recommendations and clinical practice. There are no published data on pain management practices during scheduled childhood immunisation in Australia. Determining pain management practices is important in ascertaining the need for practice improvements, and in planning targeted knowledge translation interventions aiming at providing best care during immunisation. The aim of the study was to ascertain pain management practices during scheduled childhood immunisation in Victoria, Australia.

Materials and Methods

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information

Participants

An electronic survey of pain management practices during childhood immunisation targeted Australian Nurses Federation (ANF) Victorian Branch, Immunisation Nurses Special Interest Group (INSIG) members. INSIG's membership includes immunisation nurses from diverse clinical areas and represents approximately one quarter of all Victorian accredited nurse immunisers.

The survey was adapted from a previous survey of neonatal pain management practices,[13] and was pilot tested by five nurses working in the Immunisation Service Drop-in Centre, The Royal Children's Hospital, Melbourne, Australia. The pain management interventions chosen were based on published literature about effective interventions during acute painful procedures including immunisation,[11] as well as expert opinion of five nurses working in the Immunisation Service Drop-in Centre, The Royal Children's Hospital, Melbourne, Australia. Following feedback, the survey was modified. The final version was an anonymous 20-item survey using Survey Monkey. Question one concerned the existence of an articulated pain management policy for childhood immunisation in the INSIG's main place of employment. The next 18 questions concerned use of pain reduction strategies during immunisation in infants (0–12 months), toddlers (12–18 months) and children (18 months and older), and a final question concerned injection technique, and whether a slow (>2 s) or rapid (<1–2 s) technique was used, and use of needle aspiration.

Questions relating to physical, psychological and pharmacological pain reduction strategies used during and following immunisations included oral sucrose (or other sweet solutions) for infants and toddlers or lollipops or lollies for children, breastfeeding, topical anaesthetics and age-appropriate distraction strategies. Respondents were asked to rate the frequency of use of each strategy for each age group on a four-point ordinal scale: ‘never’, ‘occasionally’, ‘often’ and ‘always’. An option of ‘not available’ was also included. A free text section at the end of the survey allowed respondents to comment on ‘other’ strategies used during immunisation.

The survey was emailed to 274 INSIG members with registered email addresses via the INSIG email distribution list in April, 2011. Four reminders were subsequently emailed over the following 2 months.[14] Each reminder included the study cover letter in the body of the email with a hyperlink to the survey. The survey was closed in June 2011, 1 month following the final reminder.

Data analysis

All data analysis was descriptive. Survey Monkey (Professional Account) data summary was used for preliminary analysis, and the data download into Excel allowed further descriptive analysis. Data were summarised and presented as frequency counts and percentages. Distraction strategies listed were sorted into categories developed independently and agreed upon by two study investigators (DH and EM).

The study was approved by the Royal Children's Hospital Human Research Ethics Committee (HREC# 30195A) and permission to administer the survey to INSIG members was granted by the President of the INSIG. Participants' consent was implied by submission of the survey.

Results

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information

Of the 274 invitations emailed to INSIG members, 28 (10%) initially responded. Following the first reminder, responses increased to 61 (22%), then further to 101 (37%) after the second reminder, to 107 (39%) following the third reminder and to 125 (46%) 1 month following the fourth and final reminder. After completing the first question concerning a pain management policy, between two and four respondents did not complete all remaining questions.

Of the 125 respondents, 86 (68.8%) indicated there was no pain management policy in their main place of employment, 19 (15.2%) stated there was a policy and 20 (16%) did not know if a policy existed. Of the 123 who completed the question concerning injection technique, 55 (44.7%) used a slow injection technique (>2 s) and 68 (55.3%) used a rapid injection technique. Only four respondents aspirated the needle prior to injecting.

Pain management strategies used

Sucrose or other sweet solutions were infrequently used for all age groups prior to, or during, immunisation (Table 1). Sucrose for infants younger than 12 months was never used by 95 (77.2%) respondents, occasionally by seven (5.7%), often by five (4.1%), always used by two (1.6%) respondents and 14 (11.4%) answered that sweet solutions were not available. Similarly, sweet solutions were almost never used for toddlers aged 12–18 months. Lollies or lollipops were rarely used for children during injections; however, they were more frequently used as a reward following completion of the immunisations.

Table 1. Frequency of use of pain management strategies during injections
No. (%) frequency of use of strategies during injectionsNeverOccasionallyOftenAlwaysNot available
  1. Numbers in brackets are the number of respondents to each question.

Oral sucrose/sweet taste     
Infants (123)95 (77.2)7 (5.7)5 (4.1)2 (1.6)14 (11.4)
Toddlers (122)93 (76.2)12 (9.8)1 (0.8)3 (2.5)13 (10.7)
Children during immunisation (123)91 (74)18 (14.6)5 (4.1)2 (1.6)7 (5.7)
Children following immunisation (122)32 (26.4)15 (12.4)46 (38)23 (19)6 (5)
Breastfeeding     
Infants 0–6 months (121)55 (45.5)54 (44.6)11 (9.1)1 (0.8) 
Infants 6–12 months (121)67 (55.4)47 (38.8)7 (5.8)0 (0) 
Toddlers 12–18 months (121)82 (67.8)37 (30.6)2 (1.7)0 
Topical anaesthetics     
Infants (122)99 (81.1)10 (8.2)0 (0)0 (0)13 (10.7)
Toddlers (121)97 (80.2)11 (9.1)0 (0)0 (0)13 (10.7)
Children (121)81 (66.9)26 (21.5)1 (0.8)0 (0)13 (10.7)
Distraction during immunisation     
All ages (125)6 (4.8)24 (19.2)64 (51.2)31 (24.8) 
Distraction following immunisation     
All ages (122)6 (4.9)16 (13.1)53 (43.4)47 (38.5) 

Breastfeeding during immunisation was infrequently used. For infants younger than 6 months, 55 (46%) responded that breastfeeding was never used and 54 (45%) responded that breastfeeding was occasionally used. Only one respondent answered that breastfeeding was always used during immunisations. For infants aged 6–12 months, over half the respondents stated that breastfeeding was never used (Table 1).

Topical anaesthetic agents were almost never used in infants or toddlers and used occasionally by 26 (21%) for children older than 18 months of age. Eleven per cent of respondents answered that topical anaesthetic agents were not available for use.

Distraction strategies were frequently used for all age groups and multiple distraction strategies were described. As summarised in Table 2, frequently listed distraction strategies used during immunisation for infants and toddlers included colourful, moving and noisy toys and distracting with talking, smiling and blowing bubbles. For older children, helping the children focus by counting was also frequently used.

Table 2. Distraction strategies during immunisation
InfantsnToddlersnChildrenn
Colourful/noisy/moving toys36Bubbles70Bubbles56
Talking27Colourful/noisy/moving toys74Talking42
Bubbles25Attention focus on person (smiling/talking)27Counting34
Attention on pictures/music/activity12Attention on pictures/music/activity25Rewards – stamps and stickers27
Physical: cuddling/changing position10Physical cuddling14Colourful/noisy/moving toys26
Attention focus on person (smiling/eye contact/waving hands)8Rewards – stamps and stickers10Attention on TV or pictures/music/activity showing pictures17
Non-nutritive sucking4Sweets/food4Sweets/food17
 Encouraged to look away1Encouraged to look away10
   Physical: cuddling3
   Physical – encouraged to wiggle toes/deep breathe4
   Encouraged to sit still1
   Attention focus on person (smiling/talking)1
Total122Total225Total238

Additional pain management strategies were described by 95 respondents. Strategies included simultaneously administered injections for 4-year-olds where possible and allowing children to choose a reward. Additional strategies used for older children included: education (showing photos of sick children with infectious diseases, such as measles), preparation (explaining the procedure and telling them it will hurt or sting for a short time) and involving children in decision-making about strategies to assist them during the injections.

Discussion

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information

This survey of pain management practices during childhood immunisation showed that most settings had no pain management policy. Injection technique varied, with just over half the respondents using a rapid injection technique, considered less painful than a slow technique,[2, 15] yet 46% of respondents reported using a slow technique. Simultaneously administered injections was listed as a pain management strategy, although despite parents preferring this method, this does not reduce children's pain.[2, 16]

Although topical anaesthetic agents reduce immunisation pain in children,[17] they were infrequently used in all age groups. Availability was not a significant barrier to their use as only 11% stated that these agents were unavailable. A study of childhood immunisation practices in Canada also reported infrequent use of topical anaesthetic agents, which was attributed to physicians' concerns about feasibility, cost and additional time to use topical anaesthetic agents.[12]

Additional effective and recommended pain management strategies were rarely used. Despite demonstrated analgesic benefits of breastfeeding infants during immunisation,[9] and oral sucrose or glucose for infants up to 12 months of age,[7] and recommendations to use sucrose in the Australian Immunisation Handbook,[8] there was minimal use of these strategies for infants. Yet, lollies, lollipops or other sweet treats were more frequently offered to children as a reward after the immunisations. It is not known if this strategy helps to reduce pain in children after the procedure,[18] or if it encourages participation in future immunisations.

A multitude of distraction strategies were used during and following immunisations by INSIG members. Although distraction is defined as a psychological intervention,[10] particular interventions listed as distraction by INSIG nurses also had physical components, for example, being held and cuddled. Blowing bubbles was the most frequently described strategy overall, but age-appropriate noisy and or colourful rattles and toys, rewards of stickers and stamps and encouraging parents to cuddle their children were also frequently used, all of which have been shown to be effective in infants, toddlers and children.[10, 19]

Most of the distraction strategies used by INSIG nurses require no, or minimal, additional resources or organisational support to implement, whereas breastfeeding, sweet solutions and topical anaesthetics require additional time, resources, organisational support and planning and education with clinicians and children's families. For example, although topical anaesthetics reduce immunisation pain and distress in children,[2, 9] especially in children older than 3 years of age,[17] these products are costly (around $20.00 for two patches, or $80.00 for a 30 g multi-use tube) and may not be feasible to use in a busy clinic due to the 40–60 min application period required for the agents to effectively work. These factors may preclude widespread use of topical anaesthetic agents[12] despite recommendations to selectively use topical anaesthetics for children who are particularly fearful, and who have had negative experiences with needle-related procedures.[3] As up to 11% of mothers report that at least one of their children has an ‘unusual fear of needles’,[12] the availability of topical anaesthetics for these children is important. Making these agents available for such children, as well as educating children with needle-related fears, and their parents about the option of using topical anaesthetics is imperative for reducing the risk of further fears and distress, and non-compliance with immunisations and other medical-related procedures.

Education and public awareness campaigns targeting clinicians and parents about the effectiveness of breastfeeding and sweet solutions for infants; topical anaesthetic agents and distraction are important to facilitate implementation of these strategies during immunisations. However, achieving sustained changes in diverse settings where immunisations take place is not easy. A brief one-to-one education session delivered to clinicians about effective pain management during immunisation resulted in an increase in use of sweet solutions for infants and distraction and breathing exercises for children at 1 month after the education, but no increase in topical anaesthetics use.[20] Clinicians reported that this increase was sustained at 6 months following the education. However, parents' report differed considerably, with minimal use of breastfeeding at all time points, and despite an initial increase in use of sucrose, this was not sustained at 6 months. These issues highlight the need to regularly target clinicians and their organisations, as well as parents, in education and public awareness campaigns.

Organisational support and practice changes required for providing family and clinician education, and facilitating use of breastfeeding, sweet solutions and topical anaesthetic agents in clinical practice may be viewed as challenging, yet these efforts need to be weighed up against having a settled, co-operative non-distressed child, facilitating an effective consultation. Importantly, effective procedural pain management in early infancy may reduce the risk of children developing needle-related anxiety and fear of subsequent medical procedures. For breastfeeding mothers, the time to ensure their infant is attached and sucking by the time the immunisations are ready to be given is minimal, and sweet solutions are easily accessible, work rapidly and require minimal extra time and effort. It is therefore conceivable that these strategies should be easy to put into place. In fact, breastfeeding was said to be an approach that is ‘easily adopted as a part of standard immunisation injection programmes’.[6]

Strengths and limitations

To our knowledge, this is the only published study of pain management practices during childhood immunisation in Australia. This study establishes baseline practices, which can be used in subsequent bench marking within and between immunisation settings.

There are however, several limitations to this study; first and foremost being the moderate response rate. Despite four reminders, considered to be effective in maximising responses without causing harassment of participants,[14] the final response rate was less than 50% of INSIG members with registered email addresses. A non-response bias is possible, and generalisability of results is limited. This response rate was 26% less than the Canadian study of immunisation pain management practices where a hard copy survey was mailed to identified paediatricians.[12] Our response rate may have been improved if a hard copy of the survey was also mailed and members given the choice of which version they would complete. As the actual number of INSIG members using their email addresses is not known, this option may have substantially improved response rates.

Secondly, only Victorian INSIG members participated, yet childhood immunisations are given by other health-care professionals. INSIG members were specifically targeted as they comprise professional nurses administering immunisations, who are in positions of leadership, therefore in key positions to influence change in practice at a local, state and national level. A further limitation is that parents' views on pain management during immunisation were not sought in this study, nor was there any observation of immunisations to validate the INSIG nurses' self-report of pain management practices. Seeking parental views would have added to our understanding of pain management practices occurring and direct observation of pain management practices would have validated self-report. Another limitation was the survey did not include questions pertaining to use of oral analgesics such as paracetamol. Despite no evidence of analgesic benefits during injections, or preventing fever following immunisations, frequent use of paracetamol (acetaminophen) associated with immunisation has been reported in the Canadian setting.[12] Inclusion of questions relating to oral analgesics would have contributed to our knowledge of immunisation practices.

Another limitation relates to the four-point scale used to ascertain frequency of use of pain management strategies. Although the definition of ‘always’ and ‘never’ are self explanatory, defining ‘occasionally’ and ‘often’ may have assisted in the interpretation of results. In contrast, Taddio et al. used a six-point scale, and defined each of the responses, for example, always = 100%, almost always = 75–99%, sometimes = 25–49%.[12] Finally, although respondents were given the option of selecting ‘not available’ for questions concerning sweet solutions and topical anaesthetics, there were no questions concerning facilitators and barriers to using pain management strategies during immunisation. Such questions may have assisted in identifying opportunities for targeted knowledge translation strategies relating to implementation of effective pain management strategies in addition to distraction.

Recommendations for practice

INSIG members and other clinicians responsible for immunising children are encouraged to promote breastfeeding, and use sweet solutions for infants and topical anaesthetics for children who are particularly fearful, in addition to the distraction techniques already used. Organisations are encouraged to facilitate the use of these strategies by supporting mothers to breastfeed their infants during immunisation and ensure easy access to sweet solutions and topical anaesthetics agents as required. Sucrose is commercially available, sold as Toot-Sweet (24% sucrose), and is also easy for parents to make up (1 teaspoon of table sugar to 1 tablespoon of warm water. Mix well and advise parents to discard all leftover solution and to discourage use in the home). In addition, topical anaesthetics (EMLA, Ametop and ANGEL cream) are available over the counter in many Victorian pharmacies.

Recommendations for future research

Using this survey data as a baseline, future research should evaluate implementation of an immunisation pain management guideline. Such research could improve pain management and contribute to our knowledge of effective ways to change practice in diverse health-care settings. In addition, ascertaining parents' perceptions of pain management strategies used would further contribute to our knowledge about pain management during childhood immunisations.

In conclusion, distraction was frequently used by INSIG members during immunisations, yet other strategies with known analgesic benefits, such as supporting mothers to breastfeed infants and giving infants sucrose, were infrequently used. Interventions to improve use of effective pain management strategies for infants and children during immunisation are warranted.

Acknowledgements

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information

Funding: Nurses Board of Victoria Legacy Ltd, Major Research Grant.

Personnel: President of the INSIG and the ANF (Vic Branch) SIG for their support in the survey administration.

Members of the INSIG for participating in the study.

References

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information
  • 1
    Briss PA, Rodewald LE, Hinman AR et al. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services. Am. J. Prev. Med. 2000; 18: 97140.
  • 2
    Taddio A, Appleton M, Bortolussi R et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. Can. Med. Assoc. J. 2010; 182: E843855.
  • 3
    Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurtry CM, Bright NS. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics 2007; 119: e11841198.
  • 4
    Dilli D, Küçük I, Dallar Y. Interventions to reduce pain during vaccination in infancy. J. Pediatr. 2009; 154: 385390.
  • 5
    Efe E, Ozer ZC. The use of breast-feeding for pain relief during neonatal immunization injections. Appl. Nurs. Res. 2007; 20: 1016.
  • 6
    Razek AA, El-Dein AN. Effect of breast-feeding on pain relief during infant immunization injections. Int. J. Nurs. Pract. 2009; 15: 99104.
  • 7
    Harrison D, Stevens B, Bueno M et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch. Dis. Child. 2010; 95: 406413.
  • 8
    Australian Government. The Australian Immunisation Handbook 9th Edition, Department of Health and Ageing and National Health and Medical Research Council, Editors. 2008.
  • 9
    Shah V, Taddio A, Rieder MJ. Effectiveness and tolerability of pharmacologic and combined interventions for reducing injection pain during routine childhood immunizations: systematic review and meta-analyses. Clin. Ther. 2009; 31: S104151.
  • 10
    Chambers CT, Taddio A, Uman LS, McMurtry CM, HELPinKIDS Team. Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin. Ther. 2009; 31 (Suppl. 2): S77103.
  • 11
    Taddio A, Chambers CT, Halperin SA et al. Inadequate pain management during routine childhood immunizations: the nerve of it. Clin. Ther. 2009; 31 (Suppl. 2): S152167.
  • 12
    Taddio A, Manley J, Potash L, Ipp M, Sgro M, Shah V. Routine immunization practices: use of topical anesthetics and oral analgesics. Pediatrics 2007; 120: e637643.
  • 13
    Harrison D, Loughnan P, Johnston L. Pain assessment and procedural pain management practices in neonatal units in Australia. J. Paediatr. Child Health 2006; 42: 69.
  • 14
    Howell SC, Quine S, Talley NJ. Ethics review and use of reminder letters in postal surveys: are current practices compromising an evidence-based approach? Med. J. Aust. 2003; 178: 43; discussion 43.
  • 15
    Ipp M, Taddio A, Sam J, Gladbach M, Parkin PC. Vaccine-related pain: randomised controlled trial of two injection techniques. Arch. Dis. Child. 2007; 92: 11051108.
  • 16
    Horn MI, McCarthy AM. Children's responses to sequential versus simultaneous immunization injections. J. Pediatr. Health Care 1999; 13: 1823.
  • 17
    Wrzosek T, Hogan ME, Taddio A. Age and efficacy of topical anesthetics. Pediatric Pain Letter 2009; 11: 811.
  • 18
    Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens B. Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Cochrane Database Syst. Rev. 2011; (10): CD008408.
  • 19
    Taddio A, Ilersich AL, Ipp M, Kikuta A, Shah V, HELPinKIDS Team. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin. Ther. 2009; 31 (Suppl. 2): S4876.
  • 20
    Schechter NL, Bernstein BA, Zempsky WT, Bright NS, Willard AK. Educational outreach to reduce immunization pain in office settings. Pediatrics 2010; 126: e15141521.

Supporting Information

  1. Top of page
  2. Abstract
  3. What is already known on this topic
  4. What this paper adds
  5. Materials and Methods
  6. Results
  7. Discussion
  8. Acknowledgements
  9. References
  10. Supporting Information
FilenameFormatSizeDescription
jpc12161-sup-0001-AppendixS1.pdf41K

Appendix S1 Survey of pain management practices during early childhood immunisation.

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