New guidance offers tips to reduce pain and fear during vaccine injections

The Help Eliminate Pain in Kids & Adults (HELPinKids&Adults) Collaborative has updated the previous (2015) guideline recommendations for reducing vaccination-related distress (pain, fear). The HELPinKids&Adults Collaborative is a national interdisciplinary team of clinicians, scientists, policy-makers and lay people interested in improving practices to reduce vaccination-related distress across the lifespan.Acute distress associated with vaccination can cause unnecessary patient suffering and increases the risk of immunization stress-related responses (e.g., dizziness, fainting) that can lead to injuries from falls. In addition, over time, vaccine recipients may develop needle-related fears and traumatic associations that contribute to vaccine hesitancy and refusal across the lifespan. Integrating evidence-based strategies to minimize distress can improve the experiences of vaccine recipients and prevent vaccination harms that erode confidence in vaccination and compromise population health.Many of the 2026 HELPinKids&Adults Collaborative recommendations are aimed at clinicians and organizations responsible for delivering vaccinations. Physical, pharmacologic and psychological recommendations are also provided for vaccine recipients and support persons. The following highlights key recommendations from the guidelines, including the strength of each recommendation and the certainty of the evidence:Education about distress-reducing interventions and use of distress-reducing interventions for vaccine injections is recommended, such as the multicomponent CARD (Comfort–Ask–Relax–Distract) intervention system (Strong recommendation, Moderate certainty of evidence).Performing vaccine injections without aspiration and using a rapid injection technique is recommended for recipients of all ages (Strong recommendation, Low certainty).It is recommended that caregivers be offered the opportunity to provide oral nutritive and non-nutritive interventions to infants (aged 0–12 months) receiving vaccinations, in the form of their preferred option: breastfeeding, bottle-feeding, other sweet-tasting liquids (expressed breast milk, oral rotavirus vaccine, sucrose solution, glucose or dextrose solution, pacifiers). (Strong recommendation, Certainty of evidence varies from moderate to very low depending on the option—see guideline for details).It is recommended that caregivers be offered the choice to use topical anesthetics or manual tapping at the injection site for infants (aged 0–12 months) receiving vaccine injections. Topical anesthetics (e.g., lidocaine/ prilocaine [EMLA], lidocaine [Maxilene], tetracaine [Ametop]) have a strong recommendation, with high certainty of evidence. Manual tapping (Helfer skin tap technique) has a strong recommendation with moderate certainty of evidence.Offering topical anesthetics at the injection site is recommended for vaccine injections in adults and children older than 12 months, and allowing recipients and their support persons to choose whether to use them. (Strong recommendation, Moderate certainty of evidence).It is suggested that caregivers be offered the option of using their choice of the following distraction interventions—toys and singing—for infants (aged 0–12 months) receiving vaccine injections. (Conditional recommendation; Low certainty of evidence).Offering distraction with music for vaccine injections is recommended in adults and children older than 12 months and allows recipients and their support persons to choose whether to use it. (Strong evidence, Moderate certainty).Offering the following distraction interventions for vaccine injections in adults and children older than 12 months is suggested—digital and nondigital activities or games, virtual reality, breathing activities with toys, toys (with or without a battery), and videos or movies—and allowing recipients and their support persons to choose their preferred option. (Conditional recommendation, Low to very low certainty)The guidelines recommend that clinicians implement other distress-reducing interventions, such as coping-promoting behaviour, support person presence, comfort positioning and muscle tension. The muscle tension technique involves repeatedly tensing and releasing (back to baseline) large muscle groups to prevent and manage hypotension-related symptoms; it can be offered to children and adults with a history of presyncopal and syncopal reactions.The guidelines also recommend that when multiple vaccines are required, they should be administered in order of increasing distress, with the least distressing vaccine given first for recipients of all ages (Strong recommendation, Moderate certainty).Two nonevidence-based interventions should be eliminated from the vaccine injection process—administration of oral analgesics and alcohol skin antisepsis.Oral analgesics are not advised for the prevention of vaccine injection–related distress because of a lack of demonstrated benefit for reducing needle-related distress and they may interfere with the effectiveness of some vaccines.The use of alcohol to cleanse the skin before vaccine injections is not advised. There is no proof that alcohol use prevents infection, and its use incurs additional costs (from supplies and personnel time) and may act as a fear cue that escalates patient distress.Clinicians should monitor vaccine recipients’ symptoms (e.g., fear, pain, immunization stress–related responses) before and after vaccination. Such assessment is considered a standard part of ethical care during painful medical procedures. The HELPinKids&Adults Collaborative concludes that vaccine injection–related distress should be viewed as a predictable and manageable consequence of vaccination, rather than an inevitable event. Implementing the recommendations outlined in these guidelines can improve the quality of vaccine delivery practices and promote person-centred care with the goal of creating more positive vaccination experiences that reduce fear and support future vaccination.ReferenceTaddio A, Shah V, McMurtry CM, et al. Reducing distress during vaccine injections: 2026 clinical practice guideline update. CMAJ 2026;198(32):E1243-63 (accessed September 24, 2026).

New guidance offers tips to reduce pain and fear during vaccine injections

Register for free access or login.

Related Topics