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Clinical Practice Question: Should you aspirate prior to administering an intramuscular (IM) Hepatitis vaccine to infants?

Recommendation: Aspiration prior to IM administration of a Hepatitis vaccine to infants is no longer recommended.

Supporters of this recommendation:

• American Academy of Pediatrics (AAP)

• American Council on Immunizations (ACIP)

• American Academy of Family Physicians (AAFP)

• Center for Disease Control (CDC)

• Cincinnati Children’s Hospital Medical Center

• Mosby’s Skills – Hepatitis B /Immunoprophylaxis (Maternal-Newborn)

• Northern Kentucky Health Department

• World Health Organization (WHO)

PAIN

1. Aspiration causes increased pain during an injection.

2. Aspiration prolongs the time the needle is in the tissue and the movement of the needle in the tissue as aspiration occurs causes pain.

3. Pain associated with injections is distressful for infant and parents.

4. If the pain is not addressed, this can lead to preprocedural anxiety, needle fears and healthcare avoidance behaviors in the future.

5. 25% of adults have a fear of needles. 10% of the population avoid vaccinations and other needle procedures because of their fear of needles (Taddio et al., 2010).

6. Rapid injection (1 sec for 0.5 ml of solution) is recommended because it is less painful than slow injection (5 sec for 0.5 ml) (Ipp et al., 2007;Taddio et al., 2010)

7. Breastfeeding during vaccination includes four activities that make it an effective analgesic intervention: holding the infant, skin-to-skin contact, the sweet tasting milk and the act of sucking (competes with the gate control pathway for pain) (Taddio et al., 2010).

BLOOD ASPIRATION

1. There is a lack of evidence in the literature to support the practice of aspiration for blood return for intramuscular injections for vaccinations in infants (ACIP, 2002; Hensel & Springmeyer, 2011).

2. Anatomic sites recommended for IM vaccination do not have large blood vessels (ACIP, 2006).

3. If the correct needle size (25 g. 5/8 in.) is used, the correct angle is used (90°),the correct site is used (vastus lateralis-anterolateral thigh), and the skin is stretched flat between the thumb and forefinger (Not bunched up) when giving the vaccination it is very unlikely that the injection will go into a major blood vessel (Mosby’s Skills, 2011). Given the size of the needle and the angle at which you inject the vaccine, it is difficult to cannulate a vessel without rupturing it and even more difficult to actually deliver the vaccine intravenously(CDC, 2011; Immunization Action Coalition, 2011).

4. There have been no report of a vaccine being administered intravenously and causing harm in the absence of aspiration (Immunization Action Coalition, 2011)

5. In order for aspiration to be effective in identifying the presence of blood, aspiration must last 5-10 seconds (Potter & Perry, 2008, Taddio et al., 2009). Clinical observations indicate people who aspirate prior to injection do it for 1-2 seconds.

6. Aspiration was added to the injection procedure in the 1920’s to counteract the problems that occurred when there were reports of arterial injection of viscous and caustic medications such as bismuth and penicillin.

References

Center for Disease Control and Prevention. (2011, January, 28). General recommendations on

immunizations: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 1-26.

Hensel, D & Springmeyer, J. (2011). Do perinatal nurses still check for blood return when

administering the hepatitis B vaccine? Journal of Obstetric, Gynecologic and Neonatal Nursing, 40, 589-594. DOI:10.1111/j.1552-6909.2011.01277.x

Hepatitis B Immunoprophylaxis (Maternal-Newborn). Mosby’s Skills. Retrieved from St.

Elizabeth on-line Mosby’s Skills.

Immunization Action Coalition – “Ask The Experts – General Vaccine Questions”. Retrieved

from:

Ipp, M. Taddio, A. Sam, J. , Goldbach, M & Oarkin, P.C. (2007). Vaccine-related pain:

Randomized control trial of two injection techniques. Archives of Disease in Childhood,

92, 1105-1108.DOI:10.1136/adc.2007.118695

Potter, P.A. & Perry, A.G. (2008). Fundamentals of nursing (5th ed.).St. Louis, MO: Mosby.

Taddio, A., Appleton, M., Bortloussi, R. Chambers, C., Dubey, V., Halprein,S. …Shah, V.

(2010, December 14). Reducing the pain of childhood vaccination: An evidence based practice guideline. Canadian Medical Association Journal, 182 (18), E843-861. Retrieved from

Taddio, A. Ilersich, A.L. Ipp, M. Kikuta, A. & Shah, V. (2009, December). Physical

interventions and injection technique for reducing injection pain during routine childhood

immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials. Clinical Therapeutics, 31, Supplement B, S48-S76.

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