Before the end of the month, Health Canada is expected to complete its review of Pfizer-BioNTech's COVID-19 vaccine for kids between 5 and 11 years old.
If given the green light, children across the country could begin getting their shots almost immediately.
For pharmacies this will mean an influx of younger, more scared patients and Anna Taddio—a professor at the University of Toronto’s Leslie Dan Faculty of Pharmacy, and senior associate scientist at SickKids—wants to share evidence-backed ways to make the experience better for both families and pharmacists.
Taddio is the lead developer of the CARD system, a program developed in 2019 to reduce the pain and fear of vaccination. Funded by the Public Health Agency of Canada for use alongside the COVID-19 vaccine rollout, it has a modified version for elementary school kids.
The goal for children, she says, is to reduce anxiety and fear. When kids are stressed, they experience more fear, pain, dizziness and, in extreme cases, fainting. “There’s no pharmacist that wants to deal with someone fainting, and it’s preventable,” says Toddio.
Children who've bad experiences are also more likely to carry that fear of needles into adulthood, or even develop a phobia, both making them averse to future vaccination.
The first step to easing anxiety is creating a helpful physical environment. “Pharmacies were never meant to be a space to give vaccines, and now we’re changing that—and that’s okay, but we need to simulate the aspects of a medical space that make it feel welcoming and people feel safe,” says Toddio.
Private rooms for vaccines help because other people watching can increase kids’ anxiety—as can watching another child have a bad experience while they’re waiting. Have chairs in the space, because sitting is less stressful than standing. And have a chair for the pharmacist, too. “Hunching over kids can be very scary. So getting at their level and meeting them eye to eye helps,” she says.
Seeing them can make many kids more afraid so keep them out of sight until the time comes. (Though if they ask to see what’s happening, that’s fine, too). And add child-friendly posters to the wall to distract kids while they’re waiting and getting the shot.
Booking longer appointments for children can also help, especially for those who are very afraid of needles. “If there’s not enough time, that really artificially sets up situations where people are going to be more stressed, because there’s this time limit,” says Toddio.
Parents should also be informed that they have the option of topical anaesthetic. They cost about $15, are applied beforehand and reduce the sensation of a needle by about 50%. “We use them in hospitals quite commonly, but they're not well known [outside of the hospital setting],” says Toddio. “But they can really be a game changer, particularly for kids who are afraid.” Topical anaesthetics do take about 20 to 30 minutes to work, so kids need to come early to get them and then come back later for the vaccine or apply them ahead of time at home.
At the appointment itself, try following CARD: it stands for comfort, ask, relax, distract. When parents book the appointment, walk them through the different steps ahead of time, so they come in prepared.
Ask kids what they want to do to feel comfortable: Do they want to sit on their parents lap or hug a stuffie? Being able to make some decisions reduces anxiety, and showing you care about their preferences reassures kids that you care about them. “Giving them some control so they are empowered and they can do what they want - that will make them feel better,” says Toddio.
Next, offer the chance to answer questions. Kids may have discussed the vaccine beforehand with parents, but if not, an age-appropriate description of a vaccine for a little kid might be “I’m going to give you a medicine to keep you healthy, and it's going to go into your arm with a needle. It’s called a vaccine. Do you have any questions for me?”
Kids usually want to know why they need the medicine, why a needle is needed and what’s going to happen, how’s it will feel, and how the people around them are prepared to help them cope. “Most of us are nervous when we don’t know enough about something, so we’re trying to promote people feeling comfortable enough to ask questions,” says Toddio.
If they ask if it’s going to hurt, don’t lie and say it won’t, but don’t overplay the pain either. You might say some people find they feel pressure and some don’t feel much at all, says Toddio. If children don’t want to talk about what’s going to happen, don’t push it.
Next, encourage kids to relax: they could take deep breaths—by imagining blowing bubbles—or tell themselves a positive mantra. Whatever they prefer, it’s best if it’s their choice and if they’ve come in with a plan of what they’re going to do.
The last step is to distract while you’re injecting the vaccine: kids can look at interesting posters or watch a video on a parent’s phone. “People can be invited—and welcomed—to zone out. They can be told, it’s not rude to do something else,” says Toddio.
Use neutral language when describing what you're doing: instead of saying 'here comes the shot' you could say 'I’m going to give you the vaccine now.' Don’t focus on the child’s discomfort, but rather offer praise and encuragement. “If you say, 'I’m so sorry,' or 'Oh, it’s almost over,' those focus the child’s attention on the needle, and you’re saying it as if it is something they should worry about,” she says.
If a child is really afraid and can’t handle the needle, Toddio advises to let the child take a break and return. If they still can’t do it, to suggest they try another day with their family doctor. “You’re not going to hold them down, because you’re just escalating that fear for the next time,” she says.
At the end of the visit, sum it up with a positive comment about what happened. “Say, 'Good for you, you got it! You did so great with your deep breathing!' Be super positive and make people feel good about that experience, because that’s what they will walk away remembering,” Toddio says.
Finally, consider asking for feedback from parents afterwards that includes questions about how to improve, she says. “That’s a great idea for a pharmacy to do in terms of learning a lot about how we can manage in this space.”