Vaccine Administration Strategies

Full update October 2020

Many patients (especially children) have anxiety and fears around needles and vaccine administration.1 A positive vaccination experience can help reduce anxiety, increase vaccination rates, and may help decrease the risk of a an ongoing general fear of needles and injections that can impact future healthcare visits.1 The following is a checklist of strategies to help reduce a patient’s fears, make the injections less painful, and prevent injuries.2


Suggestions/Pertinent Information

Strategies to Minimize Patient Anxiety

Be calm, collaborative, well-informed, and comfortable with immunizing patients.2 Maintain a positive attitude throughout.1

Let patients and caregivers know what will happen, how it will feel, and what they can do. Provide information in advance.1

Use neutral phrases like “Here I go.” rather than “Here comes the sting.” 2

Be truthful to promote trust.2 Do not tell them it won’t hurt. Tell them they will feel a pinch but that it won’t hurt for long.3

Ensure privacy to help decrease anxiety.2

If more than one vaccine is being given, administer the most painful vaccine last (e.g., M-M-R II, Prevnar).1

Let caregivers know that their behavior can influence a child’s response and distress. Give them information and tools to help them remain calm.1 Let caregivers know they should never threaten or scare a child about injections.3

Make sure caregivers remain present with children, especially if less than ten years old.1

  • Infants and children should be held by their caregivers in a position that is most comfortable for them (e.g., sitting on their laps, in a bear hug [can help to hold their arms still], etc).1,2
  • If standing, have caregivers brace themselves (e.g., against a table or a desk) to prevent accidental falls.1

Do not have patients (including infants and children) lie down for injections.1

  • If patients have a history of fainting, you can consider having them lie down for the injection (when possible).2

Do not forcibly restrain a child as this will increase their fear.1,2

Consider having parents hold neonates with skin-to-skin contact to reduce acute stress.1

Recommend breastfeeding infants before, during, and/or after injections.1,2,18 This can reduce stress with physical comfort, sucking distraction, and sweet-tasting ingestion.1 Pacifiers or bottle feeding throughout may provide some benefit as well.2,18

Use a variety of distractions with children (e.g., toys such as bubbles, pop-up books) or conversation (ask about pets, school).2

  • Encourage caregivers to bring a child’s favorite toy, book, blanket, other comfort item, or smartphone from home.3,18
  • Have caregivers tell stories, cuddle, sing, or talk softly with the child.3
  • Focus on and interact with the child throughout the procedure. Try to keep their attention on the distraction. Praise them for engaging in the distractions.1 Offer fun, colorful bandages or a lollipop (with parent permission) as a reward.

As a last resort, consider and discuss deferring pediatric vaccines to another day if your safety or the child’s safety is at risk.

Consider referring children and adults with severe fear or phobia of needles (which interferes with vaccination despite the use of anxiety and pain-reducing strategies) for cognitive behavioral therapy.19

Strategies to Minimize Injection Pain

Consider pre-application of topical anesthetic creams, gels, or patches if there is significant anxiety or fear of pain.1,2

  • Timing of application (typically one hour) and cost vary by product.1,2
  • Make sure patients apply to correct injection sites (e.g., deltoid of both arms if applicable).1

Recommend sucrose (e.g., sugar water, TootSweet) in infants less than two years if they are not breastfed during vaccination.1

  • The dose is 2 mL of a 24% to 50% solution one to two minutes before the injection. Parents can mix one teaspoon (or one packet) of white sugar with two teaspoons (10 mL) of water.1,18
  • Alternatively, give rotavirus oral vaccine first (if using) as it contains sucrose.1

Generally, do not recommend topical ethyl chloride and other vapocoolants due to lack of proven effectiveness.5

Do not recommend oral analgesics (e.g., acetaminophen) prior to injections as they are unlikely to help and it has been suggested that they could decrease the immune response.2,5-7 Save for after the injections for fever or discomfort.2

Have the patient keep their arm muscle loose, encourage slow deep breaths, and then give shot during exhalation.

  • Have children blow out into a toy pinwheel, party blower, or bubble blower.8
  • Adults can give a slight cough as you inject the vaccine but be sure to avoid arm movement and breath holding.2

DO NOT warm the vaccine (rubbing between your hands), rub or pinch the injection site (manual stimulation), rub the skin adjacent to the injection site, or apply pressure or cold (e.g., ice packs) prior to the injection.13

Do not pull back the plunger with IM administration.1,2,4 It is unnecessary, lengthens injection time, and increases pain.1,2

Be aware of devices marketed to reduce the pain of injections. For example:

  • The Buzzy (~$40) device may reduce pain with vibration and cold [Evidence Level B-1].9,10
  • The ShotBlocker is a disposable disk that surrounds the injection site to “saturate the sensory signals.” Studies are small and many do not show decreased pain in patients getting injections [Evidence Level B-1].11,12

Strategies to Reduce Risk of Injury

Choose the proper needle size based on route of administration and your patient (i.e., age and weight).

  • A needle that is too short causes more pain, may decrease efficacy, and increases the risk of skin reactions.14,16
  • A needle that is too long can hit bone or a nerve, increasing the risk of pain and injury.14,16

Position yourself correctly (sit if the recipient is sitting, or kneel, elevate, etc) to help get to eye level to ensure the injection is at a 90-degree angle into the correct area of the deltoid.15,21

Avoid lowering a patient’s shirt down over their shoulder to reduce the risk of injecting too high.17

When injecting IM vacines into the deltoid (adults, usually children ≥3 years), always inject into the central, thickest part of the muscle.20 This animated image is an example of how to locate the proper injection area.

  • Injections that are too high (i.e., upper third of the arm) have been associated with severe shoulder injuries (e.g., rotator cuff tears, bursitis, tendonitis).4,15
  • Shoulder Injury Related to Vaccine Administration (SIRVA) is rare. It occurs when an IM vaccine is administered too high on the arm, into the shoulder joint instead of the deltoid muscle.14-16 Symptoms (e.g., permanent pain, weakness, and impaired mobility) typically start about 48 hours after injection.15,16

Use caution with the “Three Finger Rule” (i.e., inject IM vaccines three finger widths below the upper crest of the arm or acromion process) to find the right spot for injection. This “rule” won’t always guide you low enough on the arm.


Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.



Study Quality


Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study


Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study


Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56.]

Prepared by the Editors of Therapeutic Research Center (361005); Last modified February 2021.


  1. Taddio A, McMurtry CM, Shah V, et al. Reducing pain during vaccine injections: clinical practice guideline. CMAJ 2015;187:975-82.
  2. WHO. Reducing pain at the time of vaccination: WHO position paper, September 2015 – recommendations. Vaccine 2016;34:3629-30.
  3. CDC. Tips for a Less Stressful Shot Visit. (Accessed September 7, 2020).
  4. Angelo LB, Ed. APhA’s Immunization Handbook. 4th ed. Washington, DC: American Pharmacists Association, 2018.
  5. Shah V, Taddio A, McMurty CM, et al. Pharmacological and combined interventions to reduce vaccine injection pain in children and adults: systematic review and meta-analysis. Clin J Pain 2015;31(Suppl 10):S38-63.
  6. Chen RT, Clark TA, Halperin SA. The yin and yang of paracetamol and paediatric immunisations. Lancet 2009;374:1305-6.
  7. Prymula R, Siegrist CA, Chilbek R, et al. Effect of prophylactic paracetamol administration at time of vaccination on febrile reactions and antibody responses in children: two open-label, randomised controlled trials. Lancet 2009;374:1339-50.
  8. Schechter NL, Bernstein BA, Zempsky WT, et al. Educational outreach to reduce immunization pain in office settings. Pediatrics 2010;126:e1541-21.
  9. Schreiber S, Cozzi G, Rutigliano R, et al. Analgesia by cooling vibration during venipuncture in children with cognitive impairment. Acta Paediatr 2016;105:e12-6.
  10. Canbulat Sahiner N, Inal S, Sevim Akbay A. The effect of combined stimulation of external cold and vibration during immunization on pain and anxiety levels in children. J Perianesth Nurs 2015;30:228-35.
  11. Drago LA, Singh SB, Douglass-Bright A, et al. Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections. Am J Emerg Med 2009;27:536-43.
  12. Cobb JE, Cohen LL. A randomized controlled trial of the ShotBlocker for children’s immunization distress. Clin J Pain 2009;25:790-6.
  13. Taddio A, Ho T, Vyas C, et al. A randomized controlled trial of clinician-led tactile stimulation to reduce pain during vaccination in infants. Clin Pediatr (Phila) 2014;53:639-44.
  14. Barnes MG, Ledford C, Hogan K. A “needling” problem: shoulder injury related to vaccine administration. J Am Board Fam Med 2012;25:919-22.
  15. Atanasoff S, Ryan T, Lightfoot R, Johann-Liang R. Shoulder injury related to vaccine administration (SIRVA). Vaccine 2010;28:8049-52.
  16. Bancsi A, Houle SKD, Grindrod KA. Shoulder injury related to vaccine administration and other injection site events. Can Fam Physician 2019;65:40-2.
  17. Ross M. Compensation growing for botched vaccine administration. September 10, 2015. Pharmacy Times. (Accessed September 11, 2020).
  18. Immunize Canada. Pain management during immunization for children. April 2019. (Accessed September 12, 2020).
  19. McMurtry CM, Taddio A, Noel M, et al. Exposure-based interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research. Cogn Behav Ther 2016:45:217-35.
  20. Immunization Action Coalition. How to administer intramuscular and subcutaneous vaccine injections. 2020. (Accessed September 20, 2020).
  21. D’Arrigo T. Proper vaccination technique is key to avoiding shoulder injury. October 1, 2017. American Pharmacists Association. (Accessed February 18, 2021).

Cite this document as follows: Clinical Resource, Vaccine Administration Strategies. Pharmacist’s Letter/Prescriber’s Letter. October 2020.

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