5 Evidence-Based Tips for Your Baby’s First Shots
As most of you know, we welcomed a new little boy into the world last December. I know how important it is to vaccinate on time, even more so because we live in a town with very low immunization rates. That means we’re low on herd immunity to protect our most vulnerable citizens, including newborn babies. So to me, it was a relief when BabyM’s 2-month appointment rolled around and he could get his first round of shots.
But. But… I hate to see my little boy cry in surprise when he gets shots. That’s always hard. And I hate to see him be uncomfortable for the day or so after the shots. So, as we approached his first shots, and the ones that followed, I wanted to do everything I could to reduce his discomfort. It’s thanks to science that we have these awesome vaccines, and it turns out that science can help us minimize discomfort from them, too.
1. Use evidence-based comfort measures to decrease pain during shots.
Both Cee and BabyM have never cried more than about 30 seconds after shots, but I feel good about helping to ease their pain as much as I can. There’s a lot of research on how to decrease pain and distress in infants receiving shots. A recent systematic review and meta-analysis (summary of many studies) found the following to be effective(1) :
– Breastfeeding – The meta-analysis found that breastfeeding during shots was effective for reducing baby’s distress, although there was a lot of variability between studies. Breastfeeding combines the comfort of holding and sucking with the sweet-taste of milk, all of which have been shown to help comfort babies.(2) In practice, not all pediatricians may encourage breastfeeding during shots. Our pediatrician’s nurse prefers to give vaccines with the baby on the exam table, and then she encourages breastfeeding as soon as the shots are over. When I asked a few other pediatricians about this, some felt that it was easier to give shots quickly and smoothly if the baby was on the exam table, while others said they routinely recommended breastfeeding during shots. It’s worth discussing with your pediatrician to see what you both are most comfortable with. Some studies also show that breastfeeding just before shots is also beneficial, so that’s another option.(1)
I want to quickly address a strange and unfortunate anti-vaccine myth that breastfeeding decreases the efficacy of the rotavirus vaccine. This myth grew out of a 2010 study that found that breast milk contained antibodies that could neutralize the rotavirus vaccine in petri dishes, and this neutralizing activity was greatest in breast milk from women in India.(3) From the start, this study had questionable relevancy to real women in the U.S., but it was enough to start an Internet myth prevalent enough to warrant this reassuring response from Arthur Eidelman, neonatogist and president of the Academy of Breastfeeding Medicine: “Bottom line: the study has absolutely NO relevance to nursing mothers in industrialized countries (surely NOT the US and Canada) and therefore NO change in the routines of breastfeeding infants who are being vaccinated are being suggested! (and so spread the word!)”
In the world of science, we know that one study is rarely enough to tell us the whole story, so researchers began studying this question in real women and babies to learn more. I’ve seen at least three so far – conducted in Pakistan, India, and South Africa – and none have found that delaying breastfeeding improved the efficacy of the vaccine.(4–6) In fact, in the Pakistan study, babies that were breastfed immediately after the rotavirus vaccine had a better immune response than those who weren’t. So, say yes to the rotavirus vaccine, and if it’s working for you, to breastfeeding.
– Sweet-tasting solutions – Babies that taste something sweet during their shots show less pain, and that’s been shown in many studies summarized in the recent meta-analysis.(1) If you’re not breastfeeding or don’t want to during shots, this is a great alternative. Your pediatrician may have some sucrose solution on hand, or you can make your own at home by mixing 1 teaspoon of table sugar with 2 teaspoons of clean water. Give to your baby on a pacifier or through a dropper.(1) Conveniently, the oral rotavirus vaccine also contains sucrose, and one recent study found that it was just as effective as a plain sucrose solution at reducing pain.(7) Thus, it might be helpful to give the rotavirus vaccine before the injectable vaccines, as it has a built-in pain reducer!
Parental behavior – It’s often said that baby’s shots hurt the parents more than baby. That may be true, but it’s important to stay calm and supportive while your baby is getting his shots. There aren’t a lot of studies on this in very young infants, but in general, studies find that when parents are excessively apologetic or reassuring, this actually increases babies’ distress. In contrast, matter-of-factly explaining what will happen and why and then using distraction or humor during shots seems to help decrease distress.(8–10)
2. After shots, be prepared to have a do-nothing day in case your baby isn’t feeling well.
It’s common for babies to have a mild fever and be fussier than usual for a day or two after receiving vaccines. These symptoms just mean that your child is having an appropriate immune response to the vaccine. If you’ve had a vaccine lately, then you know that they can sometimes make you feel a little off, too. (Hopefully you had flu and Tdap shots during pregnancy!) Recognizing this, you may not want to plan much else for the day so that you can focus on comforting your baby and helping him or her rest. (If you’re out and about, babywearing may also work well, if your baby is a fan.)
3. Don’t be surprised if your baby sleeps more than usual after receiving vaccinations.
A 2011 study found that 2-month-old babies slept an average of 69 minutes more in the 24 hours after shots compared with the 24 hours before.(11) Although the majority of babies slept more after shots, 37% of babies slept less, so don’t count on this! Babies were more likely to sleep more if they had a fever or were immunized later in the day, whereas those immunized in the morning actually slept less. Studies in adults have actually found that sleep deprivation after vaccination can reduce the immune response,(12,13) so it’s possible that longer sleep in infants might mean a better immune response – but this has yet to be tested (and quite frankly, it’s probably a stretch). But given all of this, it might be worth trying to schedule your baby’s shots for the afternoon, so that you’re less likely to have a long and fussy day and more likely to set your baby up for restorative sleep after shots.
4. There’s no need to medicate your baby before shots, but have acetaminophen on hand if needed for after shots.
Until a few years ago, doctors often recommended that parents give their babies acetaminophen (or paracetamol in some parts of the world) before receiving vaccines to reduce post-vaccination fever and other sources of discomfort. However, a randomized controlled trial conducted in the Czech Republic and published in the Lancet in 2009 called this practice into question.(14) In this study, 2-month-old babies were randomized to receive no acetaminophen or three doses of the medicine, the first dose just after receiving their scheduled vaccinations and the two following doses at 6-8 hour intervals. The same protocol was repeated when vaccines were received at 12-15 months. This study found that the babies that received prophylactic acetaminophen did indeed have a lower chance of experiencing fever, but they also had lower antibody concentrations in response to the vaccines. Most still reached the necessary thresholds for immunity, but the take-home message from this study is that treating preemptively before your child receives shots could reduce the efficacy of those vaccines.
This was an important study, but it also left many questions unanswered. It changed practice for some pediatricians, but others remained skeptical. For example, Drs. Michael Brady and Jack Swanson published this commentary in the AAP News: “Until other studies are available, pediatricians should be comfortable that this study’s results should not prevent the use of antipyretics either prophylactically or therapeutically for managing fever and discomfort. However, it might be appropriate to reconsider routine use of prophylactic antipyretics after all immunizations…”(15)
Since that 2009 study, more have been conducted, and these were summarized in a meta-analysis published in 2014.(16) The meta-analysis included 13 randomized controlled trials looking at how antipyretic (fever reducing) medications can affect vaccine side effects and/or antibody responses. Again, this analysis found that prophylactic acetaminophen reduced a range of minor side effects, including fever, local redness and swelling, and fussiness. And again, it also found that prophylactic acetaminophen reduced the antibody response after both the first dose and booster shots. The good news was that the antibody responses were still well above the level required for protection against disease, with or without acetaminophen. In other words, although antibody levels were lower from a statistical perspective, this may not make any perceptible clinical – or real world – difference in the efficacy of the vaccines.
Also included in that meta-analysis were two follow-up studies of the 2009 Czech study.(17,18) These studies measured colonization of the nasopharynx (the part of the throat that connects to the back of the nose) with the bacteria that cause pneumococcal disease and Haemophilus influenzae type b (Hib). Nasopharyngeal carriage of these bacteria is typically reduced by vaccination, which is one of the ways that immunization confers herd immunity, in addition to protecting vaccinated individuals. These follow-up studies looked at the same kids as the 2009 study but at 2 years and 3-4 years of age, and they found that whether or not acetaminophen was given at the time of vaccines in infancy did not significantly affect carriage rates.
What about ibuprofen? Ibuprofen should only be used in babies older than 6 months, and we have less data on its effect on vaccine responses. The meta-analysis mentioned above included one as-yet unpublished study that found that ibuprofen did reduce the pertussis antibody response after vaccination.(16)
So, what’s the take away from all of these studies, and what are we parents supposed to do? Although it doesn’t seem like acetaminophen will necessarily reduce the efficacy of vaccines, most pediatricians now recommend NOT giving it before shots. Wait and see if your child is actually experiencing significant discomfort after shots and try other comfort measures first (breastfeeding, holding, skin-to-skin, cool compresses). If those don’t work, then don’t be afraid to use acetaminophen to help your baby feel better. It’s always worth checking with your pediatrician or nurse’s help line about this decision.
5. Know that vaccinating your baby on time is the right thing to do.
It’s never easy to see your baby feel pain, no matter how brief. In that moment, know that you are absolutely making the right choice. As each dose of vaccine builds your baby’s immunity, you’re decreasing the chances of your baby getting sick. I sure was glad that BabyM had already had his first dose of DTap in March, when there were 4 cases of pertussis reported at an elementary school in our neighborhood. As a bonus, by vaccinating your child, you’re contributing to your local herd immunity, protecting the more vulnerable, such as younger babies and those whose medical conditions makes them unable to receive or respond appropriately to vaccines.
August is National Immunization Awareness Month. Let’s celebrate the fact that we get to be parents in the era of vaccines, and our children are protected from the pain and suffering, and even death, from so many serious diseases. There are a lot of parenting questions where we can debate what is right and where the science is still evolving, but this is one where the science is very clear. Vaccinating your baby on time is safe and effective, and with these tips, and it only has to hurt a tiny bit.
- Shah, V. et al. Pharmacological and Combined Interventions to Reduce Vaccine Injection Pain in Children and Adults: Systematic Review and Meta-analysis. Clin. J. Pain 1 (2015). doi:10.1097/AJP.0000000000000281
- Shah, P. S., Herbozo, C., Aliwalas, L. L. & Shah, V. S. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst. Rev. 12, CD004950 (2012).
- Moon, S.-S. et al. Inhibitory effect of breast milk on infectivity of live oral rotavirus vaccines. Pediatr. Infect. Dis. J. 29, 919–923 (2010).
- Ali, A. et al. Impact of Withholding Breastfeeding at the Time of Vaccination on the Immunogenicity of Oral Rotavirus Vaccine—A Randomized Trial. PLoS ONE 10, e0127622 (2015).
- Rongsen-Chandola, T. et al. Effect of withholding breastfeeding on the immune response to a live oral rotavirus vaccine in North Indian infants. Vaccine 32 Suppl 1, A134–139 (2014).
- Groome, M. J. et al. Effect of breastfeeding on immunogenicity of oral live-attenuated human rotavirus vaccine: a randomized trial in HIV-uninfected infants in Soweto, South Africa. Bull. World Health Organ. 92, 238–245 (2014).
- Taddio, A. et al. A randomized trial of rotavirus vaccine versus sucrose solution for vaccine injection pain. Vaccine 33, 2939–2943 (2015).
- Piira, T., Champion, G. D., Bustos, T., Donnelly, N. & Lui, K. Factors associated with infant pain response following an immunization injection. Early Hum. Dev. 83, 319–326 (2007).
- Schechter, N. L. et al. Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations. Pediatrics 119, e1184–e1198 (2007).
- Cohen, L. L. et al. Randomized clinical trial of distraction for infant immunization pain. Pain 125, 165–171 (2006).
- Franck, L., Gay, C. L., Lynch, M. & Lee, K. A. Infant Sleep After Immunization: Randomized Controlled Trial of Prophylactic Acetaminophen. PEDIATRICS 128, 1100–1108 (2011).
- Lange, T., Perras, B., Fehm, H. L. & Born, J. Sleep enhances the human antibody response to hepatitis A vaccination. Psychosom. Med. 65, 831–835 (2003).
- Miller, G. E. et al. Psychological stress and antibody response to influenza vaccination: when is the critical period for stress, and how does it get inside the body? Psychosom. Med. 66, 215–223 (2004).
- Prymula, 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 Lond. Engl. 374, 1339–1350 (2009).
- Brady, M. T. & Swanson, J. T. More study needed on antipyretics’ effect on vaccine responses. AAP News 31, 1–1 (2010).
- Das, R. R., Panigrahi, I. & Naik, S. S. The Effect of Prophylactic Antipyretic Administration on Post-Vaccination Adverse Reactions and Antibody Response in Children: A Systematic Review. PLoS ONE 9, (2014).
- Prymula, R. et al. Impact of the 10-valent pneumococcal non-typeable Haemophilus influenzae Protein D conjugate vaccine (PHiD-CV) on bacterial nasopharyngeal carriage. Vaccine 29, 1959–1967 (2011).
- Prymula, R., Habib, A., François, N., Borys, D. & Schuerman, L. Immunological memory and nasopharyngeal carriage in 4-year-old children previously primed and boosted with 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) with or without concomitant prophylactic paracetamol. Vaccine 31, 2080–2088 (2013).