Table 3:

Interventions without sufficient evidence to make a recommendation regarding their use to reduce pain during vaccine injections in children

Clinical question	Recommendation	Level of evidence*	Grade of recommendation*
Injection procedure
Among children undergoing vaccination, does (1) application of a vapocoolant spray or (2) application of ice or a cool/cold pack on the skin before injection of vaccine reduce pain at the time of injection?	For children undergoing vaccination, there is insufficient evidence for or against the use of skin-cooling techniques (vapocoolants, ice, cool/cold packs) to reduce pain at the time of injection	I	I
Among children undergoing vaccination, does simultaneous injection by two vaccination providers cause less pain at the time of injection than sequential injections by the same provider?	For children undergoing vaccination, there is insufficient evidence for or against the use of simultaneous injections rather than sequential injections to reduce pain at the time of injection	I	I
Route of administration
Among children undergoing vaccination, for vaccines that can be administered intramuscularly or subcutaneously, does administering the vaccines intramuscularly, rather than subcutaneously, cause less pain at the time of injection?	For children undergoing vaccination, there is insufficient evidence to recommend for or against the use of a specific route of administration for vaccines that can be administered intramuscularly or subcutaneously to reduce pain at the time of injection	I	I
Pharmacotherapy
Among children undergoing vaccination, does administration of acetaminophen or ibuprofen before the injection reduce pain at the time of injection?	For children undergoing vaccination, there is currently no demonstrated benefit of administering acetaminophen or ibuprofen to reduce pain at the time of injection	III	I

^*Levels of evidence and grades of recommendation are defined in Table 1.