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 Table of Contents  
Year : 2014  |  Volume : 28  |  Issue : 2  |  Page : 95-98

A study of 'cough trick' technique in reducing vaccination prick pain in adolescents

1 Department of Pediatrics, Subbaiah Institute of Medical Sciences and Research Centre, Shimoga, Karnataka, India
2 Department of Pediatrics, Rajarajeshwari Institute of Medical Sciences, Bengaluru, Karnataka, India
3 Department of Community Medicine, Subbaiah Institute of Medical Sciences and Research Centre, Shimoga, Karnataka, India

Date of Web Publication20-May-2014

Correspondence Address:
Vikram S. Kumar
Department of Pediatrics, Subbaiah Institute of Medical Sciences and Research Centre, Purle, HH Road, Shimoga - 577 222, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-5333.132847

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Background: The 'cough trick' (CT) technique is used in reducing intramuscular prick (IMP) pain during vaccinations and also for brief painful procedures like subcutaneous injection, intravenous cannulation, and so forth. We present the utility study of this technique in male adolescents. Materials and Methods: A Randomized Crossover Volunteer Study of 50 early adolescent male children (age 11-13) receiving immunizations was performed. Participants were recruited from four outpatient pediatric clinics. The strategy required a single "warm-up" cough of moderate force, followed by a second cough that coincided with needle puncture. The principle outcome was self-reported pain. Results: Paired 't' test revealed that the procedure was effective at a statistically and clinically significant level for participants. Children found the procedure acceptable and effective. Conclusions: The results of this study suggest that the CT can be an effective strategy for the reduction of pain for male adolescent children undergoing routine immunizations. However, additional research is needed with a larger sample size with different age groups and also including girl children.

Keywords: Adolescents, cough trick, intra muscular prick

How to cite this article:
Kumar VS, Budur SV, Odappa GH. A study of 'cough trick' technique in reducing vaccination prick pain in adolescents. Indian J Pain 2014;28:95-8

How to cite this URL:
Kumar VS, Budur SV, Odappa GH. A study of 'cough trick' technique in reducing vaccination prick pain in adolescents. Indian J Pain [serial online] 2014 [cited 2023 Mar 31];28:95-8. Available from: https://www.indianjpain.org/text.asp?2014/28/2/95/132847

  Introduction Top

The effectiveness of the cough trick (CT) as a method of pain relief during intramuscular prick (IMP) in a crossover study was tested. A total of 50 healthy male adolescent volunteers were pricked twice in the same hand after an interval of 4 weeks, once with the CT procedure and once without it. The intensity of pain and hand withdrawal was recorded. The intensity of pain during IMP with the CT procedure was less than without it, whereas the other variable changed insignificantly. CT can be easily performed and was effective in pain reduction during IMP, although the exact mechanism of pain relief remains unclear.

A number of methods to reduce IMP pain have been developed to optimize patient comfort and satisfaction. [1],[2] Various local anesthetics (LA), ethyl chloride, ice, or even distraction have all decreased IMP pain. Other strategies stimulate nerves in the skin near the injection site with a device or through pinching, rubbing, or stroking. Although they are effective, nearly all of the existing strategies require increased time, cost, and/or effort on the part of clinic staff members or patients. [3],[4],[5],[6],[7],[8],[9],[10],[11] There have been only a few studies of this technique of CT being used in childhood vaccination practice in western countries. [12],[13] To the best of our knowledge, there have been no studies from India about this method used for pain mitigation during vaccination. The patients are asked to cough simultaneously with IMP; this is called the "cough trick" (CT). The strategy can be taught easily and requires no additional cost, equipment, or staff time. Therefore, it may prove to be a practical strategy even in busy outpatient clinics. To verify the effectiveness of CT for pain relief during IMP, we performed a prospective, randomized, and crossover volunteer study in male adolescents.

  Materials and Methods Top

This study was approved by the local and institutional ethics committee. A total of 50 apparently healthy male adolescent volunteers 11-13-years old were recruited by the staff of our clinic. These ages were chosen because they represent healthcare visits in which children typically receive multiple immunizations [we have used tetanus toxoid-reduced diphtheria toxoid (Td) vaccine and typhoid polysaccharide vaccinations]. They were told that the aim of the study was to compare the intensity of pain during IMP with and without performing CT. An informed written consent from the parents and an assent form from the children were taken.

Because sex might influence pain sensitivity, female subjects were not included in the present study. [14],[15],[16] The other exclusion criteria were chronic consumption of analgesics, anticoagulants, or antiplatelet drugs; history of peripheral neuropathy; and abnormal skin conditions (infection, scars, psoriasis, or eczema) at the site of IMP. The subjects developing local IMP site complications post the first IMP were also excluded. The study was always conducted in the same room between 7:00 and 10:00 am to minimize the influence of circadian differences on pain sensitivity. [17]

To diminish situational anxiety, the subjects were asked to visit the study room before the IMP session. During this first visit, the ear lobule was pinched with fingers to make the subjects acquainted with the pain scoring on a 100-mm visual analog scale (VAS-100). On this scale, 0 mm indicates no pain and 100 mm indicates the worst imaginable pain. There is a large body of research supporting the reliability and validity of the VAS for children, and differences of ≥10 mm are generally accepted as clinically significant. [18],[19]

The subjects were randomly allocated into two groups depending on whether the IMP would be performed first with the CT and 4-weeks later without it (Group 1) or the other way around (Group 2). The first IMP session took place at least 3 days after the primary examination. During that session, the subjects were made to sit comfortably in a reclining chair and the non-dominant arm (the deltoid region) was clearly visualized, the subject was asked to turn his head in the direction opposite the side of the IMP. Then they were asked to perform a single cough of moderate intensity without moving their arms. Immediately after, the subjects were asked to cough again. IMP using a 1-inch long, 24-gauge needle and 2-ml disposable syringe was performed simultaneously with the second cough (CT during IMP). Care was taken to reinforce the practice of not moving the hand while coughing and simultaneously pricking. No subject was inadvertently injured or overpricked during the course of the study. In each subject, the same site was punctured twice after 4 weeks by the same investigator (injector). None of the volunteers had heard about the CT before. The effectiveness of blinding was verified by asking the volunteers after the second session whether they had any questions about the design of the study. The second investigator (assessor), who recorded the outcome measures, was blinded concerning whether the IMP was performed with CT or without it and left the room before the moment of IMP.

The subjects were asked to report the pain intensity at the moment of IMP to the assessor when he came in and showed them the VAS scale. Incidence of hand withdrawal was also recorded after each IMP. Using the data of our pilot observational study, the number of subjects was set at 50 to ensure statistically significant results. The results of pain measurement on the VAS-100 were analyzed with the Student's paired 't' test. P < 0.05 was considered statistically significant.

  Results Top

A total of 55 adolescent male volunteers (age 11-13 years) were enrolled and 50 completed the study. The intensity of pain on IMP with the CT procedure was less than without it in 47 subjects. Pain intensity in Group 1, which received the IMP without CT first, was more than IMP with CT. Pain intensity in Group 2, which received the IMP with CT first, was also less than IMP without CT. The intensity of pain in both groups taken together at IMP with CT was less than without the CT procedure. Only one person reported increased pain intensity on IMP with CT in comparison without without CT, and the other two found no difference between the two methods.

After applying the paired 't' test for the sample, the analysis showed that the results were statistically significant with P-value less than 0.0001 (t = 14.0, degrees of freedom (df) = 49). Results of mean and standard deviation (SD) of observations with and without CT is shown in [Figure 1]. The difference in the perception of pain with and without CT is shown in [Figure 2].
Figure 1: Results of mean and SD of observations with and without CT [without CT (mean = 54.9, SD = 8.66, 95% CI = 52.44-57.36); with CT (mean = 31.9, SD = 10.6, 95% CI = 28.88-34.92)] SD: Standard deviation, CT: Cough trick, CI: Confidence interval

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Figure 2: Shows the difference in the perception of pain with and without CT, CT: Cough trick

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  Discussion Top

These results suggest that the CT can be an effective strategy for the reduction of pain for some children undergoing routine immunizations. Children have varying degrees of distress, different histories of pain, and different experiences of effective coping with pain. [14],[15]

Our aim was to test the effectiveness of the CT in the reduction of pain during IMP in a randomized crossover study to justify its application in clinical practice. This technique is easily performed and not expensive, whereas the other methods of pain reduction for IMP require additional efforts by the staff, and some of them produce additional costs.

The effectiveness of the procedure may result from distraction (concentrating on coughing on cue), competing sensory stimuli (noise and feeling of the cough), competing physiologic stimuli (e.g. increased pressure in the subarachnoid space or increased blood pressure), or some combination of these factors. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] The strategy can be taught easily and requires no additional cost, equipment, or staff time. Therefore, it may prove to be a practical strategy even in busy outpatient clinics. [10],[11],[12]

Distraction is a well-known cognitive method of pain reduction through the direction of attention to a non-noxious stimulus in the immediate environment. However, the results of the studies on IMP pain relief using distraction are controversial. [1],[2]

There were a few limitations during the course of the study that were taken care of properly. Some children, after learning that the injection would not occur until they coughed, delayed their cough or refused to comply, apparently to avoid the injection. On the contrary few children who thought CT would decrease the pain wanted and preferred to do it again after the crossover.

The prospective power analysis indicated that this would be an adequate sample from a statistical standpoint, the small number of participants somewhat limits the external validity of these findings. Young children more than 6 years of age and females were not recruited who form a chunk of vaccinees.

Conversely, the study is strengthened by the use of a within-subject design that, statistically, allows for greater power and more confidence in observed results. This design is of particular utility in the present study because it controls for the inherently subjective nature of pain ratings. Because each participant served as his or her own control, the results provide a clearer picture of the actual effect of the procedure on individually perceived pain.

  Conclusion Top

In conclusion, in this study the CT procedure was effective in IMP pain reduction in male adolescents, although the mechanism remains unclear. Nevertheless, it is an easily performed and inexpensive method for reducing pain during IMP in clinical practice.

  Acknowledgements Top

Dr. D. Y. Baddi, Consultant pediatrician, Chirayush Children's Hospital, Shimoga. Dr. H. V. Kotturesha Rasthapuramath, Consultant Pediatrician, Kotturesha Maternity and Children's nursing home, Shimoga.

  References Top

1.Schechter NL, Zempsky WT, Cohen LL, McGrath PJ, McMurtry CM, Bright NS. Pain reduction during pediatric immunizations: Evidence-based review and recommendations. Pediatrics 2007;119:e1184-98. Available from: http://www.pediatrics.org/cgi/content/full/119/5/e1184 [Last accessed on 2014 Feb 16].  Back to cited text no. 1
2.DeMore M, Cohen LL. Distraction for pediatric immunization pain: A critical review. Clin Psychol Med Settings 2005;12:281-91.  Back to cited text no. 2
3.French GM, Painter EC, Coury DL. Blowing away shot pain: A technique for pain management during immunization. Pediatrics 1994;93:384-8.  Back to cited text no. 3
4.Cassidy KL, Reid GJ, McGrath PJ, Finley GA, Smith DJ, Morley C, et al. Watch needle, watch TV: Audiovisual distraction in preschool immunization. Pain Med 2002;3:108-18.  Back to cited text no. 4
5.Sparks L. Taking the "ouch" out of injections for children: Using distraction to decrease pain. MCN Am J Matern Child Nurs 2001;26:72-8.  Back to cited text no. 5
6.Drago LA, Singh SB, Douglass-Bright A, Yiadom MY, Baumann BM. Efficacy of ShotBlocker in reducing pediatric pain associated with intramuscular injections. Am J Emerg Med 2009;27:536-43.  Back to cited text no. 6
7.Cohen Reis E, Holubkov R. Vapocoolant spray is equally effective as EMLA cream in reducing immunization pain in school-aged children. Pediatrics 1997;100:E5. Available from: http://www.pediatrics.org/cgi/content/full/100/6/e5 [Last accessed on 2014 Feb 16].  Back to cited text no. 7
8.Uman LS, Chambers CT, McGrath PJ, Kisely S. Psychological interventions for needle related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev 2006:CD005179.  Back to cited text no. 8
9.Cohen LL, Bernard RS, Greco LA, McClellan CB. A child-focused intervention for coping with procedural pain: Are parent and nurse coaches necessary? J Pediatr Psychol 2002;27:749-57.  Back to cited text no. 9
10.Blount RL, Bachanas PJ, Powers SW, Cotter MW, Franklin A, Chaplin W, et al. Training children to cope and parents to coach them during routine immunizations: Effects on child, parent, and staff behaviors. Behav Ther 1992;23:689-705.  Back to cited text no. 10
11.Movahedi AF, Rostami S, Salsali M, Keikhaee B, Moradi A. Effect of local refrigeration prior to venipuncture on pain related responses in school age children. Aust J Adv Nurs 2006;24:51-5.  Back to cited text no. 11
12.Usichenko TI, Pavlovic D, Foellner S, Wendt M. Reducing venipuncture pain by a cough trick: A randomized crossover volunteer study. Anesth Analg 2004;98:343-5.  Back to cited text no. 12
13.Nevin K. Influence of sex on pain assessment and management. Ann Emerg Med 1996;27:424-6.  Back to cited text no. 13
14.Sheffield D, Biles PL, Orom H, Maixner W, Sheps DS. Race and sex differences in cutaneous pain perception. Psychosom Med 2000;62:517-23.  Back to cited text no. 14
15.Wallace DP, Allen KD, Lacroix AE, Pitner SL. The "cough trick": A brief strategy to manage pediatric pain from immunization injections. Pediatrics 2010;125:e367-74.  Back to cited text no. 15
16.Myers CD, Tsao JC, Glover DA, Kim SC, Turk N, Zeltzer LK. Sex, gender, and age: Contributions to laboratory pain responding in children and adolescents. J Pain 2006;7:556-64.  Back to cited text no. 16
17.Procacci P, Corte MD, Zoppi M, Maresca M. Rhythmic changes of the cutaneous pain threshold in man. A general review. Chronobiologia 1974;1:77-96.  Back to cited text no. 17
18.Powell CV, Kelly AM, Williams A. Determining the minimum clinically significant difference in visual analog pain score for children. Ann Emerg Med 2001;37:28-31.  Back to cited text no. 18
19.Stinson JN, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain 2006;125:143-57.  Back to cited text no. 19


  [Figure 1], [Figure 2]

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