Vaccine shots don’t have to hurt: new guidance targets fear and pain

Clinical takeaway: Clinicians and vaccination programs should routinely incorporate evidence-based distress-reduction strategies, including rapid injections without aspiration, topical anesthetics, age-appropriate distraction techniques, and the CARD (Comfort-Ask-Relax-Distract) framework, while allowing patients and caregivers to choose the approaches that work best for them.

The 2026 CMAJ guideline reframes vaccination distress as a predictable, manageable consequence—not an unavoidable part of immunization. Its 16 recommendations span the “5Ps”: process, procedural, physical, pharmacologic, and psychological interventions.

Vaccination programs should educate clinicians, recipients, caregivers, and organizations about distress reduction and embed these measures into routine workflows. The CARD system (Comfort, Ask, Relax, Distract) provides a practical framework for selecting strategies before and during vaccination.

For all ages, clinicians should inject rapidly without aspiration and, when administering multiple vaccines, give the least distressing vaccine first. Reducing exposure to needles and other fear cues is also suggested.

For infants aged 12 months and younger, recommended options include breastfeeding, bottle-feeding, sweet-tasting oral solutions, pacifiers, topical anesthetics, and distraction with toys or singing. For older children and adults, topical anesthetics are recommended, while music, videos, digital games, virtual reality, and other distraction techniques may also help reduce distress.

Topical anesthetics should be offered across the lifespan. For infants, topical lidocaine-prilocaine, lidocaine, or tetracaine preparations, or manual tapping, are strongly recommended; adults and children older than 12 months should also be offered topical anesthetics and allowed to choose whether to use them.

Music is strongly recommended as a distraction option for adults and children older than 12 months. Digital or nondigital games, virtual reality, toys, videos, and toy-assisted breathing may also be offered, while verbal distraction, simple breathing maneuvers such as coughing, and memory reframing are not suggested.

Oral analgesics should not be used to prevent injection distress because benefit has not been demonstrated and they may interfere with the effectiveness of some vaccines. The guideline also advises eliminating routine alcohol skin antisepsis before vaccination, while supporting comfort positioning, caregiver presence, and muscle-tension techniques for people prone to fainting.

“Fear and pain—together referred to as distress—are among the most common negative effects of vaccine injections,” said lead author Dr. Anna Taddio. “Research shows there are effective ways to reduce distress, but these strategies are still not routinely built into vaccination programs or practices.”

What's changed

• Reorganizes recommendations around the updated 5P (process, procedural, physical, pharmacologic, psychological) framework.
• Places greater emphasis on patient and caregiver choice when selecting distress-reduction interventions.
• Expands support for implementation tools such as the CARD system to integrate distress-reduction strategies into vaccination programs.
• Incorporates newer evidence supporting rapid injection techniques, minimizing exposure to fear cues before vaccination, and broader use of topical anesthetics across age groups.

Source: Taddio A, et al. (2026 Sep 21) CMAJ. Reducing distress during vaccine injections: 2026 clinical practice guideline update