Who’s Afraid of Needles?

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Patient Presentation
A 7-year-old male came to clinic for treatment of possible needle phobia. He had received a vaccine at another facility and had required multiple providers to restrain him to complete the procedure. His mother described an escalation of a fear of needles over at least 2 years. He did not have other fears in other settings nor was he described as an anxious child. He said he didn’t like thunderstorms because of the noise but wasn’t worried about them. A chart review did not show any previous mental health or behavioral concerns, but he did have a laceration 2 years previously that needed stitches which the mother described as “not going well.” The child was obviously distressed by the vaccine incident and expressed remorse for the extreme acting out. He said, “I know it’s okay but I just couldn’t stop.” The family history was positive for an aunt with anxiety and depression who was treated with medication and therapy.

The pertinent physical exam revealed a child who was hyperalert. He was very concerned when the doctor cleaned his stethoscope with an alcohol pad, and had to be shown several times that the physician had nothing in his hands so he would move to the examination table. Otherwise he was a very cooperative, pleasant child who could be distracted during the examination which was also normal.

The diagnosis of a child with an extreme needle fear or possible phobia was made. The physician described the natural history where needle fears usually decrease with age. However, the mother and the boy expressed concern about escalating fears, and the need for additional vaccines soon. The pediatrician recommended a therapist to teach additional coping skills and if needed additional therapies, in addition to briefly discussing procedural pain options for the future.

Discussion
There are products that are valued highly because of their design and function are elegantly suited for their use. Books would be one example and the hypodermic needle is another. Medical hypodermic needles are used for accessing bodily spaces (e.g. vascular, peritoneal, subarachnoid, dermal, etc.), obtaining specimens (both solid tissue and liquid) and to deliver drugs, biologicals, fluids and other treatments to patients. Medical procedures involving some type of needle are the most common procedures taught to health care providers. A brief history of syringes and hypodermic needles can be found here. A variety of medical artifacts and online books can be found in the Wellcome Collection here.

The major con of hypodermic needles is pain. Physiological pain from the actual needle, the drug delivered or associated procedure. Psychological pain from anticipation or previous experience. Pain management can be divided into 5Ps:

  • Physical – provide techniques known to decrease pain such as application of cold or vibration near the injection site, or anesthetic skin cream prior to venipuncture
  • Pharmacological – adding a buffering or anesthetic solution to the drug to decrease burning sensation
  • Procedural – provide all procedures simultaneously if possible such as coordinating multiple surgeries and providing vaccination while under anesthesia
  • Psychological – provide education or distraction before, during and after the procedure, provide emotional support with a family member or favorite toy
  • Process – decrease drug delivery rate, use smallest needles possible including microneedles, or a non-needle option (e.g. jet injector, mucosal or oral administration)

Learning Point
Fears are unpleasant emotions with behavioral, cognitive and psychological components that are in response to a recognized source. They are often protective and keep people safe within their environment. These can but generally do not cause persistent problems with functioning. Phobias have a persistent dread and preoccupation with the source. They cause persistent problems with functioning.

Needle fear occurs almost 100% in young children and decreases with age. In a systematic review, they decreased to ~30% by age 20. Overall rate of fear of needles in the adult population is ~20% with phobia felt to be around 3.5-10%. While fear and phobia does decrease, the age of onset is thought to be between 5-10 years for adults with needle fear and phobia. Patients (~80%) with phobia have a first-degree relative with phobia. Needle fear and phobia prevalence is greater in girls and women than in boys and men and this was consistent regardless of country origin. Patients who require injections because of their disease have high rates of needle fear and phobia (i.e. cancer treatment 15-84%, diabetes 1-42% and routine dental procedures (2-91%).

Some people may also have fears which are related to the general procedure process rathen than the specific needle itself and this causes problems in needle-related settings. Examples include anticipation of possible hypoglycemia with insulin injection or worry about vasovagal syncope recurrence after a previous event with a needle-based procedure. Some people fear the need to be restrained too for suturing or a similar procedure.

Needle fear and phobia can cause patients to put-off or decline care especially vaccination preventative care. Even health care workers are not immune with a systematic analysis finding 27% of hospital workers and 18% of long-term care facility workers avoiding influenza vaccine because of this fear.

Treatment for excessive fear and phobia can include short acting benzodiazepines or nitrous oxide, education, coaching, relaxation techniques, distraction, hypnosis and exposure-based interventions.

Questions for Further Discussion
1. What is dry needling and how is it used? A review can be found here
2. How does acupuncture work?
3. What techniques do you employ in your setting to decrease needle fears?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Phobias and Anxiety.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

McMurtry CM, Pillai Riddell R, Taddio A, et al. Far From “Just a Poke.”” Clin J Pain. 2015;31(Suppl 10):S3-S11. doi:10.1097/AJP.0000000000000272

Luo L, Lai C. Needle Phobia: A Vasovagal Response During Acupuncture. AFP. 2016;94(12):1002-1002.

Susam V, Friedel M, Basile P, Ferri P, Bonetti L. Efficacy of the Buzzy System for pain relief during venipuncture in children: a randomized controlled trial. Acta Biomed. 2018;89(Suppl 6):6-16. doi:10.23750/abm.v89i6-S.7378

Orenius T, LicPsych, Saila H, Mikola K, Ristolainen L. Fear of Injections and Needle Phobia Among Children and Adolescents: An Overview of Psychological, Behavioral, and Contextual Factors. SAGE Open Nurs. 2018;4:2377960818759442. doi:10.1177/2377960818759442

McLenon J, Rogers MAM. The fear of needles: A systematic review and meta-analysis. J Adv Nurs. 2019;75(1):30-42. doi:10.1111/jan.13818

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Published