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Moshe Ipp, MBBCh; Patricia C. Parkin, MD; Naomi Lear, MD; Morton Goldbach, MD; Anna Taddio, PhD

Arch Pediatr Adolesc Med. 2009;163(5):469-472.

Objective  To determine if acute pain response after administration of the diphtheria, polio, and tetanus toxoids and acellular pertussis and Haemophilus influenzae type b (DPTaP-Hib) vaccine and the pneumococcal conjugate vaccine (PCV) is affected by the order in which they are given.

Design  Single-center, double-blind, randomized clinical trial.

Setting  Outpatient pediatric clinic in Toronto, Ontario, Canada.

Participants  Healthy infants 2 to 6 months of age undergoing routine immunization.

Interventions  Infants received either their primary DPTaP-Hib vaccine or the PCV first, followed by the other vaccine.

Main Outcome Measures  The primary outcome was infant pain during vaccine injection as assessed by a validated measure, the Modified Behavioral Pain Scale (MBPS), using videotaped recordings of the procedure. In addition, parents rated pain using a 10-cm visual analog scale (VAS). Crying (yes/no) was also measured.

Results  The study was conducted between July 21, 2006, and June 21, 2007. A total of 120 infants participated: 60 received the DPTaP-Hib vaccine first and 60 received the PCV first. Infant characteristics did not differ between groups. Overall mean (SD) pain scores per infant after receiving both vaccine injections were significantly lower when DPTaP-Hib was administered first compared with when PCV was administered first (MBPS score, 7.6 [1.5] vs 8.2 [1.5], P = .037; parent VAS score, 4.2 [2.3] vs 5.6 [2.6], P = .003). When given first, the DPTaP-Hib vaccine caused significantly less pain (P < .001) than the PCV, as assessed by the MBPS, VAS, and crying.

Conclusions  Pain was reduced when the DPTaP-Hib vaccine was administered before the PCV in infants undergoing routine vaccination. We recommend that the order of vaccine injections be the DPTaP-Hib vaccine followed by the PCV.

Trial Registration  clinicaltrials.gov Identifier: NCT00390130

Author Affiliations: Department of Paediatrics (Drs Ipp, Parkin, and Goldbach) and Paediatric Outcomes Research Team (Drs Ipp and Parkin), Division of Paediatric Medicine, The Hospital for Sick Children, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute (Drs Ipp, Parkin, and Taddio), and Faculty of Medicine (Dr Lear) and Leslie Dan Faculty of Pharmacy (Dr Taddio), University of Toronto, Toronto, Ontario, Canada.

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