To our knowledge, this is the first systematic review of videos posted on YouTube of infants undergoing immunization. The reasons for which parents post such videos of their infants undergoing immunizations are not known, and we did not seek to uncover motives for these posts. We aimed to conduct a systematic review of YouTube videos to gather evidence on the use of recommended pain management strategies, and to conduct pain assessments using crying duration and FLACC, the composite validated pain assessment tool. We found that most infants were highly distressed during the injections. This is disappointing given that strong evidence clearly shows the pain-reducing effects of breastfeeding infants
[18–20, 35], sweet solutions
[17, 36], using nurse/clinician-led distraction and upright holding
[3, 22, 23] and given the work that has gone into translating this knowledge to the public and health care profession
[3, 37]. It is however possible that the pain control measures apparent during vaccinations as seen in the posted videos are not representative of all vaccinations, as the act of videotaping precludes holding the infant, breastfeeding or administering sucrose unless a tripod or third party is available to operate the camera. However, the observed infrequent use of recommended pain management strategies are concordant with results of published surveys of health care professionals’ pain management practices during immunization
[4, 7, 25, 26] as well as a recent observational study of pain management practices in infants during immunization
. This highlights that, so far, current evidence and guidelines relating to pain management strategies, most of which has been available prior to the date of the first YouTube posting, have been unsuccessful in changing immunization pain practices. It is not known whether this is an issue of reach, and therefore a lack of knowledge concerning best pain management practices, or whether this information is known, but not used by the multitude of different groups of immunizers and parents of infants. However, it is impossible to know when parents produced the videos and it is possible that some of the videos were filmed prior to the publication and dissemination of recommended evidence-based pain management practices. Regardless, a state of play exists currently where information is known, but is inconsistently used in clinical practice
[4, 7, 25, 26, 38].
Taddio et al. attributed suboptimal pain management during childhood immunization to lack of parental knowledge about pain, health care professional attitudes to pain severity and effective pain management, and societal attitudes about pain including dismissing the impact of needle pain
. Taddio et al. also presented a number of myths concerning barriers to using effective pain management strategies for infants. Myths concerning using breastfeeding for pain management include beliefs that the infants will choke, or associate the mother with pain and myths concerning sucrose include interfering with breastfeeding and damaging infants’ teeth. Myths concerning the need to provide pain management strategies include that infants cry anyway; they need to cope with pain; and they get used to shots (Pages S160- S161
). Pillai-Riddel et al. suggests that despite the knowledge health care professionals have about short-term pain and distress-reducing benefits of strategies such as breastfeeding and sweet solutions, they may not believe that putting these pain-reducing strategies into place is a clinical priority, as there is little known about the long term benefits of reducing childhood immunization pain
. This belief exists in the face of clear and extensive descriptions about high levels of distress infants exhibit during immunizations
[38, 40] and the fact that parents may avoid having their children immunized due to concerns about pain
. Additional barriers may be due to availability of commercially manufactured sucrose in diverse settings where immunizations take place and no knowledge to make home-made sucrose; cost factors such as purchase cost of topical anesthetics; organizational factors such as privacy for breastfeeding, or perceived increased ease of vaccinating if the infant is lying on an examination table as opposed to being held.
Although our findings of high levels of distress may be influenced by the proportionally larger number of videos showing 2-month old infants, who may exhibit higher levels of distress than older infants
, infants of all ages can become distressed during immunizations
[38, 40]. There is a high prevalence of fear of needles in children, which could likely have developed as a result of the painful injections in infancy
[2, 4, 7, 8, 42]. These concerning factors highlight the need for health care professionals and parents of infants and young children to work together to reduce the pain of childhood vaccinations. Although our results, consistent with previous research, show that parental talking, singing and reassurance, is commonly used (for example, talking or singing was observed in 66% the videos), and most parents instinctively use reassurance, this has been shown to lead to higher exhibition of pain behaviors
. This may also account for the high levels of distress as observed in the majority of infants in this study, highlighting that health care professionals need to support parents to provide effective pain management strategies.
YouTube may be a promising medium for disseminating knowledge to health care professionals and parents. The YouTube website attracts over 2 billion views daily
, and its use as a knowledge translation forum for researchers and health professionals is growing in popularity. In this systematic review of YouTube videos of infant immunizations, we used YouTube as the source of information to study – i.e., the ‘participants’ are the posted YouTube videos. Other topics relating to pediatric health care that have been researched using YouTube include information on the management of burn injuries
, information on tonsillectomy
, and dental fear and anxiety
. Topics researched using YouTube in adults include concussion
, inflammatory bowel disease
 and anorexia
. To facilitate the use of YouTube as an information source, Sampson et al. published a review on the methods used to undertake reviews of YouTube
One example of health care professionals using YouTube as a medium for information sharing with consumers is the Canadian Institutes of Health Research (CIHR) funded HELPinKIDS team’s utilization of YouTube for disseminating knowledge about effective pain management strategies for infants during childhood immunizations. In 2012 the team posted a comprehensive educational YouTube video discussing a variety of pain management strategies, including the use of breastfeeding, sucrose and secure front-to-front holding (HELPinKIDS Managing Infant Pain
https://www.youtube.com/watch?v=jxnDc2PxGUc&list=PLJH3y0duq2ZEQ_KkfKVkcLwZUk3HPV6xj&index=1). The video is over 8 minutes in duration, considerably longer than the typical videos posted on YouTube by parents. Since posting to YouTube in November 2012, the video had 4,869 hits in 12 months (as of November, 13, 2013). The impact of this teaching video is not yet known. However, compared to some other YouTube videos showing infants vigorously crying during their injections, the HELPinKIDS educational video has had much fewer hits, highlighting that attention seems to be drawn to the consumer posted videos showing crying infants, rather than the instructional video highlighting how to reduce pain during immunizations. This highlights the need for health care professionals and researchers wishing to utilize YouTube as a knowledge translation and dissemination tool to understand the most effective ways to ensure popularity, when practice change is a goal.
There are several limitations to this study. Consumers posted all videos with no pre-set standards for rigor or quality. A systematic review of such varying quality videos is therefore acknowledged to be less rigorous than a systematic review of published RCTs. Not all videos were of sufficient quality for analysis. For example, in 26 videos, we were not able to sufficiently see the infants to determine FLACC scores at baseline, and, in eight videos, we could not determine FLACC scores at the time of first injection. In 22 cases, pain management strategies used after completion of the injection could not be visualized due to the video footage ending as soon as the injections were completed. Furthermore, it was often impossible to determine if the vaccine administration technique and the order of vaccine administration was in accordance with current recommended guidelines (i.e. rapid injection technique with no aspiration and most painful injection administered last)
, which are known to impact pain responses
[50, 51]. In addition, as stated above, it is impossible to know when the videos were filmed, and it is possible that some videos may have been produced years prior to the availability of knowledge translation products and recommended evidence-based pain management practices.
Another limitation in conducting a systematic review of consumer posted videos on YouTube relates to the risk of ‘posting’ bias. The pain management strategies used in the reviewed videos may not be representative of all vaccinations for two reasons. First, as previously discussed, the act of videotaping precludes the use of pain management strategies such as holding the infant, breastfeeding or administering sucrose unless a tripod or third party is available to operate the camera. Second, caregivers who used pain management strategies, most notably breastfeeding, may not be comfortable choosing to have the procedure video recorded and posted publicly.