Vaccination is one of the most common painful procedures in infants. (1). Painful events such as vaccination is repeated and uncontrolled. Pain can cause short- and long-term effects in infants. (2). Its short-term effects include a delay in wound healing, a change in immunity system function, endocrine and biochemical changes, increased cortisol and catecholamine release, increased glucagon, growth hormone, aldosterone, rennin, and antidiuretic hormones, and decreased insulin secrection. They also include physiological changes such as apnea, bradycardia, tachycardia, skin color changes, hypertension, sweating palms, increased reased respiration rate and muscular tonicity, increased intracranial pressure and axygen intake, and behavioral changes, crying, ect (3). The studies have shown that uncontrolled pain experienced during early life has negative and long-term side effects, such as distress (4), and such experiences negatively affects the development of the central nervous system (5). It is therefore important that the number of painful stimuli be kept to a minimum, and that these stimuli are rendered less painful during this period for each procedure (6). The purpose in pediatric pain management is to reduce physiological and behavioral causes, to reduce intensity and duration of pain to minimum, to lessen the risk, and to give maximum benefits (7).

Nowadays various methods are used to reduce procedural pain in the newborn. Pharmacological and non-Pharmacological methods are used to relieve pain in newborn (2, 8). Non-pharmacological methods are alternatives for pain control, which implement small non-invasive attempts to reduce the pain. Position change, kangaroo care and touch, massage, teat giving, sucrose giving, breastfeeding, playing music, reducing distractions, and personalized developmental care are among these methods (2, 8, 9). In addition, methods such as distracting (10), cold application (11), massage (12, 13), vibration (11, 14) injection technique, and manual pressure application (15, 16) are used to reduce pain during invasive attempts.

Flick application at the injection area could be used to control pain during childhood (17). It was proven that applying manual pressure to the injection area (having a similar effect to the flick method) reduced injection pain (15, 16, 18). However, a response to the flick method had not been detected yet.

The purpose of this research was to examine the effect of flick application on reducing pain and duration of crying in infants during vaccination.

It was detected that, in experimental group, pain scores were lower than control group before, during, and after operation. Infants’ pain score average differences before, during, and after operation were found statistically significant. Similarly, pain score average differences of infants in experimental and control group before, during, and after operation were found statistically significant.

In addition, in experimental and control groups, pain score average comparison within group before, during, and after operation was carried out, and it was detected that there was no significant difference in pain score average before operation (p > 0.05), but there was significant difference in pain score average during (p < 0.01), and after (p < 0.001) operation.

Pain in neonates is a complicated event, which is frequent and difficult to evaluate. It was believed that neonates and infants do not feel any pain, whereas numerous studies have shown that they feel more pain than children and adults (24). Nowadays various methods are used to reduce procedural pain in the newborn. Some nonpharmacological methods of stopping pain are touching, giving position, skin stimulation, heat and cold application, teat giving, breastfeeding, kangaroo care, and sucrose giving (25).

This study was conducted with an objective of providing an alternative to other prevalent nonpharmacological methods and to define the effect of flick application on pain during vaccination. The results of this study indicated that there was no significant difference in mean pain score between infants in the experimental and control groups before vaccination (p > 0.05), but there was a significant difference in mean pain score during (p < 0.01) and after the procedure (p < 0.001).

It is identified that flick application is among the effective methods for controlling pain during childhood (17). In concurrence with other studies, we found that flick application was effective in reducing pain during vaccination. The effect of manual pressure application, which has a similar effect to flick application, has also been examined in some studies. In the studies of Yavuz (2011), Barnhill et al (1996), Chung and Wong (2002), it was detected that manual pressure to the injection area prior to vaccination reduces injection pain (15, 16, 18). Furthermore, in the study of Uğurlu (2011), in which the effect of massage during vaccination was studied, it was observed that the pain scores of infants in an experimental group were lower than those in a control group during and after the operation. In the light of these results, it is suggested that massage is effective in reducing pain, and as the massage continues, the level of pain decreases (12).

The reduction of pain through skin stimulation is based on the Gate Control Theory, which was suggested by Wall and Melzack in 1965, and is still an accepted theory (26). In this theory, the presence and severity of pain depends on the passage of neurological stimulations and pain signals are transported on small fibers. The large fibers are stimulated through massage, rubbing, and pressure and the small fibers are prevented from transporting signals. As there are numerous large fibers in the skin, most touching stimulations have the potential to reduce pain (13, 27, 28). This theory explains the possibility that manual pressure and massage can reduce pain. As flick application conveys a similar stimulus, its effect on reducing pain can also be explained by Gate Control Theory.

According to a literature survey, research concerning the effect of flick application on reducing pain during vaccination has not yet been conducted in Türkiye or worldwide. The current study is the first to investigate this topic. Crying is an important indicator of pain for infants as it is their only means of communication and, among the behavioral methods, it is accepted as a practical method to evaluate the severity and duration of pain (2, 29).

In the current study, no statistical significance was detected regarding duration of crying between the experimental and control groups; however it was noted that infants in the experimental group cried for shorter periods than those in the control group. In the study of Uğurlu and Başbakkal (2011), similarly, it was found that infants in an experimental group cried for shorter time-periods than those in a control group (12). In the same study, a significant difference in average duration of crying was detected between the control and experimental groups (p < 0.05). In the study of Razek and El-Dain (2009), in which the effect of breastfeeding on reducing vaccine pain was studied, total duration of crying was 125 ± 12 sec for infants in an experimental group and 148 ± 13 sec for infants in a control group (30).

Results indicated that the severity of pain was decreased for infants who were flicked on the vaccination area before immunization; thus, flicking before vaccination is probably effective in reducing pain and decreasing the duration of infant crying during vaccination in primary care health institutions. Finally, flicking before vaccination can be an easy to perform, guick, safe and inexpensive “add on” to other techniques in the management of vaccination pain. Furthermore, it is suggested that this study should also be performed in older groups and with larger sample sizes.