Clinical Practice Guideline: Needle-Related or Minor Procedural Pain in Pediatric Patients

Effects of blowing pinwheel and cough trick on pain in 6- to 12-year-old children during venipuncture: A randomized controlled trial

PURPOSE

To assess the effects of the blowing pinwheel and cough trick techniques on pain scores in children aged 6 to 12 years during venipuncture.

DESIGN

A randomized controlled study.

METHOD

A total of 105 children were allocated into three groups: blowing pinwheel (n: 35), cough trick (n: 35), and a control group (n: 35). Following venipuncture, pain scores were obtained from children's self-reports, parents' reports, and the nurse who carried out the venipuncture, using the Wong-Baker Faces Pain Rating Scale (FACES), Visual Analog Scale (VAS), and Face, Legs, Activity, Cry, Consolability (r-FLACC) scale, respectively.

RESULTS

Post-venipuncture pain assessments indicated that children in the blowing pinwheel and cough trick groups experienced significantly lower pain intensity compared with the control group (VAS: p < .001, r-FLACC: p < .001, FACES: p < .001). Analysis of effect sizes revealed that the cough trick group demonstrated a more substantial effect than the blowing pinwheel group. Comparable findings were observed across the VAS, r-FLACC, and FACES pain scales.

CONCLUSIONS

These findings suggest that distraction techniques, particularly the cough trick, effectively reduce pain perception in children undergoing venipuncture.

PRACTICE IMPLICATIONS

This study underscores the importance of incorporating distraction techniques, such as blowing pinwheel and the cough trick, into pediatric pain management protocols for venipuncture, thereby improving children's pain experiences.

CLINICAL REGISTRATION

This study was registered at the U.S. National Library of Medicine Clinical Trials (code: NCT06230601).

Children's fear, pain, and anxiety before and after enema: A descriptive, cross-sectional study

AIMS AND OBJECTIVES

The study aimed to determine the fear, pain, and anxiety levels of children aged 7-18 years before and after enema.

METHOD

This descriptive and cross-sectional study was conducted between January 8 and May 3, 2024. STROBE guidelines were followed in the study. The sample of the study consisted of 160 children between the ages of 7-18 who underwent enema. The data were collected using the Children's Fear Scale (CFS), Wong-Baker FACES® Pain Rating Scale (WBS) and Children's Anxiety Meter-State (CAMS) for Children. p-value less than 0.05 was considered statistically significant. Descriptive statistics tests, independent sample t-tests, and repeated measures ANOVA were used.

RESULT

Before the enema, children's fear (2.19 ± 1.09) and pain scores (2.94 ± 1.08) were high and anxiety scores (3.60 ± 1.81) were low. There was no statistical difference between fear, pain, and anxiety levels according to some sociodemographic and clinical characteristics (p > 0.05). After the enema, children's fear (2.49 ± 1.34), pain (2.94 ± 1.35) and anxiety scores (3.88 ± 2.22) increased. However, only the increase in fear level was statistically significant (p > 0.05). There was a negative correlation between the child's age and the level of fear, pain, and anxiety.

CONCLUSIONS

An enema is a medical procedure that causes negative emotions for children, such as fear and pain, before and after it is administered. Nursing interventions are needed before and during the enema.

PRACTICE IMPLICATIONS

The high levels of fear, pain, and anxiety associated with enemas suggest the need for routine assessment and nursing interventions to control these negative emotions.

Local analgesia for the relief of pain in children undergoing venipuncture and intravenous cannulation: a systematic review and network meta-analysis

BACKGROUND

Venipuncture and intravenous cannulation are common procedures in hospitals that often cause pain, particularly in children. Despite the availability of various local analgesia methods to alleviate needle-associated pain, the most effective approach remains unknown. The objective of this study is to compare and rank the efficacy of different local analgesia methods in reducing pain in children undergoing venipuncture and intravenous cannulation.

METHOD

Six databases including PubMed, Embase, CINAHL, Scopus, Web of Science, and the Cochrane Library were searched from January 1,1990 to December 1,2024. The primary outcome is the self-reported pain. We assessed the certainty of the body of evidence from the NMA for the primary outcome based on CINeMA.

RESULT

40 RCTs consisting of 4481 children and 9 local analgesia methods were included in the analysis. Results showed that vapocoolant spray was no more effective than placebo or routine care in reducing needle-associated pain in children. Other interventions including EMLA cream, lidocaine cream, lidocaine iontophoresis, amethocaine, needle-free lidocaine injection system, EMLA patch, lidocaine/tetracaine heating patch and Buzzy produced greater pain reduction in children compared to placebo and routine care. Amethocaine was the most effective local analgesia method with the probability of 57.6% being the best, followed by Buzzy and lidocaine iontophoresis with the probability of 17.0% and 8.4%, respectively.

CONCLUSION

Most local analgesia methods were effective in relieving pain in children undergoing venipuncture and intravenous cannulation except vapocoolant spray which did not show greater pain reduction than placebo or routine care. Amethocaine, Buzzy and lidocaine iontophoresis are the top 3 local analgesia methods to relieve pain in children undergoing venipuncture and intravenous cannulation. However, due to the limited number of direct comparisons, interpretation of some results should be made with caution.

The effect of Reiki on anxiety level in mothers of hospitalized children: A randomized-controlled study

CONTEXT

Reiki is considered an effective, side-effect-free, and non-invasive method to alleviate anxiety.

OBJECTIVE

This study aimed to investigate the effect of Reiki on the anxiety levels of mothers with hospitalized children.

METHOD

This three-arm parallel randomized controlled trial included 120 mothers with hospitalized children who were divided into 3 equal-sized groups. Over 2 weeks, the Reiki group (n = 40) received 4 sessions (45 minutes each) of Reiki, the placebo group (n = 40) received sham Reiki, and the control group (n = 40) received no intervention. The anxiety levels of the participants were assessed using the State-Trait Anxiety Inventory (STAI-S) before and after the intervention.

RESULTS

After receiving four Reiki sessions over two weeks, the anxiety levels of those in the Reiki group were statistically significantly lower than those in the placebo and control groups (Reiki group 43.25 ± 2.93, placebo group 51.13 ± 12.15, and control group 51.03 ± 9.27; p = 0.001). Regarding the intragroup STAI-S score changes, only the mean pre-intervention score of the Reiki group was higher compared to the post-test score, and this difference was statistically significant (t = 4.209, p = 0.001). There was no statistically significant difference between the pre-test and post-test scores of the placebo and control groups (p > 0.05).

CONCLUSIONS

The results of the study suggested that Reiki treatment significantly reduced the anxiety levels of the mothers with hospitalized children who received it compared to those who did not (the placebo and control groups).

The effectiveness of using animal-themed vacutainers to reduce pain and fear in children during bloodletting

INTRODUCTION

This study aimed to compare the effects of vacutainers of three different animal characters on pain and fear in children during bloodletting.

METHODS

This randomized controlled trial included 180 children between the ages of 4 and 7 years who required bloodletting for routine control. Children were randomized into two groups: experimental and control groups. Routine bloodletting procedure was applied to those in the control group. Animal characters (butterfly, peacock and rabbit) chosen by children in the experimental group was attached to the vacutainer, and then their blood was drawn. The data were obtained by face-to-face interviews with the child, parent and observer before and after the procedure. Children's pain and fear/anxiety levels were evaluated using the Wong-Baker FACES Pain Scale and the Children's Fear Scale, respectively.

RESULTS

There was no statistically significant difference between the groups' pre-test scores with respect to age, BMI, gender, fear/anxiety assessments of the child, parent, and observer. Children in the experimental group had significantly lower pain and fear/anxiety levels after the procedure compared to those in the control group(p < 0.000).

CONCLUSIONS

Animal characters (butterfly, peacock and rabbit) attached to the vacutainer is effective in reducing both fear and pain levels in children during bloodletting.

Hospital Fear Points and Fear Levels of Children 5-10 Years Old

Aim: This study aimed to determine hospital fear points, specific aspects of the hospital experience that are particularly frightening for children, and fear levels of children 5-10 years old who are admitted to the hospital. Methods: This descriptive cross-sectional study of 210 children in eastern Turkey aged 5-10 years used a Demographic Findings and Hospital Fears Form and the Child Fear Scale to collect data about the children's demographics, the opinions of the mothers about their children's fears, and the children's fears about the hospital. Results: Children in the outpatient treatment services and emergency department were afraid of blood drawing, intravenous insertion, injections (shots), and separation from their mothers. In the surgical department, in addition to painful procedures, children were most afraid of being forced to undergo the procedure, insertion of medications, being in the operating room, being awakened after surgery, and seeing the incision site. In the inpatient ward, children were most afraid of nurses and doctors entering the room. Conclusions: Children feared painful procedures, separation from their mothers, and the unknown in the hospital setting.

The effects of virtual reality and stress ball distraction on procedure-related emotional appearance, pain, fear, and anxiety during phlebotomy in children: A randomized controlled study

BACKGROUND

Virtual reality (VR) and stress balls can be used during phlebotomy in school-age children.

OBJECTIVES

This randomized controlled study was conducted to evaluate the effect of distraction methods using VR and stress balls on the emotional behavior, pain, fear, and anxiety associated with phlebotomy in children aged 7-12.

METHODS

A parallel trial with a three-arm design approach was adopted for this randomized controlled trial, guided by the CONSORT checklist. The study sample (n = 150) was divided into VR, stress ball, and control group using stratified randomization. The mean scores obtained from the Children's Emotional Manifestation Scale, Wong-Baker FACES Pain Rating Scale, Child Anxiety Scale-State, and Child Fear Scale were compared between the groups. Linear regression analysis and correlation analysis were performed.

RESULTS

Significant differences were found in phlebotomy-related pain, fear, and anxiety. While there was no difference in emotional behavior before the phlebotomy, a significant difference was found after the phlebotomy. Being in the virtual reality group explained 30.8 % of the difference between the before and after phlebotomy-related-emotional behavior scores. A strong, positive, and significant relationship was found between emotional behavior scores after phlebotomy and phlebotomy-related fear, pain, and anxiety scores (p < .01).

CONCLUSION

Virtual reality and stress ball distraction were found to be effective in reducing pain, fear, and anxiety during phlebotomy. Virtual reality distraction is effective in reducing negative emotional behaviors.

APPLICATION TO PRACTICE

The VR distraction can be used in the pediatric population in pain, fear, anxiety, and emotional behavior management during phlebotomy.

CLINICALTRIALS

gov Identifier: NCT05818761.

The effect of three different methods on pain and anxiety in children during blood sampling procedure in pediatric emergency department: Finger puppet, abeslang puzzle, pinwheel

PURPOSE

The primary objective of this study is to evaluate the effectiveness of finger puppets, abeslang puzzles, and pinwheels in reducing pain and anxiety in children aged 4-6 years during blood sampling procedures in a pediatric emergency department.

DESIGN AND METHODS

This study was a four-arm parallel group randomised controlled trial design conducted in the pediatric emergency department of a children's hospital in Western Türkiye between June 2023 and June 2024. Children (n = 160) were randomly assigned into four groups in a 1:1:1:1 ratio. The intervention groups consisted of children aged 4-6 years as finger puppet (n = 40), abeslang puzzle (n = 40), pinwheel (n = 40) and control group (n = 40). Data were collected using Personnel Information Form, Wong-Baker FACES Pain Rating Scale, and the Children's Anxiety Meter-State. The participants themselves, their parents, the nurse and the researcher rated the pain and anxiety levels associated with the blood sampling procedure. These trials are registered with ClinicalTrials.gov (NCT05904483).

RESULTS

ANOVA was used to compare the mean Wong-Baker FACES Pain Rating Scale scores among the groups. According to all raters (child, parent, nurse, and researcher), the finger puppet group had the lowest mean score, followed by the pinwheel, abeslang puzzle, and control groups (p < 0.05). According to the nurse and researcher evaluations after the procedure, the finger puppet group had the lowest mean score on The Children's Anxiety Meter-State, followed by the abeslang, pinwheel and control groups (p < 0.05).

CONCLUSION

Finger puppet, pinwheel and abeslang puzzle methods were effective in reducing pain and anxiety during blood sampling procedure in children.

PRACTICE IMPLICATIONS

Pediatric nurses can safely use finger puppet, pinwheel and abeslang puzzle methods to reduce pain and anxiety during blood sampling procedure in preschool children.

Venipuncture in pediatric emergency department by using Koala Attachment Distraction method: Randomized clinical trial

OBJECTIVE

To assess, compare and relate the toddler's pain and anxiety during venipuncture by using either the Koala Attachment Distraction method or the physical restraint method and to evaluate the level of anxiety perceived by the companions in both groups.

METHOD

Randomised, single-blind, controlled clinical trial in two arms (control and intervention group) conducted in the paediatric emergency department of a tertiary university hospital. The study variables were pain and stress of the child and anxiety perceived by the accompanying persons in both groups at the time before and during the technique. The pain rating scale Face, Leg, Activity, Cry, Consolability; the Groningen stress scale and the STAI questionnaire were used.

RESULTS

A total of 113 participants aged 3 to 4 years participated in the trial (n=113). 50% (55) were girls, mean total age 3.83±0.59 years and accompanying persons 37.17±6.96. During the technique the mean pain in control and intervention groups was 5.64±3.30 and 3.87±3.01; stress, 3.25±1.22 and 2.67±1.24, respectively. No statistically significant differences were found in the assessment of anxiety between the groups.

CONCLUSIONS

Patients who underwent the Koala Attachment Distraction method venipuncture show a lower level of pain and anxiety than those who received physical restraint, and the anxiety perceived by the companion is similar in both groups.

The effects of vibration and pressure interventions on children's pain, fear and anxiety: A randomized controlled trial

AIM

The effects of vibration and pressure methods on the level of fear, anxiety, and pain of pediatric patients who were admitted to the emergency department for intramuscular injection were evaluated.

METHODS

This was a parallel group and a randomized controlled study conducted in Turkey. The study sample consisted of 114 children aged between 5 and 10 years who presented to the emergency department to receive intramuscular ceftriaxone injection as part of their treatment. The children were randomized into three groups: Vibration Intervention Group (n = 38), Pressure Intervention Group (n = 38) and Control Group (n = 38). Before the procedure, the level of anxiety and fear of the children were evaluated, and the level of perceived pain during the procedure was immediately evaluated after the intervention. Parents and nurses also rated the level of pain. Data were analyzed with non-parametric tests using SPSS version 26.0.

RESULTS

According to the evaluations made by children, mothers, and nurses, there was a significant difference between pain scores of children in the vibration and pressure intervention groups during the procedure and children in the control group (p < 0.000). There was a significant difference between anxiety and fear scores of children in the vibration and pressure groups and children in the control group before and after the intervention according to the evaluations of the children, mothers, and nurses (p < 0.000).

CONCLUSION

Vibration and pressure interventions used during intramuscular injections administered to children in the emergency department were found to reduce pain, anxiety, and fear based on the evaluations of children, mothers, and nurses.

PRACTICE IMPLICATIONS

Vibration and pressure are effective and useful in relieving pain associated with intramuscular injections in children aged between 5 and 10 years.

Acceptability of a novel device to improve child patient experience during venepuncture for blood sampling: Intervention with 'MyShield'

This study aimed to explore the acceptability of a novel device ('MyShield'): a device used for distraction during clinical procedures. It is a cardboard cuff, designed to fit around the arm, either above the elbow or around the wrist and used to hide the procedure from view. This device was tested in practice, to establish acceptability to children, parents and clinical staff. Fifty-eight children tried 'MyShield' during a venepuncture procedure. Feedback from 54 children, 58 parents/carers and 16 clinical staff was collected using surveys and interviews. In 24 cases, observational data were also collected. A large majority of children (94%, n = 51) and parents (96%, n = 56) reported a positive experience when using 'MyShield'; saying they would likely use it again. Potential of 'MyShield' in promoting parent/clinician interaction with the child was highlighted. Data suggests that 'MyShield' may be a useful device for children undergoing venepuncture, when used in conjunction with standard care, and subject to individual preferences and choice. Further work is required to establish mechanism of action and whether use of 'MyShield' has any impact across a range of short- and long-term outcome measures relating to patient experience and effectiveness.

Comparison of trace image colors for kids-book with two active distractions in reducing pain and fear of children during the venipuncture procedure

This study investigated the effectiveness of trace image and coloring for kids-book (TICK-B), cough trick, and balloon inflation techniques in reducing pain and fear in children during venipuncture. The current study is a prospective, controlled, and randomized trial (RCT). School-aged children who required venipuncture were involved in the study. Pediatric patients were randomly assigned to four groups: the TICK-B group, the cough trick group, the inflation of balloons, and the control groups. Before and after the procedure, the children and their parents were interviewed. Wong-Baker (FACES) Pain Rating Scale was applied to measure the severity of pain. Children's Fear Scale was applied to measure children's fear. This study involved the 160 children (mean age, 8.39-2.18 years). The severity of pain and fear levels among the children during and after the procedure were significantly different (p = 0.001). Pain and fear were significantly decreased in children in the intervention groups compared with those in the control group (p < 0.05). In the TICK-B group, participants reported significantly less pain and fear during the venipuncture procedure than in the cough trick, balloon inflation, and control groups (P = 0.001, p = 0.001, p = 0.001) and after the procedure (p = 0.001, p = 0.002, p = 0.002). There was a similar significance found in the level of fear during the procedure (p = 0.001, p = 0.002, p = 0.006), and after the procedure (p = 0.001, p = 0.008, p = 0.015).    Conclusion: TICK-B was the most effective method for decreasing the pain and fear of children associated with venipuncture procedures. Furthermore, the distraction technique of coughing and inflating balloons also proved efficacious in decreasing the pain and fear of children during venipuncture.    Trial registration: The study has been registered with ClinicalTrials.org under the number NCT04983303. It was retrospectively registered on July 26, 2021. What is Known: • Venipuncture, one of the most painful and uncomfortable procedures for children, caused great fear and discomfort during the procedure. What is New: • The TICK-B technique, music listening, and cartoon watching techniques are effective, simple, and safe ways to reduce children's fear and pain. These interventions provide a good way for children and their parents to collaborate during painful medical procedures. • No studies have compared the impact of TICK-B during venipuncture.

SuperKid makes it easier: Effect of an intervention prepared with cognitive behavioral technique on reducing fear and pain of children during intravenous insertion

PURPOSE

The aim of this randomized controlled trial was to evaluate the effectiveness of a cognitive-behavioral SuperKid intervention, in reducing fear and pain among children undergoing intravenous insertion in outpatient services.

DESIGN AND METHODS

This study was designed as a randomized controlled trial, with 96 children aged 5-7 years. SuperKid intervention employed cognitive-behavioral techniques, implemented through a set of prepared cards. Fear was assessed using the Child Fear Scale, while pain status was measured using the Wong Baker Face Pain Scale. Scoring was performed by the mother, child, and researcher. Time series tests were conducted using the Wilks Lambda test.

RESULTS

Most children in both the experimental and control groups reported fear regarding hospital procedures, particularly those involving pain and separation from their mothers. However, children in the experimental group who underwent the SuperKid intervention during and after IV insertion procedure experienced significantly less fear and pain than those in the control group.

CONCLUSIONS

SuperKid intervention was found to be effective in reducing the procedural fear and pain of children undergoing intravenous insertion in outpatient services. The utilization of cognitive-behavioral techniques through a set of prepared cards provides an accessible and engaging means of alleviating negative emotional experiences among children undergoing medical/nursing procedures.

PRACTICE IMPLICATIONS

SuperKid intervention can potentially improve children's attitudes toward medical care and make future procedures easier for them. Healthcare providers could consider incorporating cognitive-behavioral interventions, such as the SuperKid intervention, into their clinical practice to reduce the fear and pain experienced by children during medical/nursing procedures.

The effect of visual and/or auditory distraction techniques on children's pain, anxiety and medical fear in invasive procedures: A randomized controlled trial

PURPOSE

This study was conducted to determine the effects of visual and/or auditory distraction techniques applied to children aged 7-12 during invasive procedures on pain, anxiety, and medical fear.

METHODS

This single-blinded, randomized controlled trial was carried out in the pediatric emergency department of a public hospital between November 2021 and March 2022. In the study, 144 children were assigned to three different intervention groups, in which a kaleidoscope, music, and virtual reality were applied during invasive procedures, and the control group in which the standard invasive procedure was applied, by using the stratified block randomization method. The data were collected using a Personal Information Form, Wong-Baker Faces Pain Rating Scale, Children's Anxiety Meter-State, and Child Medical Fear Scale.

RESULTS

In the study, the levels of pain, anxiety, and medical fear after the invasive procedure were lower in the intervention groups than in the control group. In addition, there was no difference between the three different distraction techniques in terms of reducing pain and medical fear, but the virtual reality application was more effective in reducing the level of anxiety.

CONCLUSION

Visual and/or auditory distraction techniques are effective methods that can be used by nurses in pediatric healthcare to reduce invasive procedure-related pain, anxiety, and medical fear.

IMPLICATIONS FOR PRACTICE

This study provides evidence that can guide the use of non-pharmacological methods such as distraction to prevent the traumatic effects of invasive procedures in children.

The Effect of Distraction Methods During Venous Blood Sampling on Pain Levels in School-Age Children: A Systematic Review

OBJECTIVES

This systematic review was conducted to examine the available evidence on the effects of distraction methods during venous blood sampling on pain levels in school-age children.

DESIGN

A systematic review.

DATA SOURCES

Pubmed, Web of Science, Scopus, Science Direct were searched using search terms.

REVIEW/ANALYSIS METHODS

A systematic review of all relevant articles published between June 2017 and June 2022, was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

The applied search strategy identified 612 articles in four databases. A total of 2,032 school-age children in the 15 studies who met the study inclusion criteria were included in the review. Four studies used active distraction, eight studies used passive distraction, and three studies used both distraction methods.

CONCLUSIONS

Active and passive distractions are efficacious interventions during venous blood sampling in reducing pain in school-age children. However, more studies are needed to determine the superiority between these two methods.

Effects of two different ball types on pain and anxiety during venous blood draw in children: A randomized controlled study

BACKGROUND

Children presenting to hospitals for healthcare are often exposed to venous blood draw procedures which cause significant pain and stress for children.

OBJECTIVES

Tactile stimulation and active distraction methods can be used during procedural pain management in children. This study was conducted to determine and compare the effects of tactile stimulation and active distraction methods on levels of pain and anxiety during venous blood draw procedure in children.

METHODS

A randomized controlled study design was adopted with a parallel trial design to compare four different intervention groups with a control group. The children's anxiety levels were evaluated using the Children's Fear Scale, and their perceived pain levels were evaluated using the Wong Baker Pain Scale.

RESULTS

The results of the child and observer evaluations revealed the perceived level of pain during the procedure to be lower in the intervention groups than in the control group, and lower in the spiky ball groups than in the round ball groups. The level of anxiety during the procedure was found to be significantly lower than that recorded prior to the procedure, based on the self-evaluation of the child and the evaluation of the observer in the intervention groups. A positive correlation was found between pain and anxiety levels during the procedure.

PRACTICE IMPLICATIONS

The results of this study support the effectiveness of the spiky ball method to reduce perceived pain and anxiety in children during venous blood draw procedures in the pediatric blood draw units.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Pharmacological and non-pharmacological interventions in management of peripheral venipuncture-related pain: a randomized clinical trial

BACKGROUND

Venipuncture is a routine nursing procedure in the pediatric ward for blood collection and transfusion. However, this procedure can cause severe pain and distress if not adequately managed.

METHODS

Children aged 3-16 years old were randomized into three groups: EMLA group, distraction group, and combined group. The primary outcome was children's self-reported pain scored using the Wong-Baker FACES® Pain Rating Scale. The parents-reported and observer-reported pain were scored using the Revised Face, Legs, Activity, Cry and Consolability Scale, and children's salivary cortisol levels, heart rate, percutaneous oxygen saturation, venipuncture duration and retaining time of IV cannulas were the secondary outcomes.

RESULTS

A total of 299 children (167 male, 55.8%, median age 8.5) were enrolled: EMLA group (n = 103), distraction group(n = 96) and combined group(n = 100). There was no statistical difference in self-reported pain (P = 0.051), parent-reported pain (P = 0.072), and observer-reported pain (P = 0.906) among the three groups. All three interventions can decrease children's pain during IV cannulations. Additionally, the distraction group's salivary cortisol levels were lower than the combined group(P = 0.013). Furthermore, no significant difference was observed in the heart rate(P = 0.844), percutaneous oxygen saturation (P = 0.438), venipuncture duration (p = 0.440) and retaining time of IV cannulas (p = 0.843) among the three groups.

CONCLUSIONS

All three groups responded with slight pain during the peripheral venipuncture procedure. Therefore, medical workers in pediatric settings can use the interventions appropriate for their medical resources and availability while involving parents and children's preferences whenever possible.

TRIAL REGISTRATION

This trial was registered on https://register.

CLINICALTRIALS

gov/ (Gov.ID NCT04275336).

Biofeedback assisted relaxation training and distraction therapy for pain in children undergoing botulinum neurotoxin A injections: A crossover randomized controlled trial

AIM

To compare biofeedback assisted relaxation training (BART) with distraction therapy for pain during botulinum neurotoxin A (BoNT-A) treatment.

METHOD

This was a crossover randomized controlled trial. Eligible participants were 7 years and older with neurological conditions. Participants were randomized to receive BART or distraction during their first BoNT-A treatment, followed by the alternative intervention in their subsequent BoNT-A treatment. BART was delivered via BrightHearts, an interactive heart-rate-responsive application. Outcomes were pain (Faces Pain Scale - Revised), fear (Children's Fear Scale), and anxiety (numerical rating scale, State-Trait Anxiety Inventory). Demographics, paired t-tests, and linear mixed models were used to compare outcomes.

RESULTS

Thirty-eight participants (mean [SD] age 13 years 5 months [3 years 4 months], 20 males, 34 with cerebral palsy) completed both interventions. There were non-significant differences in overall pain (mean difference - 0.05, 95% confidence interval [CI] -0.91 to 0.80, p = 0.902) and worst pain (mean difference 0.37, 95% CI -0.39 to 1.13, p = 0.334) when using BART and distraction therapy. There were non-significant differences in fear and anxiety between interventions. Younger age, heightened pre-procedural state anxiety, and Gross Motor Function Classification System levels III and IV were associated with poorer outcomes (p < 0.05). Participants who received BART before distraction therapy reported lower pain and anxiety scores during both BoNT-A treatments (p < 0.05).

INTERPRETATION

Children reported similar pain when using BART and distraction therapy. Those who used BART before distraction therapy reported lower pain and anxiety during both treatments.

WHAT THIS PAPER ADDS

Children reported similar pain (overall; worst) when using biofeedback assisted relaxation training (BART) and distraction therapy. Children who used BART before distraction therapy reported lower pain and anxiety over both botulinum neurotoxin A treatments. Younger age, pre-procedural state anxiety, and Gross Motor Function Classification System levels III and IV predicted a worse pain experience. Distraction therapy and BART were acceptable non-pharmacological interventions for procedural pain management.

Effects of cartoon watching and bubble-blowing during venipuncture on pain, fear, and anxiety in children aged 6-8 years: A randomized experimental study

PURPOSE

This study aimed to compare the effects of bubble-blowing (active distraction) and cartoon watching (passive distraction) techniques on pain, anxiety, and fear during venipuncture in children aged 6-8 years.

DESIGN AND METHODS

This experimental study randomly assigned 56 children aged 6-8 years to cartoon watching or bubble-blowing groups. The child, parent, and researcher assessed pain using the Wong-Baker FACES Pain Rating Scale, anxiety using the Children's State Anxiety Scale, and fear using the Children's Fear Scale. The study data were analyzed using the Chi-square tests and independent Sample t-tests.

RESULTS

The groups were similar in clinical and demographic characteristics. The scores on pain, anxiety, and fear during the procedure were lower in the cartoon watching group than in the bubble-blowing group (pain t(47) = 2.638, p = .013; anxiety t(47) = 2.358, p = .023; and fear t(47) = 2.784, p = .008).

CONCLUSION

This study revealed that cartoon watching as a passive distraction method was more effective in reducing pain, anxiety, and fear during venipuncture in children aged 6-8 years compared to bubble-blowing as an active distraction method.

PRACTICE IMPLICATIONS

The cartoon watching technique, which is affordable, easy to access, and effective (in reducing pain, anxiety, and fear), can be safely used during venipuncture in children aged 6-8 years.

Summary and Analysis of Relevant Evidence for Nondrug Nursing Programs in Neonatal Operational Pain Management

Purpose

To summarize the relevant evidence for nondrug nursing programs in neonatal operational pain management.

Methods

Computer search for the literature on neonatal procedural pain from 2015 to 2020 in Up To Date, JBI, NICE, SIGN, RNAO, NGC, PubMed, Cochrane Library, CNKI, and Wanfang database was conducted. All literature works that may meet the inclusion criteria were independently evaluated by two researchers to determine the quality grade of the articles.

Results

Finally, 9 literature works were extracted, including 4 guidelines, 3 systematic reviews, and 2 evidence summaries. The relevant contents of the literature were extracted and summarized, and 20 pieces of the best evidence were obtained.

Conclusion

Breast feeding, sweetener, Kangaroo mother care, sensory stimulation, nonnutritive sucking, and other nondrug nursing programs can reduce the neonatal operational pain, which has guiding significance in neonatal operational pain management.

A Comparison of Two Different Tactile Stimulus Methods on Reducing Pain of Children During Intramuscular Injection: A Randomized Controlled Study

INTRODUCTION

Pediatric patients in the emergency department often require intramuscular injection procedures, which may lead to pain, fear, and anxiety. The purpose of this study was to test a novel nonpharmacological intervention to reduce needle-related pain in the pediatric emergency department.

METHODS

The study was conducted as a parallel-group, randomized controlled design. The study population consisted of 159 children aged 7 to 10 years cared for in the emergency department who received an intramuscular injection of ampicillin/sulbactam. The children were randomly assigned to Palm Stimulator, ShotBlocker, or control groups. The children's preprocedure fear levels were evaluated using the Children's Fear Scale, and their perceived pain levels during the procedure were evaluated using the Faces Pain Scale-Revised and Visual Analog Scale. Parents and observers also completed the pain level scores.

RESULTS

According to all raters (child, parent, and observer), the Palm Stimulator group had the lowest mean Faces Pain Scale-Revised score averages (P < .001). The Visual Analog Scale score averages of the children in the Palm Stimulator group (Visual Analog Scale: M = 27.94, standard deviation = 19.13) were statistically significantly lower than the ShotBlocker (Visual Analog Scale: M = 46.07, standard deviation = 24.96) and control group (Visual Analog Scale: M = 53.43, standard deviation = 29.01) score averages (F = 14.94, η² = 0.16, P = .001).

DISCUSSION

The results of this study support the effectiveness of the Palm Stimulator to reduce perceived pain in children during intramuscular injection administration in the pediatric emergency department.

The Effect of Music-Moving Toys to Reduce Fear and Anxiety in Preschool Children Undergoing Intravenous Insertion in a Pediatric Emergency Department: A Randomized Clinical Trial

INTRODUCTION

Intravenous catheter insertion is a highly invasive medical procedure that causes fear and anxiety in children. This study aimed to analyze the effect of a toy (with music and movement) distraction method on fear and anxiety in children aged 4 to 6 years.

METHODS

This experimental, randomized clinical trial used parallel trial design guided by the Consolidated Standards of Reporting Trials checklist. Using simple randomization, eligible children (age 4-6; N = 60) were assigned to the intervention group (n = 30), who received the toy distraction method, or to the control group (n = 30), who received standard care. The Children's Fear Scale was used to evaluate the fear levels, and Children's State Anxiety Scale was used to evaluate anxiety levels. Physiological parameters (pulse, oxygen saturation) and crying time were monitored by the researcher as indicators of fear and anxiety. The chi-square test, repeated measures analysis of variance, Friedman test, t test, the Mann-Whitney U test, Wilcoxon test, and the intraclass correlation test were used for data analysis.

RESULTS

There was no statistically significant difference in terms of fear and anxiety scores, physiological parameters, and crying time during the procedure between the children in the intervention and control group.

DISCUSSION

We found that this method of toy distraction was not effective in reducing fear or anxiety during the intravenous catheter insertion procedure. Accordingly, we recommend that this distraction method be performed in different age groups and with larger samples in various painful and stressful practices in the future and that comparison be made with various distraction methods.

Predictive Factors for Anxiety during Blood Sampling and Insertion of Peripheral Intravenous Catheters in Paediatric Patients in Spain

INTRODUCTION

Invasive procedures for diagnosis purposes such as venepuncture and peripheral venous catheter insertion are painful procedures that cause great stress for paediatric patients. The objective of this study is to find out the factors that have an impact on the level of anxiety experienced by children undertaken these procedures.

DESIGN AND METHODS

Prospective study, 359 children between 2 and 15 years old were included, treated in a tertiary reference hospital in the region of Navarra (Spain). The impact of the variables recorded was analysed using a regressive analysis, the Wong-Baker and FLACC scales were used to measure the level of pain and the PACBIS scale to measure the level of stress and anxiety.

RESULTS

The average age of the participants was 7.93 years (SD: 4.04), with 51.8% (n = 186) boys and 48.2% (n = 173) girls. The mean value of pain recorded was 4.43 (SD:3.10). 45.7% (n = 123) of the venepuncture techniques was associated with minimum level of anxiety, including 11.1% of intravenous catheterization. Variables determining the anxiety has been detected such as age, sex, level of pain, parental conduct and time spent on the procedure.

CONCLUSIONS

Paediatric patients experience high levels of anxiety when undergoing painful procedures which are conditioned by multifactorial reasons. The increase in stress is directly related to the older age (>6 years old) of the patient, and statistically significant by the female gender, the longer duration of the technique and the parental block.

PRACTICE IMPLICATIONS

Healthcare professionals should work on some of the variables and apply measures aimed to mitigate anxiety levels. For example, reducing the duration of the procedure, training parents, and distracting techniques.

Assessing procedural pain in infants: a feasibility study evaluating a point-of-care mobile solution based on automated facial analysis

BACKGROUND

The management of procedural pain in infants is suboptimal, in part, compounded by the scarcity of a simple, accurate, and reliable method of assessing such pain. In this study, we aimed to evaluate the psychometric properties of the PainChek Infant, a point-of-care mobile application that uses automated facial evaluation and analysis in the assessment of procedural pain in infants.

METHODS

Video recordings of 40 infants were randomly chosen from a purposely assembled digital library of 410 children undergoing immunisation as part of their standard care in Prishtina, Kosovo, between April 4, 2017, and July 11, 2018. For each infant recording, four 10 s video segments were extracted, corresponding to baseline, vaccine preparation, during vaccination, and recovery. Four trained assessors did pain assessments on the video segments of 30 infants, using PainChek Infant standard, PainChek Infant adaptive, the Neonatal Facial Coding System-Revised (NFCS-R) single, the NFCS-R multiple, and the Observer administered Visual Analogue Scale (ObsVAS), on two separate occasions. PainChek Infant's performance was compared to NFCS-R and ObsVAS using correlation in changes in pain scores, intra-rater and inter-rater reliability, and internal consistency.

FINDINGS

4303 pain assessments were completed in two separate testing sessions, on Aug 31, and Oct 19, 2020. The study involved videos of 40 infants aged 2·2-6·9 months (median age 3·4 months [IQR 2·3-4·5]). All pain assessment tools showed significant changes in the recorded pain scores across the four video segments (p≤0·0006). All tools were found to be responsive to procedure-induced pain, with the degree of change in pain scores not influenced by pre-vaccination pain levels. PainChek Infant pain scores showed good correlation with NFCS-R and ObsVAS scores (r=0·82-0·88; p<0·0001). PainChek Infant also showed good to excellent inter-rater reliability (ICC=0·81-0·97, p<0·001) and high levels of internal consistency (α=0·82-0·97).

INTERPRETATION

PainChek Infant's use of automated facial expression analysis could offer a valid and reliable means of assessing and monitoring procedural pain in infants. Its clinical utility in clinical practice requires further research.

FUNDING

PainChek.

Behavioral Crisis Management: A Quality Improvement Pilot for Improving Teamwork in a Primary Care Pediatric Setting

INTRODUCTION

Children with behavioral escalations in the primary care office may pose safety risks to themselves and others. Interprofessional teams utilizing crisis resource management (CRM) skills more successfully manage behavioral crises. The purpose of this quality improvement (QI) pilot project was to improve team performance during a behavioral crisis in pediatric primary care, as well as evaluate learner satisfaction with the curriculum.

METHOD

We implemented an evidence-based curriculum using simulation and didactic techniques in primary care offices within a pediatric network. Using a one group pre-post design, we evaluated roles, communication, and patient-centered care with the KidSIM Team Performance Scale. Utilizing a post intervention survey, learner feedback was elicited regarding learning environment, facilitators and barriers to learning, skill of facilitator, and usability and applicability of content.

FINDINGS

101 interprofessional participants attended one of eight educational sessions. KidSIM Team Performance Scale results demonstrated statistically significant improved total team performance in a simulated behavioral crisis (Z = -2.52, p = 0.012). Post simulation evaluation demonstrated positive feedback about the program, content and facilitators.

DISCUSSION

This pilot QI project demonstrated that a curriculum using behavioral simulation scenarios and CRM principles can improve teamwork in an interprofessional primary care office. Additionally, participants overwhelmingly indicated satisfaction with the curriculum.

APPLICATION TO PRACTICE

Ensuring staff have the appropriate skills to manage behavioral health crises facilitates safer and more effective patient care, enhances patient-centered care and solidifies a positive staff approach in the pediatric ambulatory setting.

Active and Passive Distraction Interventions in a Pediatric Emergency Department to Reduce the Pain and Anxiety During Venous Blood Sampling: A Randomized Clinical Trial

INTRODUCTION

Distraction is a method that is easy to use in emergency departments and effective in relieving procedural pain and anxiety. This study aimed to determine the effect of 2 new distraction methods-1 active distraction (rotatable wooden toy) and 1 passive distraction (toy wristband)-on procedural pain, fear, and anxiety in children during venous blood sampling.

METHODS

This study was a randomized controlled experimental study. The sample consisted of 216 children aged 6 years to 12 years. They were divided into 3 groups using the block randomization procedure: active distraction group (n = 72); passive distraction group (n = 72); and control group (n = 72). The levels of pain and anxiety in the children were measured before and during the blood sampling by the children themselves, their parents, and the researcher using the Visual Analog Scale, the Wong-Baker FACES Pain Rating Scale, and the Children's Fear Scale.

RESULTS

The children and their parents included in the control and experimental groups had similar sociodemographic characteristics. The active distraction group had lower levels of procedural pain, fear, and anxiety than the other groups (children's visual analog scale score, F = 134.22; P < 0.05; Wong-Baker FACES Pain Rating Scale score, F = 137.54; P < 0.001; and Children's Fear Scale score, F = 92.44; P < 0.001).

DISCUSSION

Both the toy wristband and rotatable wooden toy interventions can be used to reduce procedural pain, fear, and anxiety in children during blood sampling in emergency departments.