Pediatric care often includes invasive procedures such as injections and venipuncture, which can cause pain, anxiety, and fear in children. According to Canbulat Şahiner and Türkmen (2019), pain experienced during medical procedures can lead to profound long-term physical and psychological consequences. Therefore, a healthcare provider should ensure a child’s comfort during this type of procedure to deliver responsible, ethical, and holistic care.
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This group project examines the effectiveness of various interventions within the distraction method since those interventions might greatly assist pediatric nurses in alleviating pain and distress in children. However, it is also crucial to understand which interventions are more effective than others in the context of different groups within a pediatric population. Otherwise, potentially beneficial interventions may be misused, which can result in diminished effectiveness.
As such, our project states the following PICO question: how effective is using a distraction method during an injection compared to using no distraction on a child’s perceived pain in a pediatric population? Consequently, the paper contains a review and analysis of scholarly works on the subjects of various distraction interventions and their impact on pain, anxiety, and fear reduction in children and adolescents. In addition, the paper provides age- and procedure-related recommendations to medical practitioners, which stem from the evaluated effectiveness of different intervention types.
Table 1. Evidence Summary.
|Bice & Wyatt (2017)||Exploring non-pharmacological interventions aimed at achieving holistic comfort for children||Systematic review||33 scholarly studies||Effective techniques: soap bubble blowing, music therapy, caregiver coaching|
|Birnie et al. (2018)||Evaluating the efficacy of non-pharmacological interventions in children||Systematic review||n=59 randomized control trials; 5550 participants in the 2-19-year-old range||Evidence of distraction method efficacy is weak but persistent; n=30 for self-reported pain, n=4 for self-reported distress|
|Canbulat Şahiner & Türkmen (2019)||Examining distraction cards’ effectiveness in pain, fear, and anxiety reduction||Randomized control trial||120 children aged from 6 to 11 years||Significant reduction of pain and anxiety scores in the distraction card group|
|Dabas (2019)||Exploring the effectiveness of distraction techniques during infant immunization||Randomized control trial||100 infants||Mean pain scores lowered by distraction: |
control group: 7.16±0.16
electronic toy group:
key toy group:
simple toy group: 5.44±0.18
|Loeffen et al. (2020)||Developing a clinical practice guideline (CPG) for reducing pain and distress in children with cancer||Systematic review||15 randomized control trials on psychological interventions||Active distraction is strongly recommended for all needle procedures despite weak evidence level|
|Longobardi et al. (2019)||Soap bubbles effectiveness in pain and anxiety reduction||Randomized control trial||74 children in the age between 7 and 10 years||Group distracted with bubbles showed a significant reduction in perceived pain and fear|
|Redfern et al. (2018)||Examining effects of thermomechanical stimulation with Buzzy device during needle procedures||Randomized control trial||50 children in the 3-18-year-old age range||Mean child-reported |
pain scores lower in the distracted group (3.56 vs. 5.92)
|Rezai et al. (2017)||Evaluation of distraction techniques effectiveness in pain reduction during venipuncture||Systematic review||31 randomized control trials: 2 systematic reviews||Most effective distraction techniques: |
|Russell & Harrison (2015)||Describing methods of pain reduction in infants||Secondary source study||62 surveys from nurse vaccinators||Breastfeeding during injection helps to reduce pain in infants|
Multiple scholarly papers underscored the adverse effects of pain in the pediatric population during invasive medical procedures. Dabas (2019) defined pain as “sensory and emotional feeling with actual or potential tissue damage” and “a major source of distress in infants and their family members” (p.5). Bice and Wyatt (2017) claimed that ensuring comfort for children should not be restricted to pain management but also include interventions to alleviate fear, anxiety, and distress. Redfern et al. (2018) stated that pain experienced during needle procedures might lead to delay or avoidance of treatment in adult life. Additionally, pain may disrupt communication between nurses and children, hindering care delivery (Rezai et al., 2017). Therefore, alleviating pain-induced negative experiences during a medical procedure is seemingly critical for eventual treatment success.
Non-pharmacological methods such as distraction may serve as an effective means of pain alleviation during injections or other invasive procedures. In theory, various distraction interventions can divert a child’s attention from painful sensations (Canbulat Şahiner & Türkmen, 2019). However, the effectiveness of particular distraction techniques may significantly depend on age groups within the pediatric population or specific types of invasive procedures. As a result, a problem arises — it is unclear which interventions would be helpful in a particular situation. In this regard, it is important to review existing scholarly sources to develop practical recommendations for nursing personnel.
The purpose of this study lies in providing evidence-based recommendations for nursing personnel. In particular, our group strived to confirm whether distraction interventions during invasive medical procedures are genuinely effective. If the evidence from the scholarly sources proves the effectiveness of the distraction method, it would also become possible to derive practical recommendations for pediatric nurses. In this regard, the parts of the PICO question stated in the introductory section can be defined as the following:
as little as 3 hours
- P (Population): the pediatric population included in the reviewed scholarly sources encompasses multiple age groups — from 6-month-old infants to 18-year-old adolescents;
- I (Intervention): the primary reviewed intervention method is a distraction, applied during invasive medical procedures, mainly — injections. Various types of distractions, such as soap bubbles, music, video games, and many others, were examined;
- C (Comparison): our main research interest lay in comparing perceived levels of pain, anxiety, fear, and distress in the groups which experienced distraction techniques to the groups, which did not experience them;
- O (Outcome): the desired outcome lay in confirming or refuting the effectiveness of the distraction method in pediatric care. In addition, in case if method’s effectiveness is confirmed, our group intended to provide practical, evidence-based recommendations for the pediatric nursing personnel.
To summarize, our group intended to review existing sources on the subject in order to confirm or refute the effectiveness of the distraction method in various age groups within the pediatric population. In addition, this paper aimed to derive practical, evidence-based recommendations for nurses depending on the literature review results. Essentially, our team attempted to conclude whether the distraction method is effective and which distraction techniques should be used in various circumstances.
The search for relevant scholarly sources started from accessing three significant databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and the Cochrane Database for Systematic Reviews. The following groups of crucial search terms were used to separate results into five categories:
- Child* AND distract* AND pain AND (shot OR injection) — 20 initial results located;
- Pediatric AND distraction AND injection — 14 initial results located;
- Children AND immunizations OR vaccine OR vaccinations AND distraction method AND nurse* — 60 initial results located;
- Children OR adolescents OR youth OR child OR teenager AND distraction techniques — 187 initial results located;
- Reducing vaccine pain — 3 initial results located;
As such, the initial combined searches yielded 284 possible entries, 9 of which were eligible for the final selection. The scope was narrowed down through the application of several inclusion and exclusion criteria. The article had to meet the following criteria to be eligible for text assessment:
- Research had to be published in a peer-reviewed journal in the English language;
- The date of publishing had to be not earlier than January 2015;
In addition, several exclusion criteria were applied to narrow the scope of review even further:
- Duplicate studies were removed from selection;
- Research that did not focus on non-pharmacological interventions sufficiently enough were excluded from the scope;
This approach allowed to establish a review scope of 30 sources across five categories of the initial search. The text of these 30 articles was further assessed for eligibility. In the end, only 9 articles remained eligible and were selected for inclusion in the evidence table.
Out of 9 articles deemed eligible for further research, 4 were designed as randomized control trials with control and experimental groups, and 4 presented a systematic review of scholarly sources on a subject. In addition, a study by Russell and Harrison (2015) can be described as a descriptive secondary sources research on methods of pain reduction in infants. This work is closer to a review; however, its scope does not allow to classify it as systematic. Our group has conducted a breakdown of research methods used in the scholarly studies.
Randomized Control Trials
Research by Dabas (2019) explored the effects of various distraction interventions during immunization in an infant population setting. 100 infants were pre-selected via random sampling techniques and assigned to several experimental groups tied to a particular distraction intervention. In addition, a special control group was provided with standard care. The dependent variable analyzed in the research was the mean pain score measured by the FLACC pain scale, while distraction interventions served as independent variables.
Canbulat Şahiner and Türkmen (2019) studied a pediatric population group of 120 children aged 6 to 11 years. The research goal lay in evaluating the effectiveness of distraction cards in pain and anxiety reduction during intermuscular injections. Similar to a study by Dabas (2019), the researchers separated children into experimental and control groups. Perceived levels of pain and anxiety served as dependent variables, whereas distraction cards were considered an independent variable.
Longobardi et al. (2019) studied the effects of distraction with soap bubbles in the pediatric emergency room setting where children waited for medical examination and procedures. The research population scope included 74 children aged between 7 and 10 years. The participants were separated into experimental and control groups and reported their pain, fear, and anxiety perceptions. Distraction with soap bubbles served as an independent variable; levels of pain, anxiety, and fear depended on it.
Finally, Redfern et al. (2018) examined the effects of the thermomechanical stimulation with a Buzzy device on pain, anxiety, and patient satisfaction during needle procedures. The total population sample included 50 children in the 3-18-year-old age range. Children in the experimental group were distracted with a Buzzy device, while their counterparts from the control group received injections without a distraction. Participants from both groups reported their pain and fear perceptions before and after the procedure. Final results were calculated through statistical tools, similarly to other researches in this category.
A systematic review by Bice and Wyatt (2017) explores studies, which examined various non-pharmacological interventions aimed at achieving holistic comfort for children during pediatric procedures. In total, the authors reviewed 33 scholarly studies and presented their findings in connection to four common themes of comfort intervention: music therapy, caregiver facilitation, amusement and entertainment, and multifaceted (mixed) approach. In the end, Bice and Wyatt (2017) concluded which interventions are more effective depending on the patient population and particular invasive procedures.
Birnie et al. (2018) conducted a comprehensive review of sources from six databases: CINAHL, CENTRAL, MEDLINE, PsycINFO, Embase, and Web of Science. The selection of their research included 59 randomized control trials with 5550 participants in the 2-19-year-old range who underwent various needle procedures. Non-pharmacological methods — distraction, hypnosis, preparation, breathing interventions, and combined cognitive behavioral therapy (CBT) were evaluated by their efficacy in alleviating pain and distress. In addition, pain and distress were separated into self-reported and observer-reported categories, which added an extra dimension to the review.
Loeffen et al. (2020) utilized the systematic review design to develop a CPG for treating children diagnosed with cancer. The review in the basis of CPG included 48 randomized control trials with 2271 participants, 15 of which were focused on psychological interventions. The international panel of 44 members evaluated the evidence in scholarly sources in terms of quality and composed a list of recommendations for care providers.
Lastly, Rezai et al. (2017) studied 31 randomized control trials and two systematic reviews from databases in English and Persian to evaluate distraction techniques’ effectiveness during venipuncture procedure. Additionally, the researchers tied recommendations on specific intervention usage to particular age groups within the pediatric population. However, this review was focused exclusively on pain reduction during venipuncture, so it cannot be reliably extrapolated on distress alleviation.
Regarding the previously stated PICO question, it is possible to answer with confidence — using distraction method during injection is effective since it allows to alleviate perceived pain in the pediatric population. The overall level of evidence may be weak; however, both randomized control trials and systematic reviews show the positive influence of distraction interventions during needle procedures. Most importantly, scholarly sources did not contain evidence of harm coming from using the distraction method. As such, pediatric nurses should use distraction intervention in their daily practice; however, certain recommendations should be considered to achieve optimal effectiveness.
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It is possible to provide several evidence-based recommendations which will assist pediatric nurses in their practice. Firstly, applying distraction method to children during injections is risk-free; researchers strongly recommend nurses to use it. Secondly, the distraction technique of choice should be tailored to the patient’s age. Soap bubbles are especially effective and versatile since they are easily affordable and work for a wide age range of children. Lastly, distraction is beneficial for infants as well — simply showing them a toy lowers observed levels of pain during injections. Overall, our group recommends equipping pediatric cabinets with means of distraction appropriate for different age groups of children.
Through selecting and reviewing scholarly sources on the use of distraction methods during injections, our group attempted to answer a PICO question about the effectiveness of distraction in the pediatric population. The evidence supported the beneficial character of distraction interventions in comparison to the lack of them. Despite a relatively weak level of evidence, the beneficial effect of distraction was confirmed by systematic reviews and randomized control trials. As such, the distraction method can be recommended for liberal use in pediatric practice.
Bice, A. A., & Wyatt, T. H. (2017). Holistic comfort interventions for pediatric nursing procedures: A systematic review. Journal of Holistic Nursing, 35(3), 280–295. Web.
Birnie, K. A., Noel, M., Chambers, C. T., Uman, L. S., & Parker, J. A. (2018). Psychological interventions for needle-related procedural pain and distress in children and adolescents. The Cochrane Database of Systematic Reviews, 10(10), CD005179. Web.
Canbulat Şahiner, N., & Türkmen, A. S. (2019). The effect of distraction cards on reducing pain and anxiety during intramuscular injection in children. Worldviews on Evidence-based Nursing, 16(3), 230–235. Web.
Dabas, P. (2019). Effectiveness of distraction techniques on pain intensity during immunization among infants. International Journal of Nursing Education, 11(1), 5–9. Web.
Loeffen, E., Mulder, R. L., Font-Gonzalez, A., Leroy, P., Dick, B. D., Taddio, A., Ljungman, G., Jibb, L. A., Tutelman, P. R., Liossi, C., Twycross, A., Positano, K., Knops, R. R., Wijnen, M., van de Wetering, M. D., Kremer, L., Dupuis, L. L., Campbell, F., & Tissing, W. (2020). Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline. European Journal of Cancer, 131, 53–67. Web.
Longobardi, C., Prino, L. E., Fabris, M. A., & Settanni, M. (2019). Soap bubbles as a distraction technique in the management of pain, anxiety, and fear in children at the paediatric emergency room: A pilot study. Child: Care, Health & Development, 45(2), 300–305. Web.
Redfern, R. E., Chen, J. T., & Sibrel, S. (2018). Effects of thermomechanical stimulation during vaccination on anxiety, pain, and satisfaction in pediatric patients: A randomized controlled trial. Journal of Pediatric Nursing, 38, 1–7. Web.
Rezai, M. S., Goudarzian, A. H., Jafari-Koulaee, A., & Bagheri-Nesami, M. (2017). The effect of distraction techniques on the pain of venipuncture in children: A systematic review. Journal of Pediatrics Review, 1–11. Web.
Russell, K., & Harrison, D. (2015). Managing pain in early childhood immunization. Nursing New Zealand, 21(2), 22–24.